16 Del. Admin. Code § 20000-20775

Current through Register Vol. 28, No. 7, January 1, 2025

Section 20000-20775 - Program Of All- Inclusive Care For The Elderly (Pace)

Program of All-Inclusive Care for the Elderly (PACE) is a benefit that features a comprehensive service delivery system and integrated Medicare and Medicaid financing. The PACE model was developed to address the needs of long-term care clients, providers, and payers. For most participants, the comprehensive service package permits them to continue living at home, while receiving services rather than be institutionalized. Through PACE, organizations are able to deliver all services covered by PACE which participants need rather than only those services reimbursable under the Medicare and Medicaid fee-for-service systems.

This policy applies to all individuals that elect to receive their long-term care services through the PACE and request Medicaid payment for these services.

1. Participation in PACE is voluntary.

2. A PACE participant's eligibility will be determined under rules applying to institutional groups.

See DSSM 20000

3. Spousal Impoverishment rules apply if individual is married and spouse continues to reside in the community and does not receive long-term care Medicaid.

See DSSM 20900

4. Post eligibility treatment of income does not apply to PACE participants.

Participants will not be required to contribute to the cost of their care received from the PACE Organization.

5. To be initially eligible for enrollment in PACE the individual must:

.	Be at least 55 years old;

.	Meet the State's eligibility criteria for nursing home level of care;

.	Reside in the PACE approved service area;

.	Be living in the community;

.	Be able to be maintained safely in the community based setting at the time of enrollment with the assistance of the PACE;

.	Not be enrolled in a Medicaid/Medicare managed care program; and

.	Voluntarily agree to enroll in PACE and receive services exclusively through the PACE organization and their subcontractors.

6. The Pre-Admission Screening process will be followed when determining medical eligibility.

See DSSM 20102

7. An individual's enrollment effective date is the first day of the month following the month the PACE Organization receives the signed enrollment form.

8. There is no retroactive coverage for PACE.

9. Nursing facility services are part of the PACE benefit package.

Nursing facility admission that occurs post-PACE enrollment will not have a negative impact on the individual's continued eligibility.

The PACE Organization must notify the Division of Medicaid and Medical Assistance (DMMA) eligibility worker of the individual's placement in the nursing facility.

The PACE individual is not required to contribute to the cost of their care while in a nursing facility.

10. An individual's enrollment continues until the enrollee's death unless either of the following actions occurs:

a. The enrollee voluntarily disenrolls for any reason.

b. The enrollee is involuntarily disenrolled for any of the following reasons:

.	No longer meets the nursing facility level of care requirement and there is no indication that the participant is expected to need nursing facility level of care within the next 6 months;

.	Moves out of the PACE service delivery area;

.	Has decision making capacity and is consistently non-compliant with the individual plan of care and enrollment agreement, which may impact the participant's health and welfare in the community;

.	Engages in disruptive, threatening or non-compliant behavior which jeopardizes his or her safety or the safety of others;

.	Is out of the service area for more than 30 consecutive days (unless arrangements have been made in advance with the PACE Organization); or

.	Is enrolled in a PACE Organization that cannot provide the required services due to loss of licensure or contracts with outside providers, and/or the PACE program agreement is not renewed.

11. An individual may be administratively disenrolled if the participant is admitted to a hospital prior to the effective date of PACE enrollment.

12. Medicaid appeal requirements apply to PACE cases. See DSSM 5000

16 Del. Admin. Code § 20000-20775

16 DE Reg. 532 (11/01/12)