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66 TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 3. Spousal Impoverishment rules apply if individual is married and spouse continues to reside in the community and does not receive long-term care Medicaid. See DSSM 20900 4. Post eligibility treatment of income does not apply to PACE participants. Participants will not be required to contribute to the cost of their care received from the PACE Organization. 5. To be initially eligible for enrollment in PACE the individual must: • Be at least 55 years old; • Meet the State’s eligibility criteria for nursing home level of care; • Reside in the PACE approved service area; • Be living in the community; • Be able to be maintained safely in the community based setting at the time of enrollment with the assistance of the PACE; • Not be enrolled in a Medicaid/Medicare managed care program; and • Voluntarily agree to enroll in PACE and receive services exclusively through the PACE organization and their subcontractors. 6. The Pre-Admission Screening process will be followed when determining medical eligibility. See DSSM 20102 7. An individual’s enrollment effective date is the first day of the month following the month the PACE Organization receives the signed enrollment form. 8. There is no retroactive coverage for PACE. 9. Nursing facility services are part of the PACE benefit package. Nursing facility admission that occurs post-PACE enrollment will not have a negative impact on the individual’s continued eligibility. The PACE Organization must notify the Division of Medicaid and Medical Assistance (DMMA) eligibility worker of the individual’s placement in the nursing facility. The PACE individual is not required to contribute to the cost of their care while in a nursing facility. 10. An individual’s enrollment continues until the enrollee’s death unless either of the following actions occurs: a. The enrollee voluntarily disenrolls for any reason. b. The enrollee is involuntarily disenrolled for any of the following reasons: • No longer meets the nursing facility level of care requirement and there is no indication that the participant is expected to need nursing facility level of care within the next 6 months; • Moves out of the PACE service delivery area; • Has decision making capacity and is consistently non-compliant with the individual plan of care and enrollment agreement, which may impact the participant’s health and welfare in the community; • Engages in disruptive, threatening or non-compliant behavior which jeopardizes his or her safety or the safety of others; • Is out of the service area for more than 30 consecutive days (unless arrangements have been made in advance with the PACE Organization); or • Is enrolled in a PACE Organization that cannot provide the required services due to loss of licensure or contracts with outside providers, and/or the PACE program agreement is not renewed. 11. An individual may be administratively disenrolled if the participant is admitted to a hospital prior to the effective date of PACE enrollment. 12. Medicaid appeal requirements apply to PACE cases. See DSSM 5000 16 DE Reg. 532 (11/01/12) 20800 Determining Eligibility for the Acute Care Program LTC POL- This policy applies to all applications received for Medicaid payment of Inpatient hospitalization or rehabilitation. Thirty Consecutive Days of Hospitalization Eligibility for this program will only be determined once the individual has been hospitalized for 30 consecutive days, unless: the discharge plan is for nursing home placement; or the individual is seeking out of state inpatient rehabilitation placement. Licensed and Certified Hospital or Rehabilitation Facility The medical facility must be licensed and certified as a Title XIX Acute Care or Rehabilitation Medical Facility. The Acute Care facility must be engaged in providing diagnostic and therapeutic services for medical diagnosis, treatments, and care of injured, disabled, or sick persons. These services must be provided by or under the supervision of physicians. Continuous twenty–four (24) hour nursing services are provided.