Chapter 173-50 | PACE Program

Rule 173-50-01 | PACE: introduction and definitions.

• Effective: October 5, 2020
• Promulgated Under: 119.03

(A) Introduction: Chapter 173-50 of the Administrative Code regulates PACE. PACE is a managed-care program that provides its participants with all of their necessary health care, medical care, and ancillary services in acute, sub-acute, institutional, and community settings. Examples of PACE services are primary and specialty care, adult day services, personal care services, inpatient hospital stays, prescription drugs, occupational therapy, physical therapy, and nursing facility care.

(B) Definitions for this chapter:

"Authorized representative" has the same meaning as in rule 5160-36-01 of the Administrative Code.

"CDJFS" means the "county department of job and family services."

"CMS" means "the centers for medicare and medicaid services."

"IDT" means "inter-disciplinary team."

"ODA" means "the Ohio department of aging."

"ODM" means "the Ohio department of medicaid."

"ODM's administrative agency" has the same meaning as "administrative agency" in rule 5160:1-1-01 of the Administrative Code.

"PACE" means "the program of all-inclusive care for the elderly," which is established by 42 C.F.R. Part 460 (October 1, 2019).

"PACE organization" means an entity that provides services to participants under a PACE program agreement with CMS and ODA.

"Participant" means a person who receives services through PACE.

Supplemental Information

Authorized By: 121.07, 173.01, 173.02, 173.50
Amplifies: 173.50; 42 C.F.R. 460.6
Five Year Review Date: 10/5/2025
Prior Effective Dates: 2/16/2012

Rule 173-50-02 | PACE: eligibility requirements.

• Effective: October 5, 2020
• Promulgated Under: 119.03

(A) A person is eligible for PACE only if the person meets all the following requirements:

(1) The person is at least fifty-five years of age.

(2) The person resides within a PACE organization's service area.

(3) The person has an intermediate or skilled level of care in accordance with rule 5160-3-08 of the Administrative Code.

(4) ODA or its designee determine the person can live in a community setting without jeopardizing his or her health and safety.

(5) The person, who may be enrolled as a medicaid or a non-medicaid enrollee, is responsible for payment to the PACE organization as follows:

(a) If a person is applying for, or enrolled in, PACE through the medicaid program, the person maintains medicaid eligibility either under the financial eligibility standard or under a needs allowance if the person has moved from an institutional setting to a non-institutional setting, or pays the premiums and any post-eligibility treatment of income (i.e., patient liability or share of cost) ODM may require in rule 5160:1-6-07.1 of the Administrative Code.

(b) If a person is applying for, or enrolled in, PACE as a non-medicaid enrollee, the person may remain eligible for PACE if the person pays the premiums and incurred while using PACE. (For more information, see rule 173-50-05 of the Administrative Code and 42 C.F.R. 460.150 and 460.160.)

(6) The person agrees to obtain medicaid services, if any, or medicare services, if any, only through the PACE organization during the period of enrollment in PACE.

(7) At the time of initial enrollment, the person meets the following;

(a) The person is not enrolled in one or more of the following (or will discontinue being enrolled in one or more of the following upon enrollment in PACE):

(i) A medicaid managed-care program other than PACE.

(ii) A hospice program.

(iii) The primary alternative care and treatment (PACT) program.

(iv) A medicaid waiver program (e.g., PASSPORT or assisted living).

(v) The residential state supplement (RSS) program.

(vi) A nursing facility certified by medicaid while medicaid is covering the person's nursing facility expenses.

(b) The person resides in a non-institutional setting (e.g., house, apartment).

(B) 42 C.F.R. 460.160 requires ODA to assess, at least once per year, whether each participant continues to require an intermediate or skilled level of care in accordance with rule 5160-3-08 of the Administrative Code. ODA may permanently waive the annual assessment if ODA does not reasonably expect the participant's health to improve or significantly change.

(C) At any time and for any reason listed under paragraph (A) of rule 173-50-05 of the Administrative Code, the PACE organization may use the process in that rule for involuntary disenrollment.

Supplemental Information

Authorized By: 121.07, 173.01, 173.02, 173.50
Amplifies: 173.50; 42 C.F.R. 460.150, 460.160
Five Year Review Date: 10/5/2025
Prior Effective Dates: 2/17/2013

Rule 173-50-03 | PACE: enrollment, plan of care, and reassessment.

