CMS proposes changes to PACE designed to modernize program


The Centers for Medicare and Medicaid (CMS) is proposing a number of changes to the regulations that control the Programs of All-Inclusive Care for the Elderly. PACE, as it is known, allows seniors, most of whom are eligible for Medicare and Medicaid, to live and receive care at home instead of in a skilled nursing facility.

More than 34,000 older adults are currently enrolled in about 100 PACE organizations in 31 states including Florida. Enrollment in PACE has increased by more than 60 percent since 2011, according to CMS.

The proposed 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.

CMS is looking to revise and update the policies finalized in the 2006 final rule to reflect changes that have taken place over the last decade in how frail and elderly are cared for, as well as changes in technology (for example, the use of electronic communications, including email, and the automation of certain processes).

CMS noted that while PACE has successfully allowed frail, older duel eligible individuals, to remain in community settings, it is now necessary to revise some regulatory provisions to afford more flexibility to PACE Organizations (PO) and state administering agencies as a way to encourage its expansion to more states, “thus increasing access for participants, and to further enhance the program’s effectiveness at providing care while reducing costs,†notes CMS.

Among the proposed rules:

  • Allowing non-physician medical providers, practicing within the scope of their state licensure and clinical practice guidelines, to serve in place of primary care physicians in some capacities, and permitting POs to better tailor the Interdisciplinary Teams (IDTs) to improve efficiency, while continuing to meet the needs of their participants.
  • Require each PACE organization to create compliance oversight requirements and adopt measures to prevent, detect, and correct waste, fraud, and abuse and address non-compliance with CMS’s program requirements.
  • Addresses payment methods. Under PACE, financing is capped, allowing providers to deliver all services participants need instead of only those reimbursable under Medicare and Medicaid fee-for-service plans. There is no national Medicaid rate-setting methodology for PACE. Instead, each state that elects PACE as a Medicaid state plan option must create a payment amount based on the cost of comparable services for the state’s nursing facility-eligible population. The amounts generally are based on a blend of the cost of nursing home and community-based care for the frail elderly. The monthly capitation payment amount is negotiated between the PO and the State Administering Agency (SAA) and can be renegotiated on an annual basis.
  • Revise the rule to require that the PACE program agreement contain the state’s Medicaid capitation rate or the “methodology†for establishing the Medicaid capitation rates.

“We believe that providing the option of including the state’s methodology for calculating the Medicaid capitation payment amount is consistent with the statutory requirement in section 1934(d)(2) of the Act that the program agreement specify how the PO will be paid for each Medicaid participant, and will result in less burden for POs, states and CMS by eliminating the frequency of updates to the PACE program agreement to reflect the routine changes to the PACE Medicaid capitation rates,†CMS noted in its proposal.

Create new language to ensure that the Medicaid rate paid under the PACE program agreement is not only less than what would otherwise have been paid outside of PACE for a comparable population, but also is sufficient for the population served under the PACE program, which it believes means not lower than an amount that would be reasonable and appropriate to enable the PO to cover the anticipated service utilization of the frail elderly participants enrolled in the program and adequate to meet PACE program requirements.

Public comments are due on Oct. 17, 2016 after a 60-day comment period.

The Health Law Offices of Anthony C. Vitale can assist clients with enrolling in the PACE Program or subcontractors with an already established PACE provider.

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