NC DEPARTMENT OF HEALTH AND HUMAN SERVICES EIS MANUAL

ELIGIBILITY INFORMATION SYSTEM EIS 2500

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PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)

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EIS 2500 – PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)

I. INTRODUCTION

II. PACE POLICY

III. PACE AUTHORIZATION

IV. PACE AUTHORIZATION SCREEN INSTRUCTIONS ENTRY VIA THE DSS-8125

V. PACE END DATE SCREEN INSTRUCTIONS

VI. PACE/MANAGED CARE HISTORY INQUIRY

VII. PACE PROVIDER DATA INQUIRY

VIII. CASE DATA INQUIRY

IX. INDIVIDUAL AND MEDICAID ELIGIBILITY HISTORY INQUIRY

X. COUNTY TRANSFERS

xI. ID CARDS FOR PACE RECIPIENTS

XiI. PACE NOTICES/CODES

XIiI. PACE COUNTIES AND PROVIDERS

XIV. PACE PATIENT MONTHLY LIABILITY (PML)

XV. PACE CORRECTIONS

REISSUED 08/01/11 – CHANGE NO. 01-12

XVI. PACE REPORTS

EIS 2500 – PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)

REVISED 01/01/09 – CHANGE NO. 02-09

I. INTRODUCTION

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 participants receive a comprehensive service package which permits them to live at home while receiving services. This prevents institutionalization. The PACE organization must provide all Medicaid covered services, in addition to other services determined necessary by PACE for the individual beneficiary. The PACE program becomes the sole source of services for Medicaid and/or Medicaid/Medicare eligible enrollees.

The PACE program is a fully capitated managed care benefit. The PACE organization assumes full financial risk for participants’ care without limits on amount, duration, or scope of services. CMS establishes and pays the Medicare capitation and each State establishes and pays the Medicaid capitation. When the enrollee receives Medicaid and Medicare, the PACE organization receives a Medicaid capitation payment and a Medicare capitation payment.

The PACE organizations work closely with county department of social service agencies to ensure timely processing of the capitated payment.

II. PACE POLICY

A. To qualify for PACE an individual must:

1. Be living in the approved geographic area of the PACE organization;

2. Be at least 55 years old or older;

3. Be determined by the PACE organization to be able to be cared for safely in the community;

4. Meet the State’s eligibility criteria for nursing home level of care.

B. To be authorized for PACE services, the a/r must be enrolled in the PACE program and be eligible in the Aged, Blind, and Disabled (MAABD) aid program/categories, EXCEPT:

Individuals in Family and Children’s Medicaid aid program/categories must be deleted from that coverage and be determined eligible under MAABD in order to be eligible for PACE services.

C. PACE authorization is always the first day of a month.

D. The PACE end date is always the last day of a month.

REISSUED 01/01/09 – CHANGE NO. 02-09

II. (CONT’D)

E. If eligible at 100% of poverty, an individual will have a zero patient monthly liability. If over 100% of poverty, an individual will have a patient monthly liability as defined by policy.

F. The certification period for PACE cannot exceed six months.

G. Three new living arrangement codes have been created for PACE as follows:

14 PACE Private Living Arrangement

15 PACE Living with SSI Recipient(s)

54 PACE Living in Nursing Facility

III. PACE AUTHORIZATION

A. DSS-8125 Mandatory Fields

The PACE capitated payment is authorized by completing the DSS-8125,which includes the PACE authorization screens. The following must be entered on the DSS-8125 when authorizing PACE:

1. PACE Exempt Number 9999906

2. PACE Facility Code

3. PML amount even if the amount is zero

4. Living Arrangement Code (14, 15, or 54)

B. Approvals

1. Use the retroactive Medicaid fields on the DSS-8125 to approve retroactive Medicaid (3 months prior to application month).

Example: Mr. Jones is enrolled with PACE effective 3/1/08 and has a medical need for January and February 2008. Using the DSS-8125 authorize PACE effective 4/1/08 and authorize January and February (non-PACE) retroactive months in the retroactive Medicaid fields.

