Section 471-37-002 - PARTICIPANT ELIGIBILITY002.01 Eligibility Criteria Participation in PACE is voluntary. PACE eligibility criteria include the following:
1. Be 55 years of age or older;2. Meet the nursing facility level of care (NF LOC) criteria (See 471 NAC 12);3. Live in the service area of the PACE organization; and4. Be able to safely live in a community setting, at the time of enrollment, with PACE services.002.02 Eligibility Determinations The PACE organization shall be responsible for determining eligibility based on the criteria set forth in section 37-002.01 of this chapter.
002.03 Denial of Eligibility A potential participant shall be denied enrollment if he/she does not meet the eligibility criteria as set forth in section 37-002.01 of this chapter.
37-002.03ANursing Facility Level of Care Not Met: If a potential participant does not meet NF LOC, the SAA will notify the PACE organization, and the potential participant shall receive a notice of adverse action. Upon receipt of adverse action, potential participants may appeal using the SAA's appeal process (See 465 NAC 2-001.02).37-002.03BUnsafe: If a potential participant is determined to be unable to safely live in a community setting, the PACE organization shall: 1. Notify the potential participant in writing of the reason for the denial;2. Refer the potential participant to alternative services, as appropriate;3. Maintain supporting documentation of the reason for the denial; and4. Notify CMS and the SAA and make the documentation available for review. 37-002.03B1Appeal Process: Upon receipt of the PACE organization's written denial based on the inability to safely live in the community, potential participants have the right to appeal using the SAA's appeal process (465 NAC 2-001).37-002.03CAppeal Process for Medicare-only Beneficiaries: Medicare does not have an appeal process that permits challenges of enrollment denials for Medicare-only beneficiaries within PACE. Medicare-only eligible participants, as well as private pay participants, must use the appeals process provided by the SAA (71 Fed. Reg. 71244, 71303, 71312, 71317 (Dec. 8, 2006)).002.04 Annual Nursing Facility Level of Care Recertification A PACE participant's NF LOC shall be documented by the PACE organization and recertified by the SAA within 12 months of each previous recertification.
002.05 Waiver of Annual Nursing Facility Level of Care Recertification The annual recertification requirement may be permanently waived by the SAA at the PACE organization's request. The PACE organization shall provide to the SAA the participant's diagnosis, medical record and plan of care for review for waiver and will be notified of the SAA's determination.
002.06 Deemed Continued Eligibility If a participant no longer meets NF LOC at the time of annual recertification, he/she may be allowed to continue eligibility until the next annual recertification upon the request of the PACE organization. The PACE organization shall provide information to the SAA to be reviewed under the following criteria:
1. The participant can reasonably be expected to meet NF LOC eligibility again within six months in the absence of continued coverage under the program; and2. The participant's medical record and plan of care support continued eligibility.471 Neb. Admin. Code, ch. 37, § 002