Adult Medicaid Manual MA-2275 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

III. PACE AND MEDICAID REFERRAL PROCEDURES

The DMA-5106, PACE/Medicaid Referral, is used for communication, notification, and documentation between Medicaid and the PACE organization. Page 1 is completed by the county and page 2 is completed by the PACE organization. Page 1 contains an authorization for release of information to Medicaid and page 2 includes an authorization for release of information to PACE. The authorizations for release of information must be signed by the applicant/recipient and is valid for one year.

A. Medicaid A/R Requests PACE Services

Individuals requesting PACE enrollment information should be referred to the PACE organization located in the individual’s service area. Also, complete page 1 of the DMA-5106, PACE/Medicaid Referral, and send to the PACE organization.

B. Processing PACE Referrals

The PACE organization will complete page 2 of the DMA-5106, PACE/Medicaid Referral, when an individual requests PACE enrollment and indicates a need for financial/medical assistance. PACE may also assist individuals by completing a Medicaid mail-in application. The date of the application is the date a complete application is received by the county dss.

The PACE organization will also complete page 2 of the DMA-5106, PACE/Medicaid Referral, when an individual has signed the PACE Enrollment Agreement and is enrolled in PACE.