2. Key the DSS-8125 to approve ongoing PACE.

a. Authorize the PACE payment effective the ongoing month. Enter the ongoing month in the Medicaid effective date field. Key the certification period with the begin date of the first month of Medicaid eligibility. Use the notice text fields on the DSS - 8125 to inform the applicant he/she is eligible for the prior months of Medicaid or send a manual DSS-8108. Retroactive Medicaid (3 months prior to application month) should be keyed in the retro-active fields.

REVISED 10/01/09 – CHANGE NO. 01-10

III. B. (CONT’D)

b. Use the appropriate PACE living arrangement code, the PACE facility code, the Carolina Access Exempt Number 9999906, and apply the correct Patient Monthly Liability (PML).

Example: Ms. Cooper in agency to apply for ongoing Medicaid on 03/05/08. You verify that Ms. Cooper is PACE enrolled as of 03/01/08. Key a DSS-8125 to approve ongoing PACE effective 4/1/08 using the appropriate PACE living arrangement code (14, 15, 54). Enter a certification from date of 03/01/08 and a certification through date of 08/31/08.

3. The following workday, key PML screen(s) for the non-PACE months of Medicaid eligibility. Remember to use the non-PACE living arrangement codes. If the recipient is in a nursing facility, remember to use the facility code for that nursing facility and not the PACE facility code. Indicate “Y” in the ID card field to produce a Medicaid card.

C. Late Redeterminations

1. Individual is Already Authorized for PACE

To reauthorize PACE for a review completed after pull night, key a DSS-8125 with the appropriate PACE information (living arrangement, facility code, CA exempt number 9999906, and PML). Enter the ongoing month as the Medicaid effective date. Because the review was completed after the processing deadline (fourth work night from the end of the month), there was no Medicaid eligibility on file for the following month, which prevented a timely PACE capitated payment by MMIS; however, the capitated payment will be paid retroactively the following month. It is extremely important that counties key the review by the processing deadline to prevent the need for retroactive payments.

Example: On March 28, 2008 (after the processing deadline) you process a review that is currently authorized and certified for PACE through March 31,2008. No April capitated payment will be issued on processing deadline (fourth work night from the end of the month) in March but a retroactive capitated payment will be issued for the month of April in May.

REVISED 10/01/09 – CHANGE NO. 01-10

2. Individual to be Authorized for PACE at Review

To authorize PACE for a review completed after the processing deadline, key the DSS-8125 with the appropriate PACE information (living arrangement, facility code, CA exempt number 9999906, and PML). Enter a Medicaid effective date that is the first month of PACE eligibility. This must be the ongoing month. Use the notice text fields on the DSS-8125 to inform the applicant he/she is eligible for the prior months of Medicaid or send a manual notice.

IV. PACE AUTHORIZATION SCREEN INSTRUCTIONS ENTRY VIA THE DSS-8125

The following workday, key a PML screen for the non-PACE month of Medicaid eligibility. Remember to use the non-PACE living arrangement codes. If the recipient is in a nursing facility, remember to use the facility code for that nursing facility and not the PACE facility code. Indicate “Y” in the ID card field to produce a Medicaid card.

Example: On March 28, 2008 (after the processing deadline) you process a review that is currently certified through March 31, 2008. Key a DSS-8125 to authorize PACE effective 05/01/08. Enter a certification period of 04/01/08 thru 09/30/08 and enter all PACE information (living arrangement, facility code, CA exempt number 9999906, and PML). The next day, enter Medicaid eligibility for 04/01/08 thru 04/30/08 on the PML screen.

A. General Information

1. Once the DSS-8125 is completed and is error-free, EIS will automatically display the PACE Authorization Screen. You must complete the Authorization Screen in order to process the DSS-8125.

2. If you enter the Authorization Screen through the DSS-8125 process and you PF2 out of the Authorization Screen without completing the enrollment, the DSS-8125 will be placed on hold.

For application approvals, the DSS-8124 is also placed on hold. The status on the DSS-8124 and on the Application Data (AD) Inquiry Screen will be “HD”.

