Department of Aging - PACE Program - PACE: eligibility requirements.


Published: 2020-10-05

Subscribe to a Global-Regulation Premium Membership Today!

Key Benefits:

Subscribe Now for only USD$20 per month, or Get a Day Pass for only USD$4.99.

(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.