(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) A person may
apply for PACE through either ODM's administrative agency or a PACE
organization. The two agencies coordinate intake with ODA.
(1) 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.
(2) 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.
(3) 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 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 based on a level-of-care assessment under
rule 5160-3-08 of the Administrative Code.
(I) An authorized
representative may represent an applicant in the enrollment process and a
participant in the reevaluation processes.
