016.06.06 Ark. Code R. 021
The Program of All-inclusive Care for the Elderly (PACE) is an innovative model that enables individuals who are 55 years of age or older and certified by the state to need nursing facility care, to live as independently as possible. Through PACE, fragmented health care financing and delivery system comes together to serve the unique needs of the enrolled individual with chronic care needs. The population served by PACE is historically very frail. The PACE organization must provide all needed services to the PACE participant.
In order to ensure quality and continuity of care, all PACE providers approved to receive Medicaid reimbursement for services provided must meet specific qualifications.
Prior to enrollment of an applicant as a PACE Provider, the following must occur:
Staff members (employees or contractors) of the PACE Organization must meet the following conditions:
The PACE Organization must provide training to maintain and improve the skills and knowledge of each staff member with respect to the individual's specific duties that results in his or her continued ability to demonstrate the skills necessary for the performance of the position.
A PACE Organization must have a formal process in place to gather information and must be able to respond in writing to a request from CMS and/or the State Administering Agency (SAA) for information regarding:
The PACE organization must establish, implement, and maintain a documented infection control plan that meets the following requirements:
A PACE organization's transportation services must be safe, accessible, and equipped to meet the needs of the participant population.
Except as specified in paragraphs items B or C of this section, the PACE organization must provide each participant with a nourishing, palatable, well-balanced meal that meets the daily nutritional and special dietary needs of each participant.
The State of Arkansas will utilize essentially the same non-medical and medical eligibility criteria for the PACE participants as that used for determining eligibility for nursing facility services.
An individual who does not meet the non-medical criteria may participate in the PACE Program as private pay if he or she meets the same medical criteria as Medicaid eligibles.
Medicaid eligibility for the PACE Program will be based on the following requirements:
PACE participants must meet one of the following criteria: The individual is unable to perform either of the following:
NOTE: If an individual has a serious mental illness or has mental retardation, the individual will not be eligible for PACE unless the individual has medical needs unrelated to the diagnosis of serious mental illness or mental retardation and meets the criteria set out in Sections 204.100 and 204.200 above.
All medical records of PACE participants must be completed promptly, filed and retained for a minimum of five (5) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. The records must be available upon request for audit by an authorized representative of the Arkansas Division of Medical Services, the State Medicaid Fraud Control Unit and representatives of the Department of Health and Human Services.
All services provided to the PACE participant must be properly documented in the PACE participant's record and signed by the service provider at the time the service is delivered. At a minimum, the medical record must contain appropriate identifying information and documentation of all services furnished including the following:
All documentation must be available to representatives of the Division of Medical Services at the time of an audit by the Medicaid Field Audit Unit. All documentation must be available at the provider's place of business. No more than thirty (30) days will be allowed after the date on the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted after the 30-day period.
A PACE Organization must establish and implement a written plan to furnish care that meets the needs of each participant in all care settings 24 hours per day, every day of the year.
The PACE benefit package for all participants, regardless of the source of payment, must include the following as prescribed by the interdisciplinary team assessment:
The following services are excluded from coverage under PACE:
To enroll in the PACE program, an individual must meet the requirements specified in sections 204.000 through 204.200.
Participant enrollment into the PACE Program is voluntary. When an individual expresses the wish to enroll, the PACE provider will notify the DHHS-RN to schedule an eligibility assessment for nursing facility level of care.
The Division of Aging and Adult Services of the Department of Health and Human Services must assess the potential enrollee and concur that he or she meets the requirements for nursing facility care prior to enrollment. The Department of Health and Human Services (DHHS) -RN must certify that an assessment has been completed and it is safe for the participant to live in the community. The DHHS-RN will notify the local DHHS county office and the Provider Organization (PO) that all requirements have been met.
The PACE provider must explain to the potential enrollee that enrollment in PACE results in disenrollment in any other Medicare or Medicaid plan and the provider is required to complete an intensive assessment that includes a minimum of one home visit and one visit by the potential enrollee to the PACE center unless otherwise approved by CMS.
Participants may voluntarily disenroll from the PACE program at any time for any reason. Participants may be involuntarily disenrolled due to:
In order to involuntarily disenroll a participant, the PACE Organization must obtain the prior review and approval of the Department of Health and Human Services. The request to disenroll a participant and documentation to support the request must be sent to the DHHS- RN. The DHHS- RN will review the request and corresponding documentation and will make a recommendation to the DHHS- RN Supervisor and DHHS PACE Program Manager regarding whether the PACE Organization should proceed with the involuntary disenrollment. The DHHS RN Supervisor, in consultation with PACE Program management will make a final determination regarding the appropriateness of the involuntary disenrollment and will notify the PACE Organization and the DHHS-RN.
The PACE Organization may request an administrative reconsideration pursuant to section 190.003. A request for administrative reconsideration must be directed to the Division of Aging and Adult Services (DAAS).
The PACE interdisciplinary team must meet regularly as indicated in the Provider Agreement between the PO, CMS, and DAAS to provide overall assessment of care needs and subsequent management, supervision and provision of care for eligible individuals.
The PACE interdisciplinary team must be composed of at least the following members:
The interdisciplinary team is responsible for assessment, treatment planning and care delivery once the DHHS-RN has completed the initial eligibility assessment for nursing facility level of care. The team must meet the following assessment requirements:
PACE organizations consolidate discipline specific plans into a single plan of care semi-annually through discussion and consensus of the interdisciplinary team. The consolidated plan is then discussed and finalized with the PACE participant and or his or her significant others.
