(a) To be eligible for participation the applicant must:
  (1) be 55 years old or older;
  (2) meet the medical necessity criteria for nursing facility care in accordance with §19.2401 of this title (relating to General Qualifications for Medical Necessity Determinations);
  (3) live in a Programs of All-Inclusive Care for the Elderly (PACE) service area; and
  (4) be determined by the PACE Interdisciplinary Team (IDT) as able to be safely served in the community.
(b) To be eligible for Medicaid capitated payment the applicant must be eligible for full Medicaid benefits through one of the following methods:
  (1) be eligible for Supplemental Security Income (SSI) benefits;
  (2) have been eligible for and received SSI benefits, and continue to be eligible for Medicaid as a result of coverage mandated by federal law; or
  (3) be eligible for Medicaid benefits, if institutionalized.
(c) To obtain and maintain eligibility, the client must agree to accept the provider agency and its contractors as the client's only service provider.
(d) If the provider agency denies enrollment because the IDT determines that the applicant cannot be served safely in the community, the agency must:
  (1) notify the applicant in writing of the reason for the denial;
  (2) refer the individual to alternative services, as appropriate;
  (3) maintain supporting documentation for the denial; and
  (4) notify the Centers for Medicare and Medicaid Services and the Department of Aging and Disability Services of the denial and make the supporting documentation available for review.

Source Note: The provisions of this §270.12 adopted to be effective March 24, 2004, 29 TexReg 2923; amended to be effective February 1, 2010, 35 TexReg 653; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933