CMS-10227 PACE State Plan Amendment Pre-Print

PACE State Plan Amendment Pre-Print
CMS-10227, OMB 0938-1027 (Expires: TBD)

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Enclosure 3
State of ______________
PACE State Plan Amendment Pre-Print
Citation

3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy
(Continued)

1905(a)(26) and 1934
_____ Program of All-Inclusive Care for the Elderly (PACE) services, as described and
limited in Supplement 3 to Attachment 3.1-A.
ATTACHMENT 3.1-A identifies the medical and remedial services provided to
the categorically needy. (Note: Other programs to be offered to Categorically
Needy beneficiaries would specify all limitations on the amount, duration and
scope of those services. As PACE provides services to the frail elderly population
without such limitation, this is not applicable for this program. In addition, other
programs to be offered to Categorically Needy beneficiaries would also list the
additional coverage -that is in excess of established service limits- for
pregnancy-related services for conditions that may complicate the pregnancy. As
PACE is for the frail elderly population, this also is not applicable for this
program.)

Enclosure 4
State of ______________
PACE State Plan Amendment Pre-Print
Citation

3.1(a)(2) Amount, Duration, and Scope of Services: Medically Needy (Continued)
1905(a)(26) and 1934

____ Program of All-Inclusive Care for the Elderly (PACE) services, as described and
limited in Supplement 3 to Attachment 3.1-A.
ATTACHMENT 3.1-B identifies services provided to each covered group of the
medically needy. (Note: Other programs to be offered to Medically Needy
beneficiaries would specify all limitations on the amount, duration and scope of
those services. As PACE provides services to the frail elderly population without
such limitation, this is not applicable for this program. In addition, other
programs to be offered to Medically Needy beneficiaries would also list the
additional coverage -that is in excess of established service limits- for
pregnancy-related services for conditions that may complicate the pregnancy. As
PACE is for the frail elderly population, this also is not applicable for this
program.)

Enclosure 5
Attachment 3.1-A
State of ______________
PACE State Plan Amendment Pre-Print
Amount, Duration and Scope of Medical and Remedial Care Services Provided To the
Categorically Needy
27.

Program of All-Inclusive Care for the Elderly (PACE) services, as described in
Supplement 3 to Attachment 3.1-A.
____ Election of PACE: By virtue of this submittal, the State elects PACE as an
optional State Plan service.
____ No election of PACE: By virtue of this submittal, the State elects to not add
PACE as an optional State Plan service.

Enclosure 6
Attachment 3.1-B
State of ________
PACE State Plan Amendment Pre-Print
Amount, Duration and Scope of Medical and Remedial Care Services Provided To the Medically
Needy
27.

Program of All-Inclusive Care for the Elderly (PACE) services, as described in
Supplement 3 to Attachment 3.1-A.
____ Election of PACE: By virtue of this submittal, the State elects PACE as an
optional State Plan service.
____ No election of PACE: By virtue of this submittal, the State elects to not add
PACE as an optional State Plan service.

Enclosure 7
Supplement 3 to Attachment 3.1-A
State of ______________
PACE State Plan Amendment Pre-Print
Name and address of State Administering Agency, if different from the State Medicaid Agency.
____________________________________________________________________________
____________________________________________________________________________

I.

Eligibility
The State determines eligibility for PACE enrollees under rules applying to community
groups.
A._____The State determines eligibility for PACE enrollees under rules applying to
institutional groups as provided for in section 1902(a)(10)(A)(ii)(VI) of the Act (42
CFR 435.217 in regulations). The State has elected to cover under its State plan the
eligibility groups specified under these provisions in the statute and regulations. The
applicable groups are:
(If this option is selected, please identify, by statutory and/or regulatory reference, the
institutional eligibility group or groups under which the State determines eligibility for
PACE enrollees. Please note that these groups must be covered under the State’s
Medicaid plan.)
B. _____The State determines eligibility for PACE enrollees under rules applying to
institutional groups, but chooses not to apply post-eligibility treatment of income rules
to those individuals. (If this option is selected, skip to II - Compliance and State
Monitoring of the PACE Program.
C.______The State determines eligibility for PACE enrollees under rules applying to
institutional groups, and applies post-eligibility treatment of income rules to those
individuals as specified below. Note that the post-eligibility treatment of income rules
specified below are the same as those that apply to the State’s approved HCBS
waiver(s).