• Effective: November 5, 2020
• Promulgated Under: 119.03

(A) Oversight:

(1) ODA manages the enrollment for PACE.

(2) ODA determines if a slot is available in PACE.

(3) ODA reserves the right to restrict enrollment based upon funding for PACE.

(4) ODA reserves the right to increase or decrease the maximum number of PACE slots.

(B) Enrollment process, in general:

(1) To begin the enrollment process, a person may apply through either ODM's administrative agency or a PACE organization.

(2) ODM's administrative agency and the PACE organization shall coordinate efforts regarding the enrollment process.

(C) Enrollment process when a person initially applies for PACE:

(1) The PACE organization's shall conduct a comprehensive assessment (by telephone, video conference, or in person) of the applicant's medical, physical, emotional, and social needs and ability to remain in the community without jeopardizing his/her health or safety.

(2) The PACE organization may help the applicant apply for medicaid (unless the applicant is already enrolled in medicaid).

(a) After the application is received, ODM's administrative agency shall determine if the applicant meets all financial eligibility requirements for medicaid in Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(b) If ODM's administrative agency determines the applicant does not meet all financial eligibility requirements, it shall send a notice of denial and appeal rights to the applicant (or the authorized representative) in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. It shall also send a notice of denial to ODA and the PACE organization. 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) After completing the assessment, the PACE organization shall submit the information from its assessment to ODA.

(4) After receiving the information, ODA shall determine if the applicant meets all eligibility requirements in rule 173-50-02 of the Administrative Code.

(5) If ODA determines an applicant meets all eligibility requirements, then:

(a) ODA shall notify the PACE organization of its determination.

(b) Once the PACE organization receives the determination from ODA, it shall notify the applicant (or the authorized representative) of the opportunity to proceed with the process of enrolling into PACE.

(c) In order to be enrolled into the program, the applicant shall sign the enrollment agreement with the PACE organization.

(d) The applicant's enrollment into PACE is effective the first day of the month following the day ODA determines the applicant meets all eligibility requirements and the PACE organization received the signed enrollment agreement.

(6) If ODA determines an applicant does not meet all eligibility requirements, then:

(a) ODA shall notify the PACE organization of its determination.

(b) ODA shall provide the applicant (or the authorized representative) with a notice of denial and appeal rights under section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.

(D) 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 two means: the unified waiting list or the home-first component of PACE.

(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 the terms of 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.

(E) Plan of care: The PACE organization shall do all of the following for any participant enrolled into PACE:

(1) The PACE organization shall collaborate with the participant to develop a plan of care for the participant that includes all of the following:

(a) The services necessary to meet the participant's medical, physical, emotional, and social needs, as identified in the initial comprehensive assessment in paragraph (C)(1) of this rule and the reassessment under paragraph (E)(3)(a) of this rule.

(b) The measurable outcomes to be achieved for the participant.

(2) The PACE organization shall implement, coordinate, and monitor the participant's plan of care.

(3) Reassessment:

(a) At least semiannually, or more often if the participant's condition dictates or if requested by the participant or the participant's authorized representative, the team shall conduct a comprehensive assessment (by telephone, video conference, or in person) of the applicant's medical, physical, emotional, and social needs and ability to remain in the community without jeopardizing his/her health or safety.

(b) If the comprehensive assessment in paragraph (E)(3)(a) of this rule indicates a need to revise the plan of care, the team shall collaborate with the participant to revise the plan of care.

(c) The PACE organization shall submit at least one of the semiannual comprehensive assessments in paragraph (E)(3)(a) of this rule to ODA at least once per year with no more than three hundred and sixty-five days between submissions of assessments.

(d) Deemed eligibility: ODA may deem a PACE participant to be eligible if at least one of the following conditions exist:

(i) The participant has a severe cognitive impairment (mini-mental of nine or less).

(ii) The participant has complex medical conditions that require continual clinical oversight on a weekly basis by the IDT to remain medically stable.

(iii) Within six months after the most-recent annual redetermination date, the participant has had two or more hospitalizations or two or more trips to an emergency department.

(iv) The participant has a psychiatric diagnosis and/or behavior requiring coordination of continuous and ongoing intervention(s) by the IDT. In the absence of support and services from the PACE organization, the participant would not likely be able to comply with medical regimen for chronic disease.

