PACE Programs Authorized to Conduct Eligibility Assessments and Direct Enrollment

Under a new policy, consumers seeking to enroll in Programs of All-Inclusive Care for the Elderly (PACE) may be assessed for eligibility by the PACE program, rather than the NY Independent Assessor (NYIA) (Maximus). The policy allows PACE programs to conduct initial community health assessments (CHAs) of prospective enrollees.

The new PACE process, known as Direct Eligibility, is an alternative to the NY Independent Assessment required for other types of managed long term care (MLTC) or for Medicaid coverage of personal care or consumer directed personal assistance services (CDPAS). Prospective PACE enrollees may also continue to seek assessments through the NYIA. PACE programs may not steer individuals to the Direct Eligibility option.

The new policy took effect on March 1, 2023 and is expected to allow PACE programs to enroll individuals more quickly than the NYIA, thereby advancing the State's goal of increasing enrollment in integrated managed care plans for dual eligibles. All Direct Eligibility assessments will be subject to NYIA verification reviews to ensure their validity.

Only individuals who have been determined financially eligible for Medicaid may be assessed through Direct Enrollment at this time. The following prospective enrollees are excluded from Direct Eligibility:

• Individuals already determined eligible for MLTC (i.e., those seeking to transfer from an MLTC plan to a PACE program and those who have been assessed by the NYIA in the prior 12 months and determined eligible);
• Enrollees in mainstream Medicaid managed care plans, Health and Recovery Plans (HARPs), or HIV Special Needs Plans (SNPs) who are not dually eligible for Medicare and Medicaid;
• Individuals who have been assessed by the NYIA in the past 12 months and determined ineligible for MLTC, except if the individual has had a significant change in condition.

PACE programs are required to refer individuals excluded from Direct Enrollment to the NYIA for assistance.

If the PACE program determines that the individual is eligible for PACE (i.e., the individual has a nursing facility level of care and requires more than 120 days of community-based long-term services and supports), the PACE program submits the enrollment for processing. If the PACE program determines that the individual does not meet PACE eligibility criteria, the individual may opt to have the NYIA conduct another assessment to determine their eligibility for MLTC or personal care/CDPAS.

The NYIA will verify all PACE enrollments through desk reviews and may conduct repeat assessments when the verification results in a determination that the enrollee is not eligible. If the NYIA determines that the individual is not eligible, the PACE program may involuntarily disenroll the individual, or it may dispute the determination. PACE programs are required to notify the individual of the determination and that they will receive a notice describing their right to appeal. Individuals who are determined ineligible have a right to a fair hearing, with continued enrollment ("aid continuing") if they request a hearing by the deadline.

In addition to the individual's right to request a fair hearing, PACE programs may dispute a determination that an enrollee is not eligible, based on:

• a factual disagreement with the independent review based on documented clinical or social factors or identified omissions; or
• an analysis that the individual's needs have stabilized since they have been in PACE, resulting in an improvement in condition, and, without PACE services, the individual may decline in functional status.

The Department of Health (DOH) may suspend or terminate a PACE program's ability to conduct Direct Eligibility assessments, if the program violates the guidance for conducting assessments. If there is a pattern of inappropriate PACE determinations of eligibility, the program's ability to continue to conduct assessments must be suspended.

PACE programs are exempt from NYIA reassessments and will remain responsible for all reassessments and mandated assessments.

The new policy, MLTC 23.01, and related attachments are available below:

• MLTC Policy 23.01: PACE Direct Eligibility Process for Medicaid Beneficiaries
• Attachment A – Appendix P
• Attachment B – PACE Direct Eligibility Disclosure Letter
• Attachment C – PACE Direct Eligibility Outcome Letter
• Attachment D – MLTC Enrollment Confirmation Notice Plan
• Attachment E – Intent to Disenroll Letter
• Attachment F – MLTC Involuntary Disenrollment Letter

Contact: Karen Lipson, klipson@leadingageny.org