8320 Financial
Eligibility - Financial eligibility for PACE participants is
based on the living arrangement of the individual. Beginning with the
date of enrollment and continuing while the individual remains in a non-institutional
living arrangement, all HCBS eligibility rules included in sections 8220 - 8271
are applicable, including the Spousal Impoverishment Provisions of 8244 except for the prior medical provisions
of 8232 (see 8330
below). The initial resource test (see 8241)
is also applicable beginning the month an individual found in need of
PACE and chooses PACE. For PACE participants living in an institution,
the LTC rules of 8120 - 8171
are applicable, including Spousal Impoverishment provisions of 8144.
Persons who have transferred property without adequate consideration are
not eligible for LTC services, including PACE, as determined under the
provisions of 5720.
8320.1 Participant
Obligation - PACE enrollees must participate in the cost of
care if countable income exceeds the applicable standards. The share of
cost for PACE is called the Participant Obligation.
- For persons living in the community, the Participant Obligation
is determined using HCBS rules of 8250
(Countable Income), 8260 (Income
Standard) and 8270 (Financial Eligibility).
- For persons living in an institution, the LTC rules of 8150
(Countable Income), 8160 (Income
Standard) and 8170 (Financial Eligibility)
are applicable when determining the Participant Obligation. This includes
the reduced protected income limit if the stay will exceed the temporary
stay guidelines of 8113. A CARE assessment
is also required per 8114. Information
regarding the CARE is obtained using the ES-3164.
The individual is also subject to the 300% special income and cost
of care tests described in 7430(4),
8160(3) and 8260(3).
- In either living arrangement, the PACE provider is responsible
for covering all medical needs of the PACE participant. The PACE team
is responsible for determining if items or services are medically
necessary. This determination is made without strict compliance to
the Medicaid and Medicare benefit limitations and all medically necessary
services and items are provided by the PACE. The PACE participant
will not be required to purchase any medically necessary services.
Because the PACE has already made a medical necessity determination,
there are no deductions from the participant obligation for non-covered
medical expenses incurred within the eligibility period.
The client obligation and patient liability provisions of 8172.1(2)(b)
and 8270.1(2)(b) are not applicable.
The only allowable deductions from the participant obligation are
health insurance and due & owing expenses. If the client chooses
to purchase services or items that are determined not to be medically
necessary by the PACE, the individual may still be responsible for
the cost of the items as determined by the PACE. However, the expense
cannot be used to reduce the participant obligation.
8320.2 Processing
- Persons enrolling in PACE will be identified through a designated
code combination from KEES. The MMIS uses this coding, along with the
county of residence, to establish PACE enrollment and payment.
Medical cards are suppressed for PACE enrollees, but the PACE entity
issues a separate PACE card. Beneficiaries who receive a medical card
in error are instructed to return the card to the eligibility worker.