210 R.I. Code R. 210-RICR-40-10-1.13

Current through December 3, 2024

Section 210-RICR-40-10-1.13 - Program of All-Inclusive Care for the Elderly (PACE)

1.13.1Overview

PACE provides a managed plan of coordinated Medicare and Medicaid covered services from across the care continuum to certain beneficiaries age fifty-five (55) and older. The operations of PACE are bound by a three (3) way agreement between EOHHS, CMS, and the PACE provider to integrate the full range of Medicare (if eligible) and Medicaid services (primary care, acute care, specialty care, behavioral health care, and LTSS) for PACE participants.

1.13.2EOHHS Responsibilities

EOHHS is responsible for the eligibility and enrollment functions set forth in §1.13.4 of this Part, establishing PACE provider standards, and oversight and monitoring of all aspects of the PACE program.

1.13.3PACE Provider Responsibilities

A. The PACE provider is responsible for:

1. Point of entry identification;

2. Submitting all necessary documentation for initial determinations and reevaluations of a level of need and referral to EOHHS for a determination of financial eligibility;

3. Verifying PACE enrollment prior to service delivery;

4. Verifying and collecting required beneficiary liability (cost-share amount);

5. Providing and coordinating all integrated services;

6. Reporting changes to the PACE-eligibility status of participants; and

7. Adhering to all PACE provider requirements as outlined in the PACE Program Agreement between EOHHS and CMS, and to all credentialing standards required by EOHHS including data submission.

1.13.4PACE Participation Criteria

A. To qualify as a Medicaid-eligible PACE participant, an individual must:

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

2. Meet the criteria for a high or the highest need for a nursing facility level of care in accordance with Part 50-00-5 of this Title; and

3. Meet all other financial and non-financial requirements for Medicaid LTSS such as, but not limited to, citizenship, residency, resources, income, and transfer of assets.

B. Medicaid-eligible PACE participants may be, but are not required to be, enrolled in Medicare.

1.13.5PACE Disenrollment

A. Reasons for PACE Disenrollment - Reasons for disenrollment from PACE include but are not limited to:

1. Death;

2. Loss of Medicaid eligibility;

3. Eligibility error;

4. Placement in an out-of-State residential hospital;

5. Incarceration;

6. Change of State residence;

7. Loss of functional level of care; and

8. Voluntary opt-out to Medicaid FFS.

B. The PACE provider may also request in writing that a member be disenrolled on the grounds that the member's continued enrollment seriously impairs the entity's capacity to furnish services to either the particular member or other members. In such instances, EOHHS will notify the PACE provider about its decision to approve or disapprove the disenrollment request within fifteen (15) days from the date EOHHS has received all information needed for a decision. Upon EOHHS approval of the disenrollment request, the PACE provider must, within three (3) business days, forward copies of a completed Disenrollment Request Form to EOHHS and to the Medicare enrollment agency (when appropriate). The PACE provider must also send written notification to the member that includes:

1. A statement that the PACE provider intends to disenroll the member;

2. The reason(s) for the intended disenrollment; and

3. A statement about the member's right to challenge the decision to disenroll and how to grieve or appeal such decision.

C. Disenrollment Requests Not Allowed. EOHHS does not permit disenrollment requests based on:

1. An adverse change in the member's health status;

2. The member's utilization of medical services; or

3. Uncooperative behavior resulting from the member's special needs.

D. Voluntary Disenrollment - PACE participants may voluntarily disenroll from PACE at any time. A voluntary disenrollment from PACE will become effective at midnight of the last day of the month in which the disenrollment is requested.

E. Disenrollment Process. Regardless of the reason for disenrollment, EOHHS is responsible for completing all disenrollment actions. Disenrollments requested by the PACE provider on the grounds that the member's continued enrollment seriously impairs the entity's capacity to furnish services to either the particular member or other members are subject to EOHHS approval. Beneficiaries who are disenrolled from PACE but retain Medicaid eligibility will be enrolled in Medicaid fee-for-service and may subsequently choose or be enrolled in an alternative service delivery if they qualify. Beneficiaries have the right to appeal EOHHS's disenrollment action (see Part 10-05-2 of this Title).

F. Disenrollment Effective Date. Regardless of the reason for disenrollment, all disenrollments from PACE will become effective at midnight of the last day of the month in which the disenrollment is requested.

1.13.6Disenrollment Appeal

If the member files a written appeal of the disenrollment within ten (10) days of the decision to disenroll, the disenrollment shall be delayed until the appeal is resolved.

1.13.7Re-enrollment and Transition Out of PACE

All re-enrollments will be treated as new enrollments except when a participant re-enrolls within two (2) months after losing Medicaid eligibility. In this situation, the participant's re-enrollment will not be treated as a new enrollment. The PACE provider shall assist participants whose enrollment ceased for any reason in obtaining necessary transitional care through appropriate referrals, by making medical records available to the participant's new service providers, and (if applicable), by working with EOHHS to reinstate the participant's benefits.

210 R.I. Code R. 210-RICR-40-10-1.13

Amended effective 10/5/2021