Supplemental Information

Authorized By: 121.07, 173.01, 173.02, 173.50
Amplifies: 173.50, 173.501; 42 C.F.R. 460.102, 460.106, 460.152, 460.154, 460.156, 460.158, 460.160
Five Year Review Date: 10/5/2025
Prior Effective Dates: 9/29/2011, 11/1/2018

Rule 173-50-04 | PACE: voluntary disenrollment.

• Effective: October 5, 2020
• Promulgated Under: 119.03

(A) A participant may voluntarily disenroll from PACE at any time without cause.

(B) The PACE organization shall ensure its employees or contractors do not engage in any practice that would reasonably be expected to have the effect of steering or encouraging disenrollment of participants due to a change in health status.

(C) Process for voluntary disenrollment:

(1) A participant who wishes to voluntarily disenroll from PACE shall initiate the voluntary disenrollment process by informing the PACE organization orally or in writing.

(2) Once the PACE organization receives the participant's request, it shall provide the participant with a disenrollment form.

(3) Once the participant receives the disenrollment form, he or she shall sign the form and return it to the PACE organization.

(4) After the PACE organization receives the signed disenrollment form, it shall forward the form to ODA on the participant's behalf no later than one business day after receiving the form.

(5) A participant's voluntary disenrollment is effective on the first day of the month after the date the PACE organization receives the participant's notice of voluntary disenrollment.

(6) ODA shall notify the participant of the effective date in writing.

(7) After receiving a signed document from the PACE organization, ODA shall enter the disenrollment request in the ODA- and ODM-approved eligibility systems.

(D) After a participant initiates a voluntary disenrollment, the PACE organization shall do the following:

(1) Complete the mandates regarding the disenrollment form in paragraphs (C)(2) and (C)(4) of this rule.

(2) Continue to provide necessary services to the participant until the date of disenrollment.

(E) Before disenrollment, the PACE organization shall initiate a discharge plan for each participant who is voluntarily disenrolled. In each discharge plan, it shall state how it plans to do the following:

(1) Help the participant obtain necessary transitional care through referrals to other medicaid or medicare service providers.

(2) Provide the participant's medical records to new providers no later than thirty days after disenrollment.

(F) After the participant initiates a voluntary disenrollment, he or she shall:

(1) Complete the mandate regarding the disenrollment form in paragraph (C)(3) of this rule;

(2) Continue to obtain necessary services from the PACE organization until the date of disenrollment; and,

(3) Remain liable for any premium or patient-liability costs incurred for services rendered by the PACE organization for all dates before the date of disenrollment.

Supplemental Information

Authorized By: 121.07, 173.01, 173.02, 173.50
Amplifies: 173.50; 42 C.F.R. 460.162, 460.166, 460.172, 460.210
Five Year Review Date: 10/5/2025
Prior Effective Dates: 8/1/2016

Rule 173-50-05 | PACE: involuntary disenrollment.

• Effective: October 5, 2020
• Promulgated Under: 119.03

(A) The PACE organization shall involuntarily disenroll a participant from PACE for one or more of the following reasons:

(1) Failure to pay: The participant, after a thirty-day grace period, fails to pay (or satisfactorily arrange to pay) any premium due the PACE organization, any applicable medicaid patient liability, or any amount due to the PACE organization under the post-eligibility treatment of income process, if the PACE organization documented at least one attempt it made in writing to the participant containing all the following components:

(a) The PACE organization has notified the participant of the participant's outstanding financial obligations and requested payment.

(b) The PACE organization warned the participant that disenrollment may result from non-payment.

(2) Fraud: The participant commits medicaid fraud or medicaid eligibility fraud, as described in sections 2913.40 and 2913.401 of the Revised Code, if the PACE organization has a signed narrative of the events from the staff person who discovered the fraud.

(3) Disruptive or threatening behavior: The participant (or the participant's caregiver) engages in disruptive or threatening behavior meeting the following conditions:

(a) A participant engages in disruptive or threatening behavior when he or she jeopardizes his or her health or safety, the safety of others, or when he or she has decision-making capacity and consistently refuses to comply with his or her plan of care or the terms of the enrollment agreement. When a participant with decision making-capacity fails to comply with his or her plan of care (e.g., repeated non-compliance with medical advice or repeated failure to keep appointments), the PACE organization shall document at least two attempts it made in the past six months to educate the participant on the importance of following the care plan, the negative health consequences of not doing so, and a warning that not doing so may result in disenrollment. Medical records and copies of letters written to the participation are examples of acceptable documentation.