Regular Post Eligibility

TN No.:______
Supersedes

Approval Date_____________
Effective Date______________
Enclosure 7, Page 1

TN NO.:______

1.____ SSI State. The State is using the post-eligibility rules at 42 CFR 435.726.
Payment for PACE services is reduced by the amount remaining after
deducting the following amounts from the PACE enrollee’s income.
(a). Sec. 435.726--States which do not use more restrictive eligibility
requirements than SSI.
1.

Allowances for the needs of the:
(A.) Individual (check one)
1.____The following standard included under the State plan
(check one):
(a) _____SSI
(b) _____Medically Needy
(c) _____The special income level for the institutionalized
(d) _____Percent of the Federal Poverty Level: ______%
(e) _____Other (specify):________________________
2._____The following dollar amount: $________
Note: If this amount changes, this item will be revised.
3._____The following formula is used to determine the needs
allowance:
___________________________________________________
___________________________________________________

Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the
maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A
in items 2 and 3.
(B.) Spouse only (check one):
1.____ SSI Standard
2.____ Optional State Supplement Standard
3.____ Medically Needy Income Standard
4.____ The following dollar amount: $________
Note: If this amount changes, this item will be revised.
5 .____ The following percentage of the following standard
that is not greater than the standards above: _____% of
______ standard.
6.____ The amount is determined using the following formula:
__________________________________________________
__________________________________________________
7.____ Not applicable (N/A)
(C.) Family (check one):

TN No.:______
Supersedes

Approval Date_____________
Effective Date______________
Enclosure 7, Page 2

TN NO.:______

1.____
2.____

AFDC need standard
Medically needy income standard

The amount specified below cannot exceed the higher of the need standard for a family of
the same size used to determine eligibility under the State’s approved AFDC plan or the
medically needy income standard established under 435.811 for a family of the same size.
The following dollar amount: $_______
Note: If this amount changes, this item will be revised.
4.____ The following percentage of the following standard
that is not greater than the standards above:______%
of______ standard.
5.____ The amount is determined using the following formula:
__________________________________________________
__________________________________________________
6.____ Other
7.____ Not applicable (N/A)
3.____

(2). Medical and remedial care expenses in 42 CFR 435.726.
Regular Post Eligibility
2. _____

209(b) State, a State that is using more restrictive eligibility requirements
than SSI. The State is using the post-eligibility rules at 42 CFR 435.735.
Payment for PACE services is reduced by the amount remaining after
deducting the following amounts from the PACE enrollee’s income.

(a) 42 CFR 435.735--States using more restrictive requirements than SSI.
1.

Allowances for the needs of the:
(A.) Individual (check one)
1.___The following standard included under the State plan
(check one):
(a) _____SSI
(b) _____Medically Needy
(c) _____The special income level for the institutionalized
(d) _____Percent of the Federal Poverty Level: ______%
(e) _____Other (specify):________________________
2.___The following dollar amount: $________
Note: If this amount changes, this item will be revised.
3___The following formula is used to determine the needs allowance:
___________________________________________________

