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

V. POLICY PRINCIPLES

A. General Policy Rules

To be authorized for Medicaid coverage of PACE services, the a/r must

1. Be enrolled in the PACE program.

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2. Be eligible for Medicaid in the Aged, Blind, and Disabled (MAABD) aid program/categories.

3. Be certified by the Division of Medical Assistance as meeting nursing home level of care (FL-2). Preadmission Screening and Annual Resident Review (PASAAR) requirements are not applicable to PACE.

4. Be at least 55 years old or older.

5. Be living in the approved geographic area of the PACE organization.

B. Budget Unit

Effective the month the PACE Enrollment Agreement is signed, the budget unit is one. This applies even if a couple is enrolled in PACE.

C. Living Arrangement Codes

1. The following three living arrangement codes must be used for PACE:

a. 14 PACE Private Living Arrangement

b. 15 PACE Living with SSI Recipient(s)

c. 54 PACE Living in Nursing Facility

2. Refer to EIS 4000 – Codes Appendix.

D. Retroactive Eligibility/Eligibility Prior to PACE Enrollment

1. There is retroactive coverage for regular Medicaid services if Medicaid eligibility requirements are met in the retroactive period or before PACE enrollment is effective.

2. There is no retroactive coverage for PACE services. For all months prior to the month PACE is authorized in EIS, the applicant/recipient is budgeted PLA and should be budgeted with all persons who are financially responsible for him.

E. Continuous Period of Institutionalization (CPI)

The CPI begins the first day of the month the applicant/recipient signs the PACE Enrollment Agreement with the PACE organization.

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F. Community Spouse Income Protection (Spouse in PLA)

Community Spouse Income Protection applies to PACE applicants/recipients. Follow policy in MA-2270, Long Term Care Need and Budgeting. Exception: The CPI begins the first day of the month the applicant/recipient signs the PACE Enrollment Agreement with the PACE organization.

G. Dependent Family Member Allowance

Dependent family member allowance applies to PACE applicants/recipients. Follow policy in MA-2270, Long Term Care Need and Budgeting.

H. Reserve

1. The reserve limit is for a b.u. of one in all PACE cases. Refer to MA-2230, Financial Resources, for instructions regarding reserve requirements and procedures.

2. Spousal resource protection applies in PACE. The non-institutionalized spouse is entitled to resource protection. Resource protection begins the first day of the month the PACE Enrollment Agreement is signed. Refer to MA-2231, Community Spouse Resource Protection.

I. Transfer of Assets

Transfer of assets sanctions apply to PACE. Refer to MA-2240, Transfer of Assets, and XI.C. below.

J. Estate Recovery

PACE applicants/recipients are subject to estate recovery.

K. Managed Care

PACE individuals are exempt from Carolina Access enrollment. Use special exempt code 9999906. Refer to procedures in MA-2425, Community Care of North Carolina/Carolina Access.

L. Medicare Buy-In

Medicaid-eligible PACE recipients eligible for Medicare qualify for Medicare enrollment and buy-in. Follow procedures in MA-2410, Medicare Enrollment and Buy-In.

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M. Medicare Part D

The PACE organization is also the Medicare Part D prescription drug plan provider. PACE recipients will enroll with PACE for Medicare Part D prescription drug plan. Part D enrollment is completed by the PACE organization.