Page 2

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued September 23, 2024 Page 2 of H-3600 Replacing October 17, 2022 Revised/added text indicated by underscore Deleted text indicated by “**”

H-3610.1 Coverage

Medicaid eligible PACE participants shall be eligible for payment of the monthly PACE premium. The PACE premium is paid directly to the PACE organization. No retroactive capitated payments shall be made.

The participant, while enrolled in a PACE program, must receive Medicare and Medicaid benefits solely through the PACE organization.

H-3610.2 Medical Certification

Medical approval requires that the PACE applicant meet the medical criteria for placement in a nursing facility. An assessment of the individual is completed by the PACE provider and forwarded to the Office of Aging and Adult Services (OAAS) for review. OAAS determines whether s/he needs the level of care required for coverage of nursing facility services.

OAAS will issue the medical certification form (BHSF Form 142).

The BHSF Form 142 documents the:

• Approval or disapproval for enrollment in PACE; and

• Effective date of medical certification approval.

H-3610.3 Special Income Limit (SIL)

Countable income must be equal to or below the SIL.

Income eligibility is based on the individual’s gross income (excluding VA Aid and Attendance).

The individual’s gross income is compared to the the special income limit used for individuals receiving home and community-based services. The SIL is three times the SSI Federal Benefit Rate (FBR) for an individual. The SIL for a couple is double the individual SIL. Refer to Z-700, LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.