Inclusive Care for the Elderly. (PACE) — A comprehensive service delivery and financing model that integrates medical and LTSS under dual capitation agreements with Medicare and Medicaid. The PACE program is limited to individuals age fifty‑five (55) and over who meet the skilled‑nursing‑facility level of care criteria and reside in a PACE service area. Provider Network — A network of health care and social support providers, including but not limited to primary care physicians, nurses, nurse practitioners, physician assistants, Care Coordinators, specialty providers, mental health/substance use disorder (SUD) providers, community and institutional long‑term care providers, pharmacy providers, and acute providers employed by or under subcontract with the Contractor. (See Appendix D of the Contract.) Provider Preventable Conditions (PPC) — As identified by EOHHS through bulletins or other written statements of policy, which may be amended from time to time, a condition that meets the definition of a “Health Care Acquired Condition” or an “Other Provider Preventable Condition” as defined by CMS in federal regulations at 42 C.F.R. § 447.26(b). Rating Categories (RCs) — The categories used by the MassHealth component of the capitation payment methodology, as described in Section 4.2.1.
Inclusive Care for the Elderly. (PACE) — A comprehensive service delivery and financing model that integrates medical and LTSS under dual capitation agreements with Medicare and Medicaid. The PACE program is limited to individuals age 55 and over who meet the skilled-nursing-facility level of care criteria and reside in a PACE service area. Provider Network — A network of health care and social support providers, including but not limited to primary care physicians, nurses, nurse practitioners, physician assistants, Care Coordinators, specialty providers, mental health/substance abuse providers, community and institutional long-term care providers, pharmacy providers, and acute providers employed by or under subcontract with the Contractor. (See Appendix D of the Contract.) Provider Preventable Conditions (PPC) — As identified by EOHHS through bulletins or other written statements of policy, which may be amended from time to time, a condition that meets the definition of a “Health Care Acquired Condition” or an “Other Provider Preventable Condition” as defined by CMS in federal regulations at 42 C.F.R. 447.26(b). Rating Categories (RCs) — The categories used by the MassHealth component of the capitation payment methodology, as described in Section 4.2.A.
Inclusive Care for the Elderly a capitated integrated Medicaid and Medicare managed care program very similar to Partnership, in accordance with 42 CFR § 460.6, Definitions. All members enrolled in PACE have a Wisconsin Medicaid nursing home-certifiable level of care, which is required as a condition of eligibility. As a fully integrated program, all supports and services – whether Medicare or Medicaid benefits – are delivered through the PACE model design identified in this contract.
Inclusive Care for the Elderly. The Programs of All-Inclusive Care for the Elderly, also called PACE, is a special program that combines medical and long-term care services in a community setting. When you join a PACE program, you have certain rights and protections. CHA PACE, as your PACE program, must fully explain and provide your rights to you or someone acting on your behalf in a way you can understand at the time you join. • Be age 55 or older. • Live in the service area of the PACE program. • Be certified as eligible for nursing home care by the State Administering Agency. • Be able to live safely in the community at the time of enrollment with PACE services. • To maximize the independence, dignity, and respect of PACE members. • To help make PACE members more independent and improve their quality of life. • To provide coordinated quality health care to PACE members. • To keep PACE members living safely in their homes and communities as long as possible. • To help support and keep PACE members together with their family. At CHA PACE, we are dedicated to providing you with quality health care services so that you may remain as independent as possible. This includes providing all Medicare-covered items and services and Medicaid services, and other services determined to be necessary by the interdisciplinary team across all care settings, 24 hours a day, 7 days a week. Our staff seeks to affirm the dignity and worth of each participant by assuring the following rights: You have the right to be treated with dignity and respect at all times, to have all of your care kept private and confidential, and to get compassionate, considerate care. You have the right: • To get all of your health care in a safe, clean environment and in an accessible manner. • To be free from harm. This includes excessive medication, physical or mental abuse, neglect, physical punishment, being placed by yourself against your will, and any physical or chemical restraint that is used on you for discipline or convenience of staff and that you do not need to treat your medical symptoms or to prevent injury. • To be encouraged to use your rights in the PACE program. • To get help, if you need it, to use the Medicare and Medicaid complaint and appeal processes, and your civil and other legal rights. • To be encouraged and helped in talking to PACE staff about changes in policy and services you think should be made. • To use a telephone while at the PACE Center. • To not have to do work or services for the PACE progra...
Inclusive Care for the Elderly. (PACE) — A comprehensive service delivery and financing model that integrates medical and LTSS under dual capitation agreements with Medicare and Medicaid. The PACE program is limited to individuals age 55 and over who meet the skilled-nursing-facility level of care criteria and reside in a PACE service area. Provider Network — A network of health care and social support providers, including but not limited to primary care physicians, nurses, nurse practitioners, physician assistants, Care Coordinators, specialty providers, mental health/substance abuse providers, community and institutional long-term care providers, pharmacy providers, and acute providers employed by or under subcontract with the Contractor. (See Appendix D of the Contract.) Provider Preventable Conditions (PPC) — As identified by EOHHS through bulletins or other written statements of policy, which may be amended from time to time, a condition that meets the definition of a “Health Care Acquired Condition” or an “Other Provider Preventable Condition” as defined by CMS in federal regulations at 42 C.F.R. 447.26(b). Rating Categories (RCs) — The categories used by the MassHealth component of the capitation payment methodology, as described in Section 4.2.A. Readiness Review — Prior to being eligible to accept Demonstration enrollments, each prospective Contractor selected to participate in the Demonstration must undergo a Readiness Review. The Readiness Review evaluates each prospective Contractor’s ability to comply with the Demonstration requirements, including but not limited to, the ability to quickly and accurately process claims and enrollment information, accept and transition new Enrollees, and provide adequate access to all Medicare and Medicaid-covered Medically Necessary Services. CMS and the EOHHS use the results to inform its decision of whether the prospective Contractor is ready to participate in the Demonstration. At a minimum, each Readiness Review includes a desk review and potentially a site visit to the prospective Contractor’s headquarters. Risk Corridor Percentage — The Contractor’s Total Adjusted Expenditures divided by the Adjusted Capitation Rate Revenue for Demonstration Year 1, rounded to the nearest one tenth of a percent. Self-directed PCA — A model of service delivery in which the Enrollee, or the Enrollee’s designated surrogate, is the employer of record, and has decision- making authority to hire, manage, schedule, and dismiss their PCA worker(s).
Inclusive Care for the Elderly. (PACE) – Members enrolled in the PACE program receive all Medicare and Medicaid benefits solely through the PACE organization. PACE organizations provide pre-paid, capitated, comprehensive health care services to enrolled frail elders under the authority of Sections 1894 and 1934 of the Social Security Act. The PACE benefit package for all participants, must include all Medicaid-Covered Services, as specified in the State's approved Medicaid plan, all Medicare-Covered Services, and any other services determined necessary by the interdisciplinary team to improve and maintain the individual's overall health status.
