C. Although application processing times apply to PACE, the State encourages the Medicaid PACE authorization process be expedited. Communication between the department of social services and the PACE organization is crucial in order to coordinate beginning and end dates for PACE authorization in Medicaid.
D. A referral form, DMA-5106, Medicaid/PACE Referral (MA-2275, Figure 1), has been developed to be used as a communication, notification, and documentation tool between the agencies. DMA-5106, Page 1, is completed by the county. DMA-5106, Page 2, is completed by the PACE organization.
DATE: JANUARY 28, 2008
Manual: Aged, Blind, and Disabled Medicaid
Change No: 07-08
To: County Directors of Social Services
Effective: February 1, 2008
Program of All-Inclusive Care for Elderly (PACE) is a federal program administered by the Centers for Medicare and Medicaid Services (CMS). PACE was authorized under the Balanced Budget Act of 1997 (P.L. 105-33), under which:
• Section 4801 authorizes Medicare coverage of PACE services; and
• Section 4802 authorizes the establishment of PACE as a state option under Medicaid.
The State of North Carolina has received approval from the CMS to amend the state plan to include PACE as a state plan option. House Bill 1414 of the 2004-2005 Session of the North Carolina General Assembly mandated the development of PACE programs.
The Program of All-Inclusive Care for the Elderly (PACE) is a managed care program that enables elderly individuals who are certified to need nursing facility care to live as independently as possible. PACE providers receive monthly Medicare and/or Medicaid capitation payments for each eligible enrollee. PACE providers assume full financial risk for participants' care without limits on amount, duration, or scope of services.
The PACE program is a unique managed care benefit for the frail elderly provided by a not-for-profit or public entity. The PACE model is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in the community whenever possible.
The first North Carolina PACE organization to be developed and receive approval by CMS is Elderhaus, Inc. of Wilmington. Individuals residing in New Hanover County and a small portion of Brunswick County are eligible to apply for PACE enrollment with Elderhaus.
To enroll in PACE, an individual must:
• Be 55 years of age or older;
• Certified by the State to require nursing facility level of care;
• Able to live safely in the community at the time of enrollment; and
• Reside in the service area of the PACE organization.
Services provided directly by the PACE provider include, but are not limited to:
• Interdisciplinary team case management;
• Adult day health program;
• Skilled nursing care;
• Primary care physician services;
• Specialized therapies;
• Personal care services;
• Nutrition counseling;
• Transportation; and
PACE recipients receive all medical services through the PACE Center. Individuals authorized for PACE do not receive a monthly Medicaid card because PACE is the sole source of Medicaid services.
Individuals enrolled with PACE do not enroll with a Medicare Prescription Drug Plan (PDP). The PACE organization is also the PDP provider. Medicare Part D enrollment is completed by the PACE organization.
PACE recipients eligible for Medicare qualify for Medicare enrollment and buy-in.
Third party liability requirements and procedures are not applicable for PACE applicants/recipients.
PACE individuals are subject to estate recovery.
Authorization for PACE services is always effective on the first day of the month and always ends on the last day of the month. There is no retroactive coverage for PACE.
Once an individual is enrolled into the PACE program by the PACE organization and Medicaid under PACE begins, he is ineligible for Medicaid in any aid program/category except as a PACE authorized recipient.
Keying PACE information into EIS correctly and by EIS processing dates is extremely important. Failure to enter the correct information or failure to enter the information timely will result in no payment to the PACE organization or erroneous payment to the PACE organization.
When a service is denied or not paid, PACE individuals may request a PACE internal appeal with the PACE organization. If after the PACE internal appeal process the individual is not satisfied, then a Medicaid appeal may be requested. An individual enrolled in PACE may request a Medicaid hearing through the PACE organization or by contacting the county dss.
Medicaid appeal requirements apply to PACE cases just as with any other Medicaid case.
PACE Referral, Request for a Medicaid Hearing form (MA-2275, Figure 2), is a suggested notification form to be used by the PACE organization. PACE staff will assist PACE enrollees in the hearing and appeal request process and forward requests to the Department of Social Services.
Although the EIS Manual policy is not updated at this time, the Eligibility Manual policy provides references and links to the EIS policy for use in the future. EIS policy will be incorporated into the EIS manual in the near future. Until that time, use EIS Administrative Letter 02-08 as guidance. The EIS Administrative Letter will be issued in early February.
Because the PACE organization enrolls very frail individuals in immediate need of services, close monitoring of the Medicaid application processing steps will be done by the Division of Medicaid (DMA). It should be noted that delays caused by lag time in the effective dates of Medicaid eligibility could cause significant financial hardship for the PACE organization.
Figure 3, PACE Application Report, must be completed for all individuals that request PACE services. The form should be completed at the time of an individual’s disposition and faxed to the Division of Medical Assistance (DMA), Medicaid Eligibility Unit. The fax number is (919) 715-0801.
MA-2230, Financial Resources has been revised to provide additional instructions for the annuity evaluation process for applications and redeterminations. A copy of the annuity, the a/r’s name, Medicaid ID number, case number, and a short explanation identifying the annuity as a resource or asset must be sent to TPR.
This policy is effective February 1, 2008. This policy applies to any applications taken on or after this date in the approved PACE service area.
If you have any questions regarding this information, please contact your Medicaid Program Representative. For any issues that are not able to be handled through that venue, Mrs. Angela Floyd, Assistant Director for Recipient and Provider Services, will be your point of contact and can be reached at (919) 855-4000.
Dr. William W. Lawrence, Jr., M.D.
[This material was written by Charlotte Gibbons, Policy Consultant, Medicaid Eligibility Unit.]
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.