5160-36-01 Program of all-inclusive care for the elderly (PACE) definitions and acronyms.

The purpose of this rule is to define the terms used in Chapter 5160-36 of the Administrative Code governing the medicaid funded portion of the program of all-inclusive care for the elderly (PACE).

(A) As used in this chapter:

(1) "Authorized representative" means a person, eighteen years of age or older, who stands in place of an individual who is applying for or receiving medical assistance including PACE enrollment and participation. The authorized representative may include a legal entity assisting in the application process, a family member, attorney, licensed social worker, or any other person chosen to act on the individual's behalf. In accordance with Chapter 5160:1-2 of the Administrative Code, the individual shall provide a written statement naming the authorized representative and the duties that the authorized representative may perform on the individual's behalf.

(2) "CMS" means the centers for medicare and medicaid services, a federal agency that is part of the U.S. department of health and human services and administers the medicaid program.

(3) "C.F.R." means the code of federal regulations.

(4) "CDJFS" means county department of job and family services.

(5) "Capitated payment" means the monthly payment paid to the PACE organization by ODM for medical care and services provided to medicaid recipients enrolled in the PACE program.

(6) "Individual" is the applicant for or recipient of a medical assistance program such as medicaid.

(7) "Involuntary disenrollment" means the disenrollment of a participant from the PACE program at the request of the PACE organization or a CDJFS.

(8) "ODA" means the Ohio department of aging.

(9) "ODM" means the Ohio department of medicaid.

(10) "PACE" means the 'program of all-inclusive care for the elderly' provided for in 42 U.S.C. 1396u-4 and 42 C.F.R. Part 460 as in effect on October 1, 2013.

(11) "PACE center" means a facility operated by a PACE organization where primary care or other related services offered by the PACE program are furnished to participants.

(12) "PACE organization" means an entity that has a medicaid provider agreement and also has in effect a PACE program agreement with CMS and ODA.

(13) "PACE program agreement" means an agreement between a PACE organization, CMS, and ODA.

(14) "Participant" means a person enrolled in PACE and receiving services through the PACE program.

(15) "Private pay participant" means an individual who does not meet the medicaid eligibility criteria but chooses to participate in PACE and is responsible for payment of the PACE organization's private pay premium.

(16) "Service area" means the geographic area in which a PACE organization is approved by CMS and ODA to furnish services to PACE participants.

(17) "State administering agency" means the state agency responsible for administering the PACE program agreement. Pursuant to section 173.50 of the Revised Code ODA shall serve as the state administering agency for PACE in Ohio.

(18) "Voluntary disenrollment" means the disenrollment of a participant from the PACE program at the request of the participant or the participant's authorized representative.

Effective: 1/1/2015
Five Year Review (FYR) Dates: 09/30/2014 and 01/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02 , 173.50 and 5162.35
Prior Effective Dates: 3/28/09, 7/1/11 (Emer.), and 9/29/11