D.C. Mun. Regs. tit. 29, r. 29-8801

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-8801 - PARTICIPANT ENROLLMENT

8801.1

To be eligible to enroll in PACE, an individual shall meet the following requirements, as determined by the PACE organization:

(a) Be fifty-five (55) years of age or older;

(b) Reside in the designated service area of the PACE organization;

(c) Meet the level of care required under the District's State Medicaid Plan for coverage of nursing facility services as determined by the Department of Health Care Finance (DHCF) or its designated agent, in accordance with 29 DCMR § 989.12; and

(d) At the time of enrollment, be able to live in a community-based setting without jeopardizing his or her health or safety, as determined using the criteria specified in the PACE program agreement and guidance published on the DHCF website at https://dhcf.dc.gov .

8801.2

Eligibility to enroll in PACE is not limited to individuals who are eligible for or enrolled in either Medicare or Medicaid.

8801.3

If an individual is denied enrollment in PACE based on a determination that his or her health or safety would be jeopardized by living in a community-based setting, the PACE organization shall do the following:

(a) Notify the individual in writing of the denial and reason for the denial, in accordance with 42 CFR § 431.210;

(b) Refer the individual to alternative services, as appropriate;

(c) Maintain supporting documentation of the reason for the denial;

(d) Provide the individual with information regarding the process for requesting reconsideration of the denial;

(e) Provide the individual with information regarding the right to appeal the denial by filing a fair hearing request with the Office of Administrative Hearings, in accordance with 1 DCMR § 2971; and

(f) Notify the Centers for Medicare and Medicaid Services (CMS) and DHCF of the denial and make all relevant documentation available for review by CMS, DHCF, and the individual.

D.C. Mun. Regs. tit. 29, r. 29-8801

Final Rulemaking published at 69 DCR 6400 (6/3/2022)