8320 Financial Eligibility

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.

1. 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).
2. 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 online 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).

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.