Rule 173-50-03 | PACE: application, assessment, enrollment, plan of care, reassessment, and continued enrollment.
(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.
Last updated July 3, 2024 at 9:22 AM
Supplemental Information
Amplifies: 173.50, 173.501, 173.56; 42 C.F.R. 460.104, 460.106, 460.152, 460.154, 460.156, 460.158, 460.160.
Five Year Review Date: 6/29/2029
Prior Effective Dates: 3/28/2009, 1/14/2010, 3/12/2011, 9/29/2011, 2/17/2013, 8/1/2016, 11/1/2018, 6/11/2020 (Emer.), 11/5/2020, 2/7/2022