Reassessments and treatment plan changes are completed when the health or psychosocial situation of the participant changes.
When an adverse decision is received, the PACE participant may appeal. The appeal request must be in writing and received by the Appeals and Hearing Section of the Department of Health and Human Services within thirty (30) days of the date on the letter explaining the decision. View or print Appeals and Hearings Section contact information.
The Department of Health and Human Services will conduct site visits annually in conjunction with CMS or as needed to review the quality of service provision by the PACE Organization. The annual site visit review will include a clinical and administrative component and a review of compliance with life safety codes. The annual on-site review will include but not be limited to a review of the PACE Organization's compliance with requirements in 42 CFR § 460, or its successor, in the following compliance areas:
DHHS will be responsible for conducting an exit conference with the PACE Organization to discuss any review findings and to provide technical assistance in developing corrective action plans and to assist the PO in their efforts to implement the required corrections.
Due to the requirement that PACE Organizations be licensed as Arkansas Adult Day Health Care Centers, the Office of Long Term Care will be conducting monitoring and oversight of the PACE Center operations. The Division of Aging and Adult Services will coordinate their on-site visits and monitoring with the Office of Long Term Care.
DHHS- RN's are also required to monitor at least 25% of their PACE caseload during each performance evaluation period (12 months). Of this 25%, at least 50% of those contacts must be face to face and must include interviews with participants and caregivers/participant representatives. In addition, one-half of these in person contacts must take place in the PACE center and the remaining contacts must take place in the participants' homes.
During each monitoring contact, questions must be asked regarding quality of care, provision of services, and compliance with the established plan of care. These monitoring requirements are in addition to those contacts made routinely by maintaining the caseload.
Manager
The DHHS-RN supervisors must review at least 10% of the charts for each DHHS- RN under their supervision during each performance evaluation period. These may be random selections or selections based on information documented in the chart. During these thorough reviews, the RN supervisors will note any deviations from policy and discuss with the RN and verify that for the period under review, the appropriate amount of PACE capitation payments have been paid for the participant charts under review. Charts are chosen at random based on the latest ANSWER Monthly Report. Random selections are made by the RN Supervisor based on assessments and reassessments, the start dates and the dates on the DHHS 703-Evaluation of Medical Need Criteria. The results of this review are shared with the PACE Program Manager so that the manager can assess program quality assurance issues.
Semi-annually, the DHHS-RN supervisors and the PACE Program Administrator must review charts selected at random from each nurse's caseload. The charts will be reviewed for compliance with program policy. In addition, the RN Supervisor and Program Administrators will review payment records to verify that capitation payments have been paid appropriately to the PACE Provider. The PACE Organization will make available charts for review at the PACE site or as requested by DHHS Review Staff.
Annually, the DHHS- RN Supervisors and the Program Administrator will accompany the DHHS-RNs on assessment and reassessment home visits. During these visits, the RN will be reviewed for interviewing techniques, compliance with program policy, compliance with medical criteria application and compliance with documentation requirements.
In compliance with federal requirements, each PACE Organization will enter required information for nine (9) key indicators into the Health Plan Management System (HPMS), or any successor data elements or data system on a quarterly basis. Both CMS and the State Administering Agency (SAA) will use the data entered into HPMS or its successor system to monitor the ongoing operations of the PACE Organization and identify potential problems or unusual events that may be the first indication of problems in patient care, site operations or financial solvency. These reviews will also be used to determine if further onsite monitoring will be necessary.
Prior authorization of specific services does not apply to the PACE Program.
PACE services are financed primarily through Medicaid and Medicare capitated payments. Providers must provide all needed services for PACE participants with the monthly capitated funds.
The PACE rates are based on the Upper Payment Limit (UPL) methodology. The historical fee-for-service population data is extracted for claims and eligibility for PACE eligible populations for more than one fiscal period. Data for participant aged, blind and disabled aid categories for those 55 or greater is used in the UPL and rate calculations. The level of care codes are limited to nursing facility level of care eligible or waiver level of care eligible (waivers included are the ElderChoices Waiver and the Adults with Physical Disabilities Waiver).
The base rates are calculated using calendar year base data. The base year data is trended forward using the historical claims and eligibility information extracted for the fee-for-service population. The recent trend rates are compared to linear regression model trend rates to determine comparability, and to determine if any adjustments are necessary. The trend rates for future periods are expected to be consistent with the most recent cost-data available.
The UPL amounts are reduced by a percentage amount to establish the PACE capitation rate. The percentage (%) amount will be based on the anticipated reductions in health care service costs due to the implementation of the managed care PACE program. Reductions in costs are anticipated to be realized through a reduction in nursing facility and in-patient hospital costs. The UPL will be reset and recalculated every two years.
Participants may be private pay if they choose the service, but do not meet the requirements for Medicaid eligibility.
A provider may request reconsideration of a program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel, established by the Director of the Division of Medical Services, which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Health and Human Services (DHHS) Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
ATTACHMENT 3.1-A
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM STATE ARKANSAS
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
CATEGORICALLY NEEDY
ATTACHMENT 3.1-B
MEDICALLY NEEDY
016.06.06 Ark. Code R. 021