Common use of Inclusive Care for the Elderly Clause in Contracts

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 — For each Demonstration Year, the Contractor’s Total Adjusted Expenditures divided by the Adjusted Capitation Rate Revenue for the applicable Demonstration Year, 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). Serious Reportable Event (SRE) —An event that occurs on premises covered by a hospital’s license that results in an adverse patient outcome, is clearly identifiable and measurable, usually or reasonably preventable, and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the hospital. An SRE is an event that is specified as such by the Department of Public Health (DPH) and identified by EOHHS. Service Agreement — A written plan of services developed in conjunction with the Enrollee, as appropriate, that describes the responsibilities of parties as they relate to the management of the Enrollee’s Self-directed PCA Services. Service Area — The specific geographical area of Massachusetts designated in the CMS HPMS, and as referenced in Appendix K, for which the Contractor agrees to provide Covered Services to all Enrollees who select or are passively enrolled with the Contractor.

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 — For each Demonstration Year, the The Contractor’s Total Adjusted Expenditures divided by the Adjusted Capitation Rate Revenue for the applicable Demonstration YearYear 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). Serious Reportable Event (SRE) —An event that occurs on premises covered by a hospital’s license that results in an adverse patient outcome, is clearly identifiable and measurable, usually or reasonably preventable, and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the hospital. An SRE is an event that is specified as such by the Department of Public Health (DPH) and identified by EOHHS. Service Agreement — A written plan of services developed in conjunction with the Enrollee, as appropriate, that describes the responsibilities of parties as they relate to the management of the Enrollee’s Self-directed PCA Services. Service Area — The specific geographical area of Massachusetts designated in the CMS HPMS, and as referenced in Appendix K, for which the Contractor agrees to provide Covered Services to all Enrollees who select or are passively enrolled with the Contractor.

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 — For each Demonstration Year, the The Contractor’s Total Adjusted Expenditures divided by the Adjusted Capitation Rate Revenue for the applicable Demonstration YearYear 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). Serious Reportable Event (SRE) —An event that occurs on premises covered by a hospital’s license that results in an adverse patient outcome, is clearly identifiable and measurable, usually or reasonably preventable, and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the hospital. An SRE is an event that is specified as such by the Department of Public Health (DPH) and identified by EOHHS. Service Agreement — A written plan of services developed in conjunction with the Enrollee, as appropriate, that describes the responsibilities of parties as they relate to the management of the Enrollee’s Self-directed PCA Services. Service Area — The specific geographical area of Massachusetts designated in the CMS HPMS, and as referenced in Appendix K, for which the Contractor agrees to provide Covered Services to all Enrollees who select or are passively enrolled with the Contractor.