3. If the authorization is not resolved that day, the following message will appear on the Error and Attention Report the next workday: FORM HELD – PACE ENROLLMENT NOT CREATED.

ISSUED 10/01/08 – CHANGE NO. 01-09

IV. A. (CONT’D)

4. To process the DSS-8125 after it was placed on hold using the PF2 key:

a. Complete a re-entry on the form and press ENTER.

b. EIS will again display the PACE Authorization Screen.

c. Complete the authorization to process the DSS-8125.

5. You may not place the Authorization Screen on hold. You must always start over if you use the PF2 key to get out of the authorization process.

B. Screen Instructions – Initial PACE Authorization

Use the following instructions when accessing the PACE Authorization Screen through the DSS-8125 process:

1. To authorize the PACE capitated payment, enter the facility code, PML, living arrangement code, and 9999906 (in the Carolina Access Provider/Exempt Number field) on the DSS-8125.

2. When the DSS-8125 is error free, EIS will automatically display the PACE Authorization Screen.

ISSUED 10/01/08 – CHANGE NO. 01-09

IV. B. (CONT’D)

3. Key S in the SELECT field on the PACE Authorization Screen and press ENTER.

4. When you press ENTER, EIS will display the PACE eligible recipient. The following screen will be displayed:

REVISED 10/01/09 – CHANGE NO. 01-10

IV. B. (CONT’D)

5. At this point, you have the following options:

a. To discontinue the authorization process and return to the EIS Menu, press PF2. Remember that the DSS-8125 will be put on hold.

b. To select the PACE provider chosen by the recipient, key S in the SELECT field beside the appropriate provider and press ENTER. (Note: If additional providers are enrolled, you will see more listed).

c. EIS will display a blank DSS-8125.

d. The PACE authorization will be created by EIS in the nightly update.

e. Authorization will be the first day of the ongoing month (NOTE: PACE authorizations for all recipients must be keyed by the fourth work day from the end of the month).

C. PACE Authorization Errors

If you authorized someone for PACE in error and you discover this before the DSS-8125 form processes in the nightly update, complete a re-entry on the DSS-8125 and go through the process again deleting all PACE related codes or delete the form altogether.

D. Screen Instructions – Redeterminations

1. Use the following instructions when completing a redetermination of eligibility on a PACE case and you want to continue authorization of the PACE capitated payment:

a. Update the PACE PML, if necessary.

b. When the DSS-8125 is error free, EIS will automatically display the PACE Authorization Screen.

REISSUED 10/01/09 – CHANGE NO. 01-10

IV. D. (CONT’D)

c. Key S in the SELECT field on the PACE Authorization Screen and press ENTER.

d. When you press ENTER, you will get the message “CASE IS PACE AUTHORIZED 6700850 DO YOU WISH TO UNAUTHORIZE?”

REISSUED 10/01/09 – CHANGE NO. 01-10

IV. D. 1d. (CONT’D)

e. Key N in the space to the far right of this message (your cursor will automatically move to this field) to continue PACE authorization.

f. Press ENTER and you will be taken back to the EIS Menu and the following message will display: “PACE AUTHORIZATION PROCESS EXITED.”

2. Use the following instructions when completing a redetermination of eligibility on a PACE case and you want to end the PACE payment:

a. Remove the PACE facility code from the DSS-8125.

REVISED 10/01/09 – CHANGE NO. 01-10

IV. B. 2. (CONT’D)

b. Update the PML as necessary.

c. Use the appropriate notice code (See EIS 4000 Codes Appendix, Appendix B).

d. Change the living arrangement code from a PACE code to a non-PACE code.

e. Change the CA exempt number from 9999906 to a valid PCP number or another exempt number.

f. EIS will automatically end date the PACE payment in the nightly update.

V. PACE END DATE SCREEN INSTRUCTIONS

A. Age Correction on Name Change Screen

If you discover that a person is under age 55, you will first need to disenroll the individual from PACE via the DSS-8125. The following day, change the date of birth using the Name Change Screen.

