FROM: KIM EVANS, DIRECTOR
SUBJECT: PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) INFORMATION AND MANUAL UPDATE
MANUAL REVISION #
0825.030.35
0830.000.00 Obsolete
1030.010.05
1040.030.00
1040.030.30
DISCUSSION:
Missouri has a new PACE provider in the Saint Louis area, New Horizons PACE. The Family Support Division (FSD) is not responsible for making eligibility determinations for the PACE program. The enrollment process begins with the PACE provider and is coordinated by the MO HealthNet Division (MHD).
The PACE program provides comprehensive health care services to eligible participants age 55 or older who live in the community of a PACE provider and need a nursing home (NF) level of care, but do not live in a nursing home. PACE participants receive Medicare and Medicaid covered services from their PACE provider team.
Requests for PACE Benefits
Individuals who are eligible for any level of care of MO HealthNet (MHN) can be evaluated for PACE eligibility. To find a local PACE provider, refer to PACE information on the Medicare.gov site.
Individuals interested in the PACE program begin the process by contacting the PACE provider.
PACE providers accept Medicare, Medicaid, and direct payments. An individual is not required to receive MHN coverage in order to receive services from a PACE provider.
Determination for PACE
MHD makes the determination for PACE benefits. Enrollment is identified in the Medicaid Management Information System (MMIS). Staff with access to MMIS can identify PACE participants by reviewing the “Lockin” information when completing a Participant Inquiry.
For questions regarding PACE eligibility, participants should contact New Horizons PACE directly by calling 833-654-7223.
FSD staff should send PACE eligibility questions to MHD.PACE@dss.mo.gov.
FSD Determination for MHN
There is no change to how FSD determines eligibility for MHN coverage.
FSD does not determine eligibility for PACE, therefore, manual section 0830.000.00 Program of All-Inclusive Care for the Elderly (PACE) is now obsolete.
The following manual sections have been updated to remove references to the PACE program:
0825.030.35 Income and Budgeting
1030.010.05 Homestead Exemption
1040.030.00 Determining the Penalty Period
1040.030.30 Required Documentation
The FSD eligibility system will no longer be used to authorize PACE eligibility. Until the PACE option in the Type field on the Home and Community Based/PACE Information (HCBINFO/FMJ7) screen can be deactivated, do NOT use the PACE type code.
PACE and Spend Down
The PACE organization will pay the participant’s spend down to MHD directly. PACE will bill the participant for the charges used to meet the spend down.
PACE and Vendor
There are no changes to FSD’s existing processes for vendor coverage. Participants will continue to pay their surplus to the nursing home.
Hearings
Hearings regarding MHN eligibility continue to be processed by FSD. MHD will conduct all hearings regarding PACE enrollment.
Hearing requests for a PACE enrollment determination must be forwarded to MHD using the following contact information:
• Email: statefairhearings@dss.mo.gov
• Phone: 800-392-2161
• Mail: MO HealthNet Division
Attn: Hearings
PO Box 6500
Jefferson City, MO 65109
NECESSARY ACTION:
• Review this memorandum with appropriate staff.
KE/rnr
