The purpose of this rule is to
define the terms used in Chapter 5160-36 of the Administrative Code governing
the medicaid funded portion of the program of all-inclusive care for the
elderly (PACE).
(A) As used in this
chapter:
(1)
(A) "Authorized representative"
has the same meaning as in rule
5160:1-1-01
of the Administrative Code.
means a person,
eighteen years of age or older, who stands in place of an individual who is
applying for or receiving medical assistance including PACE enrollment and
participation. The authorized representative may include a legal entity
assisting in the application process, a family member, attorney, licensed
social worker, or any other person chosen to act on the individual's behalf. In
accordance with Chapter 5160:1-2 of the Administrative Code, the individual
shall provide a written statement naming the authorized representative and the
duties that the authorized representative may perform on the individual's
behalf.
(2) "CMS" means the centers for
medicare and medicaid services, a federal agency that is part of the U.S.
department of health and human services and administers the medicaid
program.
(3) "C.F.R." means the code of
federal regulations.
(4) "CDJFS" means county department
of job and family services.
(5)
(B) "Capitated
payment" means the monthly payment paid to the
program
of all inclusive care for the elderly PACE organization by
the Ohio department of medicaid ( ODM
) for medical care and services provided to medicaid
recipients enrolled in
the PACE
.
program.
(6)
(C) "Individual" is
the applicant for or recipient of a medical assistance program such as
medicaid.
(7)
(D) "Involuntary disenrollment" means the
disenrollment of a participant from
the
PACE
program at the request of the PACE
organization or a
county department of job and family
services.
CDJFS.
(8) "ODA" means the Ohio department
of aging.
(9) "ODM" means the Ohio department
of medicaid.
(10)
(E) "PACE" means the
'program of all-inclusive care for the elderly'
provided
as set forth
for in
42 U.S.C.
1396u-4 and42 C.F.R. Part
460 as in effect on October 1,
2013.
2019.
(11)
(F) "PACE center"
means a facility operated by a PACE organization where primary care or other
related services offered by
the PACE
program are
furnished
provided to
participants.
(12)
(G) "PACE organization" means an entity that has a
medicaid provider agreement and also has in effect a PACE
program agreement with
CMS
the centers for
medicare and medicaid services (CMS) and
the Ohio
department of aging ( ODA
).
(13)
(H)
"PACE program agreement" means an agreement
between a PACE organization, CMS, and ODA.
(14)
(I) "Participant"
means a person enrolled in
PACE and
receiving services through
the PACE
.
program.
(15)
(J) "Private pay
participant" means an individual who does not meet the medicaid eligibility
criteria but chooses to participate in PACE and is responsible for payment of
the PACE organization's private pay premium.
(16)
(K) "Service area"
means the geographic area in which a PACE organization is approved by CMS and
ODA to
furnish
provide services to PACE participants.
(17)
(L)
"State administering agency" means the state agency responsible for
administering the PACE program agreement.
Pursuant to section 173.50 of the Revised Code ODA
shall serve as the state administering agency for PACE in Ohio.
(18)
(M)
"Voluntary disenrollment" means the disenrollment of a participant from
the PACE program at the request of the participant or the
participant's authorized representative.
