Chapter 5160-36 | Program of All-Inclusive Care for the Elderly (PACE)

Rule 5160-36-01 | Program of all-inclusive care for the elderly (PACE) definitionsand acronyms.

• Effective: January 1, 2020
• Promulgated Under: 119.03

(A) "Authorized representative" has the same meaning as in rule 5160:1-1-01 of the Administrative Code.

(B) "Capitated payment" means the monthly payment paid to the program of all inclusive care for the elderly PACE organization by the Ohio department of medicaid (ODM) for medical care and services provided to medicaid recipients enrolled in PACE.

(C) "Individual" is the applicant for or recipient of a medical assistance program such as medicaid.

(D) "Involuntary disenrollment" means the disenrollment of a participant from PACE at the request of the PACE organization or a county department of job and family services.

(E) "PACE" means the 'program of all-inclusive care for the elderly' as set forth in 42 C.F.R. Part 460 as in effect on October 1, 2019.

(F) "PACE center" means a facility operated by a PACE organization where primary care or other related services offered by PACE are provided to participants.

(G) "PACE organization" means an entity that has a medicaid provider agreement and also has in effect a PACE agreement with the centers for medicare and medicaid services (CMS) and the Ohio department of aging (ODA).

(H) "PACE agreement" means an agreement between a PACE organization, CMS, and ODA.

(I) "Participant" means a person enrolled in and receiving services through PACE.

(J) "Private pay participant" means an individual who does not meet the medicaid eligibility criteria but chooses to participate in PACE and is responsible for payment of the PACE organization's private pay premium.

(K) "Service area" means the geographic area in which a PACE organization is approved by CMS and ODA to provide services to PACE participants.

(L) "State administering agency" means the state agency responsible for administering the PACE agreement. Pursuant to section 173.50 of the Revised Code ODA shall serve as the state administering agency for PACE in Ohio.

(M) "Voluntary disenrollment" means the disenrollment of a participant from PACE at the request of the participant or the participant's authorized representative.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.35, 173.50
Five Year Review Date: 1/1/2025

Rule 5160-36-02 | Program of all-inclusive care for the elderly (PACE) program administration.

• Effective: January 1, 2020
• Promulgated Under: 119.03

(A) In accordance with section 173.50 of the Revised Code, the Ohio department of aging (ODA) shall serve as the designated state administering agency for PACE and shall adhere to and monitor the implementation of all applicable requirements for the program's administration as set forth in 42 C.F.R Part 460 as in effect on October 1, 2019.

(B) ODA shall:

(1) Facilitate the process in which prospective PACE organizations apply to the centers for medicare and medicaid services (CMS) for approval to provide PACE services;

(2) Enter into a PACE agreement with (CMS) and each PACE organization approved by CMS to provide PACE services to participants in Ohio who reside in the PACE organization's designated service area. The content and duration of that agreement shall conform to standards set forth in 42 C.F.R. Part 460 as in effect on October 1, 2019.

(3) Verify that PACE organizations providing PACE services have signed medicaid provider agreements as required by rule 5160-1-17 of the Administrative Code.

(4) Work with PACE organizations to assist individuals seeking enrollment in PACE.

(5) Manage PACE enrollment.

(6) Adopt rules including, but not limited to, participant eligibility, participant enrollment, participant voluntary disenrollment and participant involuntary disenrollment.

(7) Confer as necessary and appropriate with the Ohio department of medicaid (ODM) on matters including but not limited to:

(a) Participant eligibility;

(b) Participant enrollment and disenrollment, and program waiting list;

(c) Establishing the payment for PACE organizations operating in Ohio;

(d) Designating each PACE organization's service area;

(e) The enrollment and disenrollment of PACE organizations; and

(f) The termination of PACE agreements.

(C) ODM shall be responsible for the capitated payments made to PACE organizations for medicaid services rendered to PACE participants.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.35; 173.50
Five Year Review Date: 1/1/2025
Prior Effective Dates: 3/28/2009

Rule 5160-36-03 | Medicaid funded program of all-inclusive care for the elderly (PACE) eligibility.

