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Glossary

State administering agency

The state agency responsible for PACE in that state. Under 42 CFR 460.150 and 460.152 it determines whether a prospective participant needs the nursing facility level of care, Medicaid-eligible or not, and under 460.160 it reevaluates that at least annually. States delegate the assessment in different ways.

Also SAA, state administering agency for PACE

PACE is a federal program run through a state. The state administering agency is the body that signs the program agreement with CMS and the PACE organization, pays the Medicaid capitation, and makes the one eligibility determination the PACE organization cannot make for itself: whether the person needs a nursing facility level of care. 42 CFR 460.152(a)(3) is explicit that “the State administering agency must assess the potential participant, including any individual who is not eligible for Medicaid”, and 460.160(b) requires it to reevaluate “at least annually”.

How that assessment happens is the state’s choice, and the choices differ:

  • Ohio assigns it to the Department of Aging in OAC 173-50-03, which “in its discretion, may delegate this responsibility”, and keeps the financial determination with the Medicaid department. The rule sets no deadline for the level-of-care decision.
  • California has the PACE organization complete the nursing facility level of care form and submit it to a DHCS nurse for approval; the enrollment log records “the date that the Level of Care was approved by the DHCS Nurse”.
  • Michigan has the PACE organization’s own clinician run the state’s Level of Care Determination tool online, within fourteen days of enrollment, with the state’s system making the determination.

The agency’s determination and the organization’s intake run in parallel and wait on each other. The organization cannot enroll until the state says yes; the state’s assessor often wants the same clinical documentation the organization is collecting for its own initial comprehensive assessment. The hospital discharge summary and the physician’s recent notes serve both, which is one reason to have them early rather than twice.

Financial eligibility for Medicaid is a third determination, made by the state’s Medicaid office on the 45-day clock in 42 CFR 435.912, and separate from level of care. From referral to enrollment lays the three clocks side by side.

Where it is defined

Vivlio for paceThe intake checklist, from twelve months of progress notes to the medication list, assembled before the team meets.

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