B. EIS end dates the PACE payment when the following updates are completed via the DSS-8125:

1. PACE facility code is deleted, and

2. PML is deleted, and

3. Living arrangement code is changed from 14, 15, or 54, and

4. The CA exempt number is changed to something other than 9999906,

5. Aid program/category is changed from MAABD (to MQB for example), or

6. A case termination date is entered.

C. EIS will automatically end date the PACE capitation payment and the following will occur in the EIS nightly update:

1. Adequate Change Code – The PACE end date will be set to the current calendar end of month. However, if this action occurs after the processing deadline, (4th workday from the end of the month) the PACE end date will be effective the next calendar end of month.

2. Timely Change Code – If the timely action processes by the processing deadline, the PACE end date will be the current end of month. If after the processing deadline, it will be effective the next calendar end of month.

ISSUED 10/01/08 – CHANGE NO. 01-09

V. C. (CONT’D)

3. The PACE indicator on the Case and Individual databases will be automatically spaced out.

4. The last change date on the Case and Individual databases will be updated.

VI. PACE/MANAGED CARE HISTORY INQUIRY

A. To view a PACE segment, enter MI in the SELECTION field and the individual ID in the KEY field and press ENTER.

NOTE: You may enter the MI SELECTION from any screen in EIS that displays the SELECTION field.

B. The PACE/Managed Care History Inquiry Screen will be displayed:

C. EIS will move the cursor to the "Selection" field at the bottom of the screen. To view a PACE segment for a subsequent individual, you may key the new individual ID number in the KEY field.

VII. PACE PROVIDER DATA INQUIRY

A. To view the information for a PACE provider or exempt number, key MP in the SELECTION field and press ENTER.

B. The Managed Care Provider Database Screen will be displayed:

ISSUED 10/01/08 – CHANGE NO. 01-09

VII. B (CONT’D)

C. Key the PROVIDER NUMBER and press enter and the MANAGED CARE Provider information will be displayed.

VIII. CASE DATA INQUIRY

A. If a recipient is authorized for PACE, the Case Data (CD) screen will display the PACE Indicator “Y” beside the EPICS CLAIM INDICATOR.

B. If a recipient is not authorized for PACE, the Case Data (CD) screen will display a blank space beside the PACE Indicator.

IX. INDIVIDUAL AND MEDICAID ELIGIBILITY HISTORY INQUIRY

A. ID Inquiry

The following is an example of an ID screen for an individual who is currently authorized for PACE. Note the PACE Indicator = Y.

REVISED 10/01/09 – CHANGE NO. 01-10

IX. (CONT’D)

B. IE Inquiry

The following is an example of a Medicaid Eligibility History Screen for an individual who is currently authorized for PACE.

X. COUNTY TRANSFERS

When a PACE recipient moves to another county, follow instructions in EIS 3500, County Transfers.

A. Move to Another PACE County with Same Provider

If the recipient moves to another PACE county and the new county has the same PACE provider as the old county, the EIS will retain the PACE provider number and the PACE authorization will continue.

REISSUED 10/01/09 – CHANGE NO. 01-10

X. A. (CONT’D)

Example: Recipient is authorized for PACE in New Hanover County with Elderhaus as their provider. Recipient moves to Brunswick County where Elderhaus is also a provider. The EIS retains the Elderhaus provider number.

B. Move to Non-PACE County

If the recipient moves to a non-PACE county, EIS will automatically end PACE effective the last workday of the next calendar month. Everything on the individual and case will be changed to reflect non-PACE related codes and the managed care will display an end date.

Example: On 02/29/08, EIS processes a county transfer from New Hanover to Hoke County. The transfer is effective 04/01/08. Beginning 04/01/08, Hoke County is responsible for the individual. New Hanover is no longer responsible. EIS will enter a PACE disenrollment date of 03/31/08.

When the county transfer processes on the last day of the month, EIS will:

1. End date the PACE authorization effective the last day of the next calendar month.

2. Change the Carolina Access exempt number from 9999906 to county transfer exempt number 9900029.

3. Delete the PACE facility code.

4. Change the living arrangement code (14 to 10, 15 to 13, and 54 to 50).

C. Move from Pace County to PACE County with Different Provider

If a current PACE recipient moves to another PACE county with a different provider, EIS will automatically end PACE effective the last workday of the next calendar month.

