CMS Releases Final Rules for PACE Programs

PUBLISHED: May 30, 2019
Relevant to: All Healthcare Organizations

The US Centers for Medicare and Medicaid Services (CMS) has released their final rule that updates the requirements for the Programs of All-Inclusive Care for the Elderly (PACE) under the Medicare and Medicaid programs. The rule addresses application and waiver procedures, sanctions, enforcement actions and termination, administrative requirements, PACE services, participant rights, quality assessment and performance improvement, participant enrollment and disenrollment, payment, federal and state monitoring, data collection, record maintenance, and reporting. According to CMS, the changes will provide greater operational flexibility, remove redundancies and outdated information, and codify existing practice.

PACE provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits. An interdisciplinary team of health professionals provides PACE participants with coordinated care. For most participants, the comprehensive service package enables them to remain in the community rather than receive care in a nursing home. Financing for the program is capped, which allows providers to deliver all services participants need rather than only those reimbursable under Medicare and Medicaid fee-for-service plans.

PACE organization must, at a minimum:

  • Have a governing body or a designated person functioning as a governing body that includes participant representation
  • Be able to provide the complete service package regardless of frequency or duration of services;
  • Have a physical site and staff to provide primary care, social services, restorative therapies, personal care and supportive services, nutritional counseling, recreational therapy, and meals
  • Have a defined service area
  • Have safeguards against conflict of interest
  • Have demonstrated fiscal soundness
  • Have a formal Participant Bill of Rights
  • Have a process to address grievances and appeals
  • Have a policy of non-discrimination against any participant in the delivery of required PACE services based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, or source of payment.

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