Chapter 173-50 | PACE Program

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

• Effective: July 1, 2024
• Promulgated Under: 119.03

(A) Introduction: This chapter regulates PACE, which 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, an adult day service, personal care, 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.

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

"IDT" means "inter-disciplinary team."

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

"ODA's designee" has the same meaning as in rule 173-39-01 of the Administrative Code.

"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 was established under 42 U.S.C. 1396u-4 (August 5, 1997).

"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.

Last updated July 2, 2024 at 9:57 AM

Supplemental Information

Authorized By: 121.07, 173.01, 173.02, 173.50
Amplifies: 173.50; 42 C.F.R. Part 460
Five Year Review Date: 6/29/2029
Prior Effective Dates: 12/19/2013, 8/1/2016

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: 8/1/2016, 11/1/2018

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

• Effective: July 1, 2024
• 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 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 1, 2024 at 4:06 AM

Supplemental Information

Authorized By: 121.07, 173.01, 173.02, 173.50, 173.56
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: 1/14/2010, 8/1/2016

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

• Effective: July 1, 2024
• 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 verbally, electronically, or in writing.

(2) Once the PACE organization receives the participant's request, the PACE organization shall notify ODA in writing.

(3) 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.

(4) After receiving a written notice of disenrollment from the PACE organization, ODA shall enter the disenrollment in the ODA- and ODM-approved eligibility systems.

(D) After a participant initiates a voluntary disenrollment, the PACE organization shall continue to provide PACE services as outlined in the participant's plan of care until the effective 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, the participant remains liable for any premium or patient-liability costs incurred for services rendered by the PACE organization until the effective date of disenrollment.

Last updated July 1, 2024 at 4:24 PM

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: 6/29/2029
Prior Effective Dates: 10/5/2020

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

• Effective: July 1, 2024
• Promulgated Under: 119.03

(A) A participant is subject to involuntary disenrollment from PACE for an reason outlined in 42 C.F.R. 460.164(b).

(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 documentation reflecting grounds for involuntary disenrollment and the PACE organization's efforts to remedy the situation.

(2) ODA shall approve or deny the request based upon the requirements in paragraph (A) of this rule and notify the PACE organization of the decision.

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

(4) If ODA approves the request, the PACE organization is subject to the involuntary disenrollment process in 42 C.F.R. 460.164, 460.166, and 460.172.

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

(6) After ODA approves an involuntary disenrollment, ODA sends the participant a notice of denial and hearing rights under division 5101:6 of the Administrative Code.

(a) 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.

(b) If the decision of the state hearing is that ODA made a correct decision to disenroll, then ODA enters the decision into the ODA- and ODM-approved eligibility systems.

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

Last updated July 1, 2024 at 4:25 PM

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: 6/29/2029
Prior Effective Dates: 10/5/2020