TN No.:______
Supersedes

Approval Date_____________
Effective Date______________
Enclosure 7, Page 3

TN NO.:______

___________________________________________________
Note: If the amount protected for PACE enrollees in item 1 is equal to, or greater than the
maximum amount of income a PACE enrollee may have and be eligible under PACE, enter N/A
in items 2 and 3.
(B.) Spouse only (check one):
1._____The following standard under 42 CFR 435.121:
___________________________________________________
2._____The Medically needy income standard
___________________________________________________
3.____The following dollar amount: $________
Note: If this amount changes, this item will be revised.
4 .____The following percentage of the following standard that is not
greater than the standards above: _____% of ______
standard.
5._____The amount is determined using the following formula:
__________________________________________________
__________________________________________________
6._____Not applicable (N/A)
(C.) Family (check one):
1.____AFDC need standard
2_____Medically needy income standard
The amount specified below cannot exceed the higher of the need standard for a family of
the same size used to determine eligibility under the State’s approved AFDC plan or the
medically needy income standard established under 435.811 for a family of the same size.
3.____The following dollar amount: $_______
Note: If this amount changes, this item will be revised.
4.____The following percentage of the following standard that is not
greater than the standards above:______% of______ standard.
5.____The amount is determined using the following formula:
__________________________________________________
__________________________________________________
6.____ Other
7.____ Not applicable (N/A)
(b) Medical and remedial care expenses specified in 42 CFR 435.735.

TN No.:______
Supersedes

Approval Date_____________
Effective Date______________
Enclosure 7, Page 4

TN NO.:______

Spousal Post Eligibility
3.____ State uses the post-eligibility rules of Section 1924 of the Act (spousal
impoverishment protection) to determine the individual’s contribution toward
the cost of PACE services if it determines the individual’s eligibility under
section 1924 of the Act. There shall be deducted from the individual’s
monthly income a personal needs allowance (as specified below), and a
community spouse’s allowance, a family allowance, and an amount for
incurred expenses for medical or remedial care, as specified in the State
Medicaid plan.
(a.) Allowances for the needs of the:
1. Individual (check one)
(A).____The following standard included under the State plan
(check one):
1. _____SSI
2. _____Medically Needy
3. _____The special income level for the institutionalized
4. _____Percent of the Federal Poverty Level: ______%
5. _____Other (specify):________________________
(B)._____The following dollar amount: $________
Note: If this amount changes, this item will be revised.
(C)_____The following formula is used to determine the needs
allowance:
___________________________________________________
___________________________________________________
If this amount is different than the amount used for the individual’s
maintenance allowance under 42 CFR 435.726 or 42 CFR 435.735,
explain why you believe that this amount is reasonable to meet the
individual’s maintenance needs in the community:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
II.

Rates and Payments

TN No.:______
Supersedes

Approval Date_____________
Effective Date______________
Enclosure 7, Page 5

TN NO.:______

A. The State assures CMS that the capitated rates will be equal to or less than the cost to
the agency of providing those same fee-for-service State plan approved services on a
fee-for-service basis, to an equivalent non-enrolled population group based upon the
following methodology. Please attach a description of the negotiated rate setting
methodology and how the State will ensure that rates are less than the cost in fee-forservice.
1.___
2.___
3.___
4.___

Rates are set at a percent of fee-for-service costs
Experience-based (contractors/State’s cost experience or encounter
date)(please describe)
Adjusted Community Rate (please describe)
Other (please describe)

B. The State Medicaid Agency assures that the rates were set in a reasonable and
predictable manner. Please list the name, organizational affiliation of any actuary used,
and attestation/description for the initial capitation rates.
C. The State will submit all capitated rates to the CMS Regional Office for prior approval.
III.

Enrollment and Disenrollment

The State assures that there is a process in place to provide for dissemination of enrollment and
disenrollment data between the State and the State Administering Agency. The State assures
that
it has developed and will implement procedures for the enrollment and disenrollment of
participants in the State’s management information system, including procedures for any
adjustment to account for the difference between the estimated number of participants on which
the prospective monthly payment was based and the actual number of participants in that month.

TN No.:______
Supersedes

Approval Date_____________
Effective Date______________
Enclosure 7, Page 6

TN NO.:______