048-27 Wyo. Code R. §§ 27-5 - Eligibility, Applications, and Grievances for the PACE

(a) Eligibility under this Chapter shall be limited to persons who:

(i) Meet current Medicaid income and resource eligibility through the process set forth in Chapter 18;

(ii) Are fifty-five (55) years of age or older;

(iii) Reside within the service area of a PACE provider;

(iv) Meet medical necessity for long-term care level of care determination in accordance with Chapter 22; and

(v) Meet home assessment requirements demonstrating that the individual is able to live in the community setting without jeopardizing his or her health or safety, pursuant to 42 C.F.R. § 460.150.

(b) Participant application process.

(i) The Department and PACE providers shall provide applications for Medicaid enrollment to possible Medicaid eligible applicants.

(ii) Each applicant shall sign acknowledgement of informed consent for Medicaid participants electing to participate in the PACE program in lieu of receiving fee for service Medicaid benefits. Completed Applications shall be submitted to PACE provider.

(iii) The PACE provider shall ensure objective and nondiscriminatory enrollment practices without regard to religion, race, creed, national origin, economic status, sex, sexual orientation, or disability, which are applied equitably to all applicants.

(iv) The PACE provider shall verify that the applicant's age, zip code of residence, and Wyoming Medicaid eligibility are consistent with the eligibility criteria.

(v) The PACE provider shall request an evaluation of medical necessity in accordance with Chapter 22.

(vi) The PACE provider shall conduct a home assessment to verify the ability of the applicant to live safely in the community pursuant to 42 C.F.R. § 460.150.

(vii) Upon notification of eligibility status by the Department, the PACE provider shall contact the prospective applicant. If eligible and the prospective applicant chooses to enroll, an enrollment agreement shall be signed by the applicant. The applicant's enrollment in the program is effective on the first day of the calendar month following the date the PACE program provider receives the signed enrollment agreement.

(viii) All applications denied by the PACE program provider must be submitted to the Department or its designee for review pursuant to 42 C.F.R. § 460.152

(c) Loss of eligibility.

(i) A participant shall be determined to be no longer eligible for PACE program services when the participant:

(A) Does not meet Medicaid financial eligibility requirements as determined by the Department or its designee pursuant to Chapter 18; or

(B) Is determined to no longer meet the Medicaid medical necessity requirements pursuant to Chapter 22.

(ii) A participant may request a hearing regarding loss of Medicaid eligibility through the process set forth in Chapter 18, Chapter 22 and Chapter 4.

(d) Grievance procedure. Wyoming PACE participants, their representatives, and others have the right to have their complaints and grievances addressed by the PACE Provider or the Department, in a timely, reasonable, and consistent manner without concern that making a complaint and grievance will negatively affect their treatment in any manner. The formal grievance procedure is outlined in the three-way Program Agreement between the State, CMS, and the PACE provider.

Notes

048-27 Wyo. Code R. §§ 27-5

Adopted, Eff. 7/12/2016.