Program of All-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.
Program of All-Inclusive Care for the Elderly. (PACE) — As defined in 42 C.F.R. § 460.6, and authorized under California law at Welfare and Institutions Code section 14591 et seq., PACE is a capitated program for individuals over the age of 55 certified by DHCS for nursing home level of care. PACE organizations cover all Medicare and Medicaid benefits, including medical services and long-term services and support, organizes a comprehensive service delivery system governed by federal regulations, and integrate Medicare and Medicaid financing. PACE is a three-way partnership between the federal Government, California, and the PACE Organizations.
Program of All-Inclusive Care for the Elderly. (PACE) (Xxxxxx County ALTC, ALTCEW and Snohomish County LTCA AAAs only)
Program of All-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 aged fifty-five (55) and over who meet the nursing-facility level of care (LOC) criteria and reside in a PACE service area. Provider – An individual, group, facility, agency, Institution, organization, or business that furnishes or has furnished medical services to Enrollees. Provider Contract – An agreement between the Contractor and a Provider for the provision of services. Provider Network - The collective group of health care and social support Providers, including but not limited to PCPs, nurses, nurse practitioners, physician assistants, GSSCs, specialty Providers, mental health/substance use disorder Providers, community and institutional long-term care Providers, pharmacy Providers, and acute hospital and other Providers employed by or under subcontract with the Contractor. 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 - An identifier used by EOHHS to identify a specific grouping of Enrollees for which a discrete Base Capitation Rate applies pursuant to the Contract. Readiness Review – Prior to being eligible to accept SCO enrollments, each prospective Contractor selected to operate a SCO plan must undergo a Readiness Review. The Readiness Review evaluates each prospective Contractor’s ability to comply with the requirements specified in this Contract, 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. EOHHS will use the results to inform its decision of whether the prospective Contractor is ready to operate a SCO plan. At a minimum, each Readiness Review includes a desk review and potentially a site visit to the prospective Contractor’s headquarters. Recovery Learning Community (RLC) – Consumer-run networks of self-help/peer support, information and referral, advocacy and training activities. Training in recovery concepts and tools, advocacy forums a...
Program of All-Inclusive Care for the Elderly. (PACE)
A. The Contractor shall determine NF LOC for potential PACE members not in Medicaid Managed Care. The Contractor shall review initial and annual/continued stay LOC requests for PACE using the Medicaid Nursing Facility (NF) criteria and instructions. The Contractor shall approve or deny the requested NF LOC.
B. The Contractor shall ensure that its PACE reviewers meet the following minimum criteria for education and experience:
1. Active Nursing license in New Mexico or compact license (RN or LPN) with a minimum of one (1) year of relevant experience.
2. Medical Social Worker with a minimum of 1 year of relevant experience.
3. Physical, Occupational, or Rehab Therapists with a minimum of one (1) year of relevant experience.
C. The Contractor shall perform PACE LOC reviews by Record Abstract Review of all enrollment requests. The provider submits a MAD 379 Form, History and Physical, physician order, and required supporting documentation.
D. The Contractor shall attend the initial NF LOC criteria and instructions training held by HSD. The Contractor shall develop internal reviewer trainings and evaluation using HSD approved materials. The Contractor shall submit an initial training material, evaluation and calendar of training events to HSD for approval. After final approval is given, HSD will attend the initial Contractor internal trainings. The Contractor shall ensure that all reviewers have, at a minimum, initial and annual training.
E. In cases of LOC requests pertaining to recipients whose PACE Medicaid eligibility has not yet been decisioned by ISD, the Contractor shall determine the LOC, and send the LOC data to the ISD office via the ASPEN interface, or by fax if the interface is unavailable or if the Contractor is otherwise directed by HSD. The Contractor is to assign a temporary alternative ID number and later merge the member profile with the assigned Medicaid ID when the ID determines that the participant has received approval of eligibility.
F. For new PACE eligible members transferring from a Medicaid Managed Care MCO, an existing NF LOC determination and functional assessment performed by the MCO can be used for NF LOC for PACE certification and TPA/FFS UR data entry.
Program of All-Inclusive Care for the Elderly
