La. Admin. Code tit. 50 § XXIII-501

Current through Register Vol. 50, No. 11, November 20, 2024

Section XXIII-501 - Eligibility

A. In order to be eligible for services from a PACE site an applicant must:

1. be 55 years of age or older;

2. be determined by the state administering agency to meet nursing facility level of care, as established by the Department of Health;

3. reside in the service area of the PACE organization; and

4. at the time of enrollment, an individual must be able to live in a community setting without jeopardizing his or her health or safety.

B. Eligibility to enroll in a PACE program is not restricted to an individual who is either a Medicare beneficiary or Medicaid participant. A potential participant 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; or

3. eligible for Medicaid.

C. The determination whether a potential participant can be cared for in the community at the time of enrollment without jeopardizing his or her safety is based on the PACE organization's evaluation of the potential participant. The following are issues to consider when making this determination.

1. The potential participant does not have the capability to call for emergency assistance or does not have the capability to determine when emergency assistance is needed.

2. A physician, familiar with the potential participant's health and social history, has documented a condition for the potential participant that requires 24-hour/7-days per week of skilled care.

3. The potential participant's residence:

a. has been condemned; or

b. has been determined unsafe by habitation by PACE provider (detailed documentation of specifics required); or

c. poses a threat to PACE program staff due to:

i. physical condition and integrity of dwelling; or

ii. evidence of abuse and/or neglect from other household members; or

iii. criminal activities or behavior; or

iv. illegal drug use; or

v. brandishing of weapons; or

vi. dangerous pets/animals.

4. The potential participant exhibits health concerns that involve dangerous behavior(s) which would pose a threat to him/her, other PACE participants, or PACE program staff.

5. The potential participant whose current medical treatment or regimen requires 24-hour supervision and whose care is more appropriately provided in an institutional setting (hospital or skilled nursing facility).

6. Repealed.

D. If the PACE organization determines that an applicant's health and safety cannot be ensured with the services that PACE can provide, the PACE organization shall submit the following within five working days to the Office of Aging and Adult Services (OAAS):

1. justification for the determination that health and safety cannot be ensured; and

2. any and all assessments and medical records use to make the determination;

E. If OAAS agrees with the PACE organization, OAAS will provide documentation to the PACE organization in writing acknowledging the health and safety concern.

1. - 2. Repealed.

F. If the potential participant is denied enrollment because the potential participant's health or safety would be jeopardized by living in a community setting, the PACE organization must meet the following requirements:

1. notify the potential participant in writing of the reason for denial with notification of appeal rights through the state fair hearing process;

2. refer the potential participant to alternative services, as appropriate;

3. maintain supporting documentation of the reason for denial; and

4. notify CMS and OAAS in the form and manner specified by CMS and make the documentation available for review.

G. If OAAS disagrees with the PACE organization, OAAS will provide the PACE organization with specific information as to why OAAS believes that with PACE services in place, a plan of care can be developed that is adequate to ensure the participant's health, social, and welfare needs. In addition, OAAS will provide suggestions for services that would be beneficial to the participant.

H. A PACE organization shall assess the potential participant to ensure that he or she can be cared for appropriately in a community setting and that he or she meets all requirements for PACE eligibility.

I. Reevaluation of Eligibility

1. LDH shall annually reevaluate whether the participant continues to meet level of care for nursing facility services. LDH may permanently waive the annual recertification of level of care requirements for a participant if it determines that there is no reasonable expectation of improvement or significant change in the participant's condition because of the severity of a chronic condition or the degree of impairment of functional capacity.

2. LDH may determine that a PACE participant who no longer meets the state Medicaid nursing facility level of care requirements be deemed to continue to be eligible for the PACE program until the next annual reevaluation, if, in the absence of continued coverage under this program, the participant reasonably would be expected to meet the nursing facility level of care requirement within the next six months.

La. Admin. Code tit. 50, § XXIII-501

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:247 (February 2004), LR 33:850 (May 2007), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 50401 (3/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, Title XIX of the Social Security Act, and 42 CFR 460 et seq.