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

(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.

Replaces: 173-50-03

Effective: 11/5/2020
Five Year Review (FYR) Dates: 10/05/2025
Promulgated Under: 119.03
Statutory Authority: 121.07, 173.01, 173.02, 173.50
Rule Amplifies: 173.50 , 173.501 ; 42 C.F.R. 460.102, 460.106, 460.152, 460.154, 460.156, 460.158, 460.160
Prior Effective Dates: 03/28/2009, 01/14/2010, 03/12/2011, 09/29/2011, 02/17/2013, 08/01/2016, 11/01/2018