• Effective: November 5, 2023
• Promulgated Under: 119.03

(A) To be eligible and maintain eligibility for PACE, an individual will meet the requirements for PACE participant eligibility set forth in rule 173-50-02 of the Administrative Code and will have been determined to be eligible for medicaid in accordance with Chapters 5160:1-3 to 5160:1-6 of the Administrative Code.

(B) If a PACE participant who is also enrolled in medicaid has a continuous period of institutionalization as defined in rule 5160:1-6-01.1 of the Administrative Code, that individual's patient liability amount is to be calculated by the county department of job and family services as directed in rule 5160:1-6-07.1 of the Administrative Code.

(C) Individuals who fail to meet the eligibility requirements in paragraph (A) of this rule will not be enrolled as a medicaid participant in PACE.

(1) Once enrolled, participants who no longer meet the eligibility requirements in paragraph (A) of this rule will be involuntarily disenrolled from the medicaid-funded component of PACE pursuant to rule 173-50-05 of the Administrative Code.

(2) An individual who no longer meets medicaid eligibility requirements in paragraph (A) of this rule may continue non-medicaid funded enrollment in PACE as defined within rule 173-50-02 of the Administrative Code.

(D) PACE eligibility and enrollment for persons who are either medicaid enrollees or non-medicaid enrollees are described in section 173.50 of the Revised Code.

Last updated November 7, 2023 at 8:15 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.35, 173.50
Five Year Review Date: 11/5/2028
Prior Effective Dates: 1/1/2015, 1/1/2020, 6/12/2020 (Emer.)

Rule 5160-36-05 | Program of all-inclusive care for the elderly (PACE)interdisciplinary team, participant plan of care, and services.

• Effective: January 1, 2020
• Promulgated Under: 119.03

(A) Each PACE organization shall establish and maintain at each PACE center an interdisciplinary team to assess the care and service needs of participants. The composition, qualifications, and activities of the interdisciplinary team shall be consistent with 42 C.F.R. Part 460 as in effect on October 1, 2019.

(B) PACE organizations shall ensure that all participants have access to all medically necessary services including, but not limited to, services covered by Ohio's medicaid program, in addition to those prescribed in 42 C.F.R. Part 460.92 as in effect on October 1, 2019 to 42 C.F.R. Part 460.96 as in effect on October 1, 2019.

(1) Services provided shall be sufficient in their amount, duration and scope to meet the participant's medical, physical, emotional, and social needs as identified in the comprehensive assessment to achieve the measurable outcomes identified in the participant's plan of care.

(2) Services provided shall be reflected in the participant's plan of care unless the services are an emergency service.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.35, 173.50
Five Year Review Date: 1/1/2025
Prior Effective Dates: 1/1/2015

Rule 5160-36-06 | Program of all-inclusive care for the elderly (PACE) organization reimbursement.

• Effective: January 1, 2020
• Promulgated Under: 119.03

(A) PACE is a full-risk program in which the PACE organization assumes all financial risk for the cost of the medical care and services provided to participants.

(B) PACE organizations shall receive a monthly capitated payment from the Ohio department of medicaid (ODM) for each PACE participant enrolled in the medicaid program including individuals enrolled in both medicaid and medicare.

(C) The amount of the capitated payment shall be established in the PACE agreement.

(D) The amount paid in accordance with paragraph (B) of this rule represents the total maximum payment obligation of the state administering agency to the PACE organization for the cost of medical care and services provided to participants enrolled in medicaid including those participants enrolled in both medicaid and medicare.

(E) The PACE organization shall accept the capitation payment amount as payment in full for medicaid participants and shall not bill, charge, collect, or receive any other form of payment from ODM or from, or on behalf of, the participant, except as permitted under 42 C.F.R. Part 460.182(c) as in effect on October 1, 2019.

Supplemental Information

Authorized By: 119.03
Amplifies: 5164.02, 173.50, 5162.35
Five Year Review Date: 1/1/2025
Prior Effective Dates: 3/28/2009