Or. Admin. Code § 411-045-0050 - Enrollment
(1) ELIGIBILITY: To
be eligible to enroll in a PACE program a person must:
(a) Reside in the PACE program's approved
service area upon enrollment;
(b)
Be 55 years of age or older;
(c)
Be able to be maintained in a community-based setting at the time of enrollment
without jeopardizing his or her health or safety or the health and safety of
others;
(d) Be determined by the
local Department/AAA agency to need the level of care required under Oregon's
State Medicaid Plan for coverage of nursing facility services in accordance
with the rules in OAR chapter 411, division 15 (Long-Term Care Service
Priorities for Individuals Served);
(e) Be Medicaid eligible or be willing to pay
private fees; and
(f) Be willing
to abide by the provision that requires enrollees to receive all health and
long term care services exclusively from the PACE program and its contracted or
referred providers.
(2)
The criteria for determining that an individual is unable to live safely in the
community and thereby may be denied enrollment is as follows:
(a) The individual demonstrates imminent
danger to self or others in accordance with the definition in OAR
411-015-0005;
(b) There is evidence in the individual's
clinical record that shows he or she has been repeatedly placed in appropriate
care settings and, despite medically appropriate treatment, placement has
resulted in frequent hospitalizations or failed placements;
(c) At the time of application, the
individual is determined to be eligible for enhanced care services or long term
care at Oregon State Hospital by either the enhanced care Services Coordinator
or the OSH Gero-Psychiatric Outreach Team;
(d) At the time of application, the
individual has a physician documented condition that meets the criteria for
Medicare skilled care and does not appear to be able to be discharged to the
community within the next 30 days; or
(e) At the time of application, the applicant
lives in his or her own home and wishes to remain there but requires 24-hour
care to remain safely in their home.
(3) If either the PACE program or the local
Department/AAA case manager has concerns about the safety of a potential
enrollee, a case conference may be convened to review the case with outside
consultants as needed for further evaluation.
(4) ENROLLMENT/SCREENING AND INTAKE:
(a) Department/AAA staff processes an
application for Medicaid services and determines the level of care required
under Oregon's State Medicaid Plan for coverage of nursing facility services.
Department/AAA staff follows the appropriate PACE enrollment protocols as
outlined in the Department/AAA Policy Manuals.
(b) Department/AAA staff conducts initial
screening and intake, including providing assistance in completing the
application and obtaining relevant information.
(c) The Department provides for the
calculation of any applicable spend-down liability and for post-eligibility
treatment of income for Medicaid participants in the same manner as the
Department treats spend-down liability and post-eligibility income for
individuals receiving Medicaid home and community-based services (OAR
461-160-0620).
(d) The Department/AAA staff forwards intake
information of potential enrollees to the PACE program staff who assesses the
applicant's appropriateness for enrollment in the PACE program in accordance
with these rules and the requirements of
42 CFR
460.152. Potential enrollees may be denied
enrollment by the PACE program if the PACE program determines the individual is
not able to be maintained in a community-based setting without jeopardizing his
or her health or safety or the health and safety of others.
(e) If the potential enrollee or his or her
representative is in disagreement with the PACE program's decision not to
enroll the person, he or she may file an appeal with the Department.
(f) All letters to applicants regarding
denial of enrollment by the PACE program must include the reason for the denial
and the applicants appeal rights. This letter along with documentation of
pertinent information related to the decision must be forwarded to the
Department for review.
Notes
Stat. Auth.: ORS 410.090
Stats. Implemented: ORS 410.070
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