Ala. Admin. Code r. 560-X-53-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-53-.03 - Eligibility Criteria

(A) General Rule. The PACE program provides for medically necessary services. To enroll in a PACE program, an individual must meet eligibility requirements specified in this section. To continue to be eligible for PACE, an individual must meet the annual recertification requirements specified in Rule No. 560-X-53-.04.

(B) Basic eligibility requirements. To be eligible to enroll in a PACE program, an individual must meet the following eligibility requirements:

(1) Be 55 years of age or older;

(2) Be approved by the Alabama Medicaid Agency to meet the nursing facility level of care as set forth in Rule No. 560-X-10-.10;

(3) Reside in the PACE organizations service area;

(4) Be able to live in a community setting at the time of enrollment without jeopardizing his/her health or safety based on criteria set forth in the program agreement; and

(5) Meet any additional program-specific eligibility conditions imposed under its respective PACE program agreement.

(C) Eligibility to enroll in a PACE program is not restricted to an individual who is either a Medicare or Medicaid beneficiary. A potential PACE enrollee may be, but is not required to be, any or all of the following:

(1) Entitled to Medicare Part A;

(2) Enrolled under Medicare Part B;

(3) Eligible for full Medicaid;

(4) Dual eligibles for Medicaid and Medicare.

(D) Reasons for Denial.(

(1) Is not 55 years of age or older;

(2) Has not been approved by the Alabama Medicaid Agency to meet the nursing facility level of care as set forth in Rule No. 560-X-10-.10;

(3) Does not reside in the PACE service area;

(4) Is not able to live in a community setting at the time of enrollment without jeopardizing his/her health or safety based on criteria set forth in the program agreement;

(5) Does not meet additional program-specific eligibility conditions imposed under the respective PACE program agreement.

(E) The Alabama Medicaid Agency will initiate recoupment of payment for services when it determines that state and federal medical necessity and eligibility requirements are not met.

Ala. Admin. Code r. 560-X-53-.03

Emergency rule effective May 1, 1991. Permanent rule effective August 14, 1991. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed November 10, 2011; effective December 15, 2011. Amended: Filed May 9, 2013; effective June 13, 2013.

Author: Linda Lackey, Medicaid Administrator, LTC Project Development Unit.

Statutory Authority: State Plan, Attachment 2.2-A, Attachment 3.1-A and Supplement 3; 42 CFR 460.150.