(A) Oversight:
(1) ODA manages the
enrollment for PACE.
(2) ODA determines if a
slot is available in PACE.
(3) ODA may restrict
enrollment based upon funding for PACE.
(4) ODA may increase or
decrease the maximum number of PACE slots.
(B) Intake process:
(1) A person may apply
for PACE through either ODM's administrative agency or a PACE
organization. The two agencies coordinate intake with ODA.
(2) The PACE organization
is responsible for completing its intake duties under 42 C.F.R. 460.152 and
notifying ODA of any applicant and its determination under 42 C.F.R.
460.152(a)(4). The PACE organization may help the applicant apply for medicaid,
unless the applicant is already enrolled in medicaid.
(3) ODM's
administrative agency is responsible for determining whether the applicant
meets all financial eligibility requirements for medicaid in Chapters 5160:1-1
to 5160:1-6 of the Administrative Code, notifying ODA, the PACE organization,
and the applicant (or the applicant's representative) of its
determination, and, if the applicant does not meet all financial eligibility
requirements, notifying the applicant (or the applicant's authorized
representative) of the denial and appeal rights under section 5101.35 of the
Revised Code and division 5101:6 of the Administrative Code. An applicant who
is denied medicaid may still enroll in PACE if the applicant is willing to
privately pay the premium that would have been covered by
medicaid.
(4) ODA is responsible
for the level-of-care assessment under 42 C.F.R. 460.152(a)(3) and rule
5160-3-08 of the Administrative Code. ODA, in its discretion, may delegate this
responsibility.
(C) Enrollment: If ODA determines that an
applicant meets all eligibility requirements in rule 173-50-02 of the
Administrative Code, then the following apply:
(1) ODA notifies the PACE
organization of its determination.
(2) The PACE organization
is responsible for notifying the applicant of the opportunity to proceed with
the process of enrolling into PACE, providing the applicant with the enrollment
agreement under 42 C.F.R. 460.154, and completing the enrollment procedures in
42 C.F.R. 460.156 if the applicant signs the enrollment agreement.
(3) 42 C.F.R. 460.158
determines the effective date of the applicant's enrollment into
PACE.
(D) Denial: If the PACE organization
determines that an applicant does not meet all eligibility requirements, then
the PACE organization shall notify CMS and ODA of its determination and need to
notify the applicant of the denial and appeal rights under section 5101.35 of
the Revised Code and division 5101:6 of the Administrative Code.
(E) No available slot: If a slot is not
available in PACE, the PACE organization shall enroll the applicant when a slot
becomes available (if the individual continues to meet the eligibility
requirements) by one of the following two means:
(1) Unified waiting list:
If the applicant meets the non-financial eligibility requirements for
enrollment into PACE, but a slot in the program is not available, the PACE
organization shall place the applicant on the unified waiting list under rule
173-44-04 of the Administrative Code.
(2) Home first: If the
applicant meets all requirements for the home first component of PACE in
section 173.501 of the Revised Code, the PACE organization shall enroll the
applicant in PACE before enrolling any applicant from the unified waiting list
in PACE.
(F) Initial comprehensive assessment: The
PACE organization's IDT is responsible for completing the initial
in-person comprehensive assessment of the participant under 42 C.F.R.
460.104.
(G) Plan of care:
(1) The PACE
organization's IDT is responsible for the initial in-person assessment and
in-person semi-annual reassessment under 42 C.F.R. 460.104.
(2) In addition to the
semi-annual reassessments, the IDT may conduct an unscheduled reassessment
under under 42 C.F.R. 460.104 in person.
(3) The IDT is
responsible for the comprehensive plan of care under 42 C.F.R. 460.106 based on
the assessments in paragraphs (G)(1) and (G)(2) of this rule.
(H) Continued enrollment: Continued
enrollment is dependent upon the annual recertification requirements in 42
C.F.R. 460.160.
(I) An authorized representative may
represent an applicant in the enrollment process and a participant in the
reevaluation processes.
