Program of Allinclusive Care for the Elderly PACE

Program of All-inclusive Care for the Elderly (PACE) Deeming & Extended Waiver Eligibility Grievances, Appeals, and Hearings

Objectives General understanding of PACE Deeming General information on PACE grievances, appeals, and State Administrative Hearings with regard to PACE

Deeming & EWE In PACE, CFR § 460. 160(2)(3) allows a consumer to be “deemed continued eligibility” (also referred to ‘deeming’) if the participant is found to be ineligible for Medicaid funded Long Term Care Services & Supports (LTCSS) as assessed by the State and would have a significant decline in health within 6 months of disenrollment from PACE. Extended Waiver Eligibility (EWE) criteria are utilized when a consumer receiving LTCSS and has been assessed, according to the process outlined in OAR 411 -015 -0008, at Service Priority Level (SPL) 14 – 18. A consumer may be eligible for EWE if he/she meets the criteria outlined in OAR 411 -0150030(1)(a-c) and Section (4)(a-b) of this rule.

Deeming & EWE When a participant is assessed at an SPL 14 or higher and receives PACE services, the hierarchy for screening continued eligibility is as follows: *Deeming process, when initiated by the PACE organization *Screen for Extended Waiver Eligibility (EWE) initiated by the APD/AAA case manager. No closure notice for long-term care services will be sent while the case is being reviewed for deeming through PACE and/or EWE. The progress and the outcome for both the PACE deeming process and the EWE process must be narrated in the Oregon ACCESS case. APD-PT-18 -038 provides details of the process when deeming and EWE may be utilized.

Deeming & EWE When a PACE participant scores above SPL 14 at reassessment, the local office and the PACE organization, will review the PACE participant’s previous and current assessments, along with the PACE organization’s documents to evaluate the effect of disenrollment on the participant’s health status, activities of daily living, and social functioning. If both parties agree that the participant’s health would deteriorate without PACE services within the six months after disenrollment, the participant may be ‘deemed’ eligible until the next annual assessment.

Deeming & EWE When the local office and the PACE organization cannot agree to deeming, the documentation is sent to the PACE Policy Analyst for review. The PACE Policy Analyst will coordinate a Central Office (CO) review team to review the documentation and make a final decision. When a decision is made that the PACE participant is not appropriate for deeming through PACE – either a unanimous decision between the local office and PACE organization or a final decision by the PACE Policy Analyst – the local case manager will begin the process of screening for EWE eligibility. Refer to APD-PT-18 -038 for an explanation of the process. For additional information, refer to the Deeming Process guide located on the Case Manager Tools page under Program of All-inclusive Care for the Elderly.

Case Set-up for PACE Deeming APD/AAA case manager will: o Ensure the new assessment is in ‘Complete’ status o Narrate the approval for deeming in Oregon ACCESS o Ensure all coding on the case is accurate and related to a PACE case o Provide payment instructions to the consumer regarding liability/pay-in, room & board, and PIF o Set up a reminder on the case for the reassessment to be completed in 12 months o Set up a reminder on the case to send a Buckley notice prior to the reassessment o Send to the State PACE Policy Analyst via email: Participant name Prime number Start and end dates of benefit and service plans (start date of the new benefit and service plans is the first date after the ADMIN extension is ended; the end date is the same as the end date of the reassessment)

Case Set-up for PACE Deeming DO NOT extend the previous assessment for the remainder of the new assessment period. DO NOT create new service and benefit plans in Oregon ACCESS. The State PACE Policy Analyst will work with the Mainframe Analysts to code SELG with the appropriate information for continued service eligibility. The Mainframe Analysts will notify the case manager and the State PACE Policy Analyst when SELG has been updated. When a reassessment is completed and the participant is assessed SPL 113, the case manager will notify the PACE organization and the State PACE Policy Analyst of the change in condition. The State PACE Policy Analyst will work with the Mainframe Analysts to end the current SELG record so the case manager can set up new benefit and service plans in Oregon ACCESS.

Grievances, Appeals, and Hearings Definitions with respect to PACE: Grievance: a complaint, either in writing or verbally, expressing dissatisfaction with the service delivery or the quality of care being provided. Appeal: a request for review of an ‘action’ or ‘inaction’ of service(s) that may be perceived as having a negative impact on the participant’s care. The participant has the right to request a State Administrative Hearing if dissatisfied with the outcome of the grievance and/or appeals processes. The APD/AAA case manager will assist the participant with completing the appropriate form(s) and submitting the request to the Office of Administrative Hearings (OAH).

Grievances, Appeals, and Hearings When filling out an Administrative Hearing form, the participant needs to complete the Aid Paid Pending (APP) section. Granting APP is necessary so the PACE organization can continue to provide services during the hearings process and the participant’s medical, dental, et. al. benefits will not be disrupted. If APP is not updated on the case, the participant may be disenrolled from the PACE services and medical, dental, et. al. benefits in MMIS; the consumer may be automatically assigned to a different CCO/MCO and the provider will not be paid timely.

Collaboration & Communication PACE is a partnership, not just between participants and the program, but also with the APD/AAA Offices, the PACE organization and the State of Oregon. We all share the same goal of enhancing the quality of life for Oregon’s aging population!

PACE Resources

PACE Resources

PACE Resources Medicare. gov PACE Overview https: //www. medicare. gov/your-medicare-costs/get-help-payingcosts/pace National PACE Association https: //www. npaonline. org/ PACE CFR 460 Title 42 → Chapter IV → Subchapter E → Part 460 https: //www. ecfr. gov/cgi-bin/textidx? SID=a 3 fe 0 a 6 a 52 f 47235 c 57 d 9 b 04 bea 47999&node=42: 4. 0. 1. 3. 16&rg n=div 5 APD Case Management Tools – PACE Website http: //www. dhs. state. or. us/spd/tools/cm/PACE/index. htm

PACE Resources Oregon Administrative Rules – OAR 411 -045 http: //www. dhs. state. or. us/policy/spd/rules/411_045. pdf PACE Links on DHS-APD Internet site https: //www. oregon. gov/DHS/seniors-disabilities/SPPD/Pages/index. aspx https: //www. oregon. gov/DHS/SENIORSDISABILITIES/LTC/Pages/index. aspx State PACE Brochure Form DE 2658 https: //apps. state. or. us/Forms/Served/DE 2658. pdf

PACE Organization Contacts Providence Elder. Place Intake Specialists 503 -215 -6556 (metro service areas) 503 -717 -7150 (North Coast service area) All. Care PACE (Jackson & Josephine Counties) 541 -474 -8000

State Contacts Lisa Bouchell, PACE Policy Analyst, APD 503 -947 -0192 or lisa. bouchell@dhsoha. state. or. us Cindy Susee, PACE Financial Analyst, APD 503 -945 -6448 or Cynthia. susee@dhsoha. state. or. us PACE Oregon Toll-free: 1 -844 -224 -7223