PRA Disclosure Statement The purpose of the PRA package is to provide a mechanism for states who voluntarily elect to provide medical assistance under Section 1934(a)(1) with respect to PACE program services to PACE program eligible individuals who are eligible for medical assistance under the State plan and who are enrolled in a PACE program under a PACE program agreement.  42 CFR 460.2 implements sections 1895, 1905(a), and 1934 of the Act, which authorizes the establishment of PACE as a State option under Medicaid to provide for Medicaid payment to, and coverage of benefits under, PACE.  Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1027 (Expires: TBD). The time required to complete this information collection is estimated to average 20 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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.
____________________________________________________________________________
____________________________________________________________________________

Regular Post Eligibility

The state applies post-eligibility treatment of income rules to PACE participants who are eligible under section 1902(a)(10)(A)(ii)(VI) of the Act (42 C.F.R. §435.217 of the regulations).   Yes ____ No ____
Post-eligibility for states that have elected to apply the rules to PACE participants

Note:  Section 2404 of the Affordable Care Act mandated that, for the five-year period beginning January 1, 2014, the definition of an “institutionalized spouse” in section 1924(h)(1) of the Social Security Act include all married individuals eligible for certain home and community-based services (HCBS), including HCBS delivered through 1915(c) waivers.  As of this writing, the ACA provision has been extended through December 31, 2019.  This means that married individuals eligible in the eligibility group described at 42 C.F.R. §435.217 must have their post-eligibility treatment-of-income rules determined under the rules described in section 1924(d).  Because states that elect to apply post-eligibility treatment-of-income rules to PACE participants may only do so to the same extent the rules are applied to individuals eligibility under 42 C.F.R. §435.217, application of the post-eligibility treatment-of-income rules must be applied to married individuals receiving PACE services consistent with the provisions described herein under “Spousal post-eligibility” so long as the amendment to section 1924 of the Act made by the ACA remains in effect. 

1.	1634 and SSI States

	The State applies the post-eligibility rules to individuals who are receiving PACE services and are eligible under 42 C.F.R. §435.217 consistent with the rules of 42 C.F.R. §435.726, and, where applicable, section 1924 of the Act.  Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee’s income.

1.	Allowances for the maintenance needs of the individual (check one):
1.The amount deducted is equal to:
(a) _____The SSI federal benefit rate
(b) _____Medically Needy Income Level (MNIL)
(c) _____The special income level standard for the institutionalized individuals eligible under section 1902(a)(10)(A)(ii)(V) of the Act
(d) _____Percentage 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 a PACE enrollee in item 1 is equal to, or greater than, the PACE enrollee’s income, enter N/A in items 2 and 3.

				2. 	Allowance for the maintenance needs of the spouse:
The amount deducted for the PACE enrollee’s spouse is equal to: 
1.____	The SSI federal benefit rate
2.____	Optional State Supplement Standard
3.____	Medically Needy Income Level Standard
4.____	The following dollar amount (provided it does not exceed the amount(s) described in 1-3): $________
5 .____	The following percentage of the following standard that is not greater than the standards above: _____% of ______ standard.
6.____	Not applicable (N/A)

				3. Allowance of the maintenance needs of the 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)

4.  Allowance for medical and remedial care expenses, as described in 42 CFR 435.726(c)(4).

	
	2. 209(b) States, 

		The State applies the post-eligibility rules to individuals who are receiving PACE services and are eligible under 42 C.F.R. §435.217 consistent with the rules of 42 C.F.R. §435.735, and, where applicable, section 1924 of the Act.  Payment for PACE services is reduced by the amount remaining after deducting the following amounts from the PACE enrollee’s income.

1.	Allowances for the maintenance needs of the individual (check one):
1.The amount deducted is equal to:
(a) _____The SSI federal benefit rate
(b) _____Medically Needy Income Level (MNIL)
(c) _____The special income level standard for the institutionalized individuals eligible under section 1902(a)(10)(A)(ii)(V) of the Act
(d) _____Percentage 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 a PACE enrollee in item 1 is equal to, or greater than, the PACE enrollee’s income, enter N/A in items 2 and 3.

			2. 	Allowance for the maintenance needs of the spouse:
The amount deducted for the PACE enrollee’s spouse is equal to: 
1.____	The more restrictive income standard established under 42 C.F.R. §435.121 
2.____	Optional State Supplement Standard
3.____	Medically Needy Income Level Standard
4.____	The following dollar amount (provided it does not exceed the amount(s) described in 1-3): $________
5 .____	The following percentage of the following standard that is not greater than the standards above: _____% of ______ standard.
6.____	Not applicable (N/A)

			3. Allowance of the maintenance needs of the 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)

	4.  Allowance for medical and remedial care expenses, as described in 42 CFR 435.735 (c)(4).

Spousal Post Eligibility

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 consistent with the minimum monthly maintenance needs allowance described in section 1924(d), a family allowance, for each family member, calculated as directed by section 1924(d)(1)(C), and an amount for incurred expenses for medical or remedial care, as specified in the State Medicaid plan.  
Yes ____ No ____

		Note: states must elect the use the post-eligibility treatment-of-income rules in section 1924 of the Act in the circumstances described in the preface to this section.  

	(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

A.	The State assures CMS that the capitated rates will be less than the cost to the agency of providing State plan approved services 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 amount the state would have otherwise paid for a comparable population.

1.___	Rates are set at a percent of the amount that would otherwise been paid for a comparable population.
2.___	Experience-based (contractors/State’s cost experience or encounter date)(please describe)
3.___	Adjusted Community Rate (please describe)
4.___	Other (please describe)

B. The State Medicaid Agency assures that the rates were set in a reasonable and predictable manner.  

C.	The State will submit all capitated rates to the CMS Regional Office for prior approval, and will include the name, organizational affiliate of any actuary used, and attestation/description of the capitation rates.

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.