(b) A participant's caregiver engages in disruptive or threatening behavior when he or she jeopardizes the participant's health or safety, or the safety of himself, herself, or others.

(c) The PACE organization shall only involuntarily disenroll a participant for the participant's or caregiver's disruptive or threatening behavior if the PACE organization retains the following in the participant's medical record:

(i) The reasons for proposing to disenroll the participant.

(ii) Documentation of all efforts to remedy the situation.

(iii) One or both of the following records regarding at least one incident of disruptive or threatening behavior:

(a) A signed statement from a witness or the provider.

(b) A police report or a security staff report.

(4) Geography:

(a) The participant's permanent residence is no longer located in the service area.

(b) The participant remains outside the service area for a period of more than thirty consecutive days, unless the PACE organization authorizes a longer period of absence for extenuating circumstances.

(5) Incarceration: The participant is incarcerated for a period of more than thirty consecutive days.

(6) Level of care: The participant no longer meets the level-of-care requirements in rule 173-50-02 of the Administrative Code and is not deemed eligible.

(7) Providers: The PACE organization is unable to offer healthcare services because of a loss of state licenses or contracts with outside providers.

(8) PACE agreement: The agreement between the PACE organization, ODA, and CMS is not renewed or is terminated.

(B) Process to involuntarily disenroll a PACE participant:

(1) If a PACE organization requests permission to disenroll a participant under this rule, it shall submit the request to ODA along with:

(a) Documentation supporting one or more requirements in paragraph (A) of this rule; and,

(b) The participant's utilization profile.

(2) In the time between the request and ODA's decision, the PACE organization shall continue to provide necessary services to the participant.

(3) ODA shall approve or deny the request based upon the requirements in paragraph (A) of this rule, then notify the PACE organization and send the participant a notice of denial and hearing rights under section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.

(4) If ODA does not approve the request, the PACE organization shall continue to provide necessary services to the participant.

(5) If ODA approves the request:

(a) A participant's involuntary disenrollment is effective on the first day of the month beginning thirty days after the day the PACE organization sends notice of the disenrollment to the participant.

(b) The PACE organization shall notify the participant in writing of the last day of enrollment;

(c) The PACE organization shall continue to provide for the necessary services to the participant through the last day of enrollment;

(d) The participant shall continue to obtain necessary services through the PACE organization and shall continue to remain liable for any premiums or post-eligibility treatment of income costs incurred through the last day of enrollment; and,

(e) Before disenrollment, the PACE organization shall initiate a discharge plan for each participant who is involuntarily disenrolled. In each discharge plan, it shall state how it plans to do the following:

(i) Help the participant obtain necessary transitional care through referrals to other medicaid or medicare service providers.

(ii) Provide the participant's medical records to new providers no later than thirty days after disenrollment.

(6) After ODA approves an involuntary disenrollment, ODA does all of the following:

(a) ODA notifies the PACE organization.

(b) ODA sends the participant a notice of denial and hearing rights under section 5101.35 of the Revised Code and division 5101:6 of the Administrative Code.

(i) If the participant requests a hearing within fifteen days after ODA approves the involuntary disenrollment, ODA places the disenrollment on hold until a state hearing has been conducted.

(a) If the decision of the state hearing is that ODA made a correct decision to disenroll, ODA implements the requirements under paragraph (B)(5) of this rule and enters the decision into the ODA- and ODM-approved eligibility systems.

(b) If the decision of the state hearing is that ODA made an incorrect decision to disenroll, the participant remains enrolled in PACE.

(ii) If the participant does not request a hearing, ODA proceeds with disenrolling the participant from PACE and implement the requirements under paragraph (B)(5) of this rule.

Supplemental Information

Authorized By: 121.07, 173.01, 173.02, 173.50
Amplifies: 173.50; 42 C.F.R. 460.164, 460.166, 460.172, 460.210
Five Year Review Date: 10/5/2025
Prior Effective Dates: 3/28/2009, 2/17/2013