173-50-02 Eligibility criteria.

 

 

 

173-50-02                    Eligibility criteria.

 

 

 

(A)A person may enroll in PACE only if the person:

 

(1)Is at least 55 years of age;

 

(2) Resides within a PACE organization's service area;

 

(3)Requires intermediate level of care under rule 5101:3-3-05 of the Administrative Code or skilled level of care under rule 5101:3-3-06 of the Administrative Code;

 

(4)Resides   in   a   non-institutional   setting   (e.g.,   house,   apartment)   without jeopardizing his/her health or safety;

 

(5)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 for the premiums and patient-liability costs;

 

(6)Agrees to obtain medicaid services, if any, or medicare services, if any, only through the PACE organization during the period of enrollment in PACE; and,

 

(7)Is not enrolled in the following (or will discontinue enrollment in the following to transfer to PACE):

 

(a) A medicaid managed-care program other than PACE;

 

(b) A hospice program;

 

(c) The primary alternative care and treatment (PACT) program;

 

(d)A  medicaid  waiver  program  (e.g.,  PASSPORT,  choices,  or  assisted living);

 

(e) The residential state supplement (RSS) program; or,

 

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

 

(B)At least once per year, ODA shall assess whether each participant continues to require an intermediate level of care under rule 5101:3-3-05 of the Administrative Code or a skilled level of care under rule 5101:3-3-06 of the Administrative Code. ODA may permanently waive the requirement to perform the assessment if there is no reasonable expectation of improvement or significant change in the participant's condition of health.

 

 

 

 

(C) If, at any time, a participant in PACE no longer meets the criteria in paragraph (A) of rule 173-50-05 of the Administrative Code, the PACE organization may use the process for involuntary disenrollment described in that rule. However, a participant who may no longer meet the financial eligibility criteria for medicaid may remain eligible for PACE as long as the participant pays the premiums and the patient-liability costs incurred while using PACE. (For more information see rule 173-50-05 of the Administrative Code, 42 C.F.R. 460.150 (d), and 42 C.F.R. 460.160 (a).)

Effective:	03/28/2009
R.C. 119.032 review dates:	02/27/2013
CERTIFIED ELECTRONICALLY
Certification
03/18/2009
Date
Promulgated Under:	119.03
Statutory Authority:	173.02, 173.50
Rule Amplifies:	173.50