Once the county transfer processes, the receiving county will need

to make the case PACE by entering all appropriate PACE codes and select the new PACE provider using the PACE Authorization Screen.

REISSUED 03/01/10 – CHANGE NO. 03-10

xI. ID CARDS FOR PACE RECIPIENTS

PACE recipients are not issued Medicaid cards. A PACE enrollment card will be issued by the PACE provider. If the PACE recipient is enrolled in Medicare, an identification sticker will be placed on the Medicare card by the PACE provider.

When PACE ends and the recipient remains Medicaid eligible, EIS will automatically issue a Medicaid card.

XiI. PACE NOTICES/CODES

A. Two new change codes have been created for PACE. They are timely code 3P, used for involuntary disenrollments and adequate code 8P, used for voluntary disenrollments.

1. Notice for new timely code 3P states, “You have been involuntarily disenrolled from the PACE program. Medicaid authorization for the PACE payment ends effective ___.” (Since this is timely, the end date is based on when the 10 workdays are up and based on whether it processes before or after the processing deadline). Notice gives 10 workdays to appeal. Manual section reference is MA-2275 of the Aged, Blind and Disabled Medicaid Manual.

2. Notice for new adequate code 8P states, “You have voluntarily disenrolled from the PACE program. Medicaid authorization for the PACE payment ends effective ___.” (Since this is adequate, the end date is the end of the current calendar month as long as it is on or before the processing deadline when keyed. If keyed after the processing deadline, the end date is the end of the following month). Manual section reference is MA-2275 of the Aged, Blind and Disabled Medicaid Manual

REVISED 03/01/10 – CHANGE NO. 03-10

XII. (CONT’D)

B. The following text will print on notices to PACE recipients and the PACE organization based upon the type of action taken:

1. Approvals, reviews, changes, etc. (DSS-8108) includes text: “PACE/Medicaid application approved.” This is only printed on the notice if the person is authorized for PACE. “(Date) is the PACE effective date. $______ is your monthly liability. You must pay your liability to the nursing home or the PACE center each month.” Manual section reference is MA-2304 of the Aged, Blind, and Disabled Medicaid Manual.

2. You may use codes 02 and 50 with notice text giving information on PACE.

3. A copy of the notice is generated to Elderhaus if the PACE agency name and address is entered in the authorized representative name and address fields on the DSS-8125.

4. A notice is generated to the recipient when PACE ends. (Termination of Medicaid, timely and adequate, change to MQB, change to deductible, change to another Carolina Access code other than 9999906, change to non-PACE living arrangement code, etc.) Notice text: “Medicaid authorization for PACE payment ends effective _________.”

5. An adequate notice is generated to the recipient when a county transfer processes at the end of the month and the new county is not a PACE county. The notice states “You have moved out of the PACE area. Medicaid authorization for the PACE payment ends effective ___.” (Last calendar day of the end of the following month). Manual section reference is MA-2275 of the Aged, Blind, and Disabled Medicaid Manual.

C. Being age 55 or older is a requirement to be enrolled in PACE. No automated notice is produced when the date of birth is changed by the Name Change screen or the SDX. Therefore, it is imperative that county workers send a manual timely notice to a recipient when they become aware that their age is less than 55.

REVISED 08/01/11 – CHANGE NO. 01-11

XII. C. (CONT’D)

For example, if SDX enters a date of birth resulting in an age less than 55 and it is verified to be the correct date of birth, send a manual timely notice to the recipient notifying them that PACE is ending.

D. Three new codes have been created for PACE recipients who are sanctioned due to transfer of assets. They are denial code P1, and termination codes 2P (timely) and 7P (adequate).

Send a manual DSS-8109 to the recipient when the application is being denied or withdrawn due to transfer of assets (Notice code P1). Use notification text, “Due to asset transfers, you are ineligible for Medicaid to pay for PACE services. You are also ineligible for other Medicaid services because you are enrolled in the PACE program.”

Send a manual DSS-8109 to the recipient when the ongoing case is being terminated due to transfer of assets (Timely code 2P and adequate code 7P). Use notification text, “Due to asset transfers you are ineligible for Medicaid to pay for PACE services. You are also ineligible for other Medicaid services because you are enrolled in the PACE Program.”

E. The new adequate transfer code 8J is to be used when completing a program transfer from MQB to PACE authorized MAABD. This code will be valid for MAABD only.

Notice for new transfer code 8J states, “You are eligible for PACE effective _______.” Manual Section reference is MA-2275 of the Aged, Blind, and Disabled Medicaid Manual.

F. The new adequate change code 8K is to be used when transferring a case to PACE. Notice for adequate change code 8K states, “You are eligible for PACE effective _______.” Manual Section reference is MA-2275 of the Aged, Blind, and Disabled Medicaid Manual.

XIiI. PACE COUNTIES AND PROVIDERS

Brunswick, New Hanover, Alamance, Caswell, Orange, Durham, Cumberland, Moore, Robeson, Hoke, Harnett, Guilford, and Rockingham counties are participating in PACE. Current PACE providers are: Elderhaus, Inc. Piedmont Health SeniorCare, LIFE St. Joseph of the Pines, and PACE of the Triad.

REVISED 08/01/11 – CHANGE NO. 01-12

XIII. (CONT’D)

Individuals requesting PACE enrollment information should be referred to one of these facilities at the following addresses:

Piedmont Health SeniorCare

Providing All-Inclusive Care for the Elderly

1214 Vaughn Road

Burlington, NC 27217

phone: 336-532-0000

fax: 336-532-0001

(Serving: Alamance and Caswell Counties)

Elderhaus PACE

The Alpher Center

1950 Amphitheater Drive

Wilmington NC 28401

(910) 343-8209

(Serving: Brunswick and New Hanover Counties)

Life St. Joseph of the Pines, Inc.

100 Gossman Drive

Ste B

Southern Pines, NC 28387

(910) 246-3105

(Serving: Cumberland, Moore, Robeson, Hoke, and Harnett Counties)

PACE of the Triad

1471 E. Cone Blvd

Greensboro, NC 27405

(336) 550-4040

(Serving: Guilford and Rockingham Counties)

The PACE providers are responsible for enrolling individuals in the PACE program and referring them to the local DSS to determine Medicaid eligibility. Upon receipt of the referral from the PACE provider, DSS will complete a Medicaid eligibility determination and, if eligible, authorize the PACE payment in the EIS system.

XIV. PACE PATIENT MONTHLY LIABILITY (PML)

All PACE recipients will have a Patient Monthly Liability (PML), even if the amount is zero. DMA makes a prospective monthly payment to the PACE organization of a capitation amount for each eligible participant. Therefore, if the PML must be changed, it must be changed for a future month on the DSS-8125 as it cannot be decreased using the P Screen.

Contact the Division of Medical Assistance, Medicaid Eligibility Unit, at (919) 855-4000 when a correction is needed on a PACE case.

XV. PACE CORRECTIONS

Contact the Division of Medical Assistance, Medicaid Eligibility Unit, at (919) 855-4000 when a correction is needed on a PACE case.

REISSUED 08/01/11 – CHANGE NO. 01-12

XVI. PACE REPORTS

A. PACE Enrolled Recipients Report

A report of PACE recipients in XPTR is titled DHRWBD PACE ENROLLED RECIPIENTS. This report is kept in XPTR for 365 days. It is run once per month on pull night and is sorted by county and district number and displays the following information:

1. PACE recipient name

2. PACE recipient ID number

3. EIS case ID number

4. County name and number

5. District number

6. PACE agency providing services

B. 5016 Forms Printed Report

A list of 5016 forms printed daily is titled DHREJA PACE PML REGISTER. This report lists all 5016s that were sent to the PACE facility to notify them of the patient’s monthly liability.

C. PACE County Transfer Notices Report

A report of PACE county transfer cases in XPTR is titled DHRWBD PACE CNTY XFER NOTICE. This report is kept in XPTR for 1098 days and is sorted by county name and number and displays the following information: