La. Admin. Code tit. 50 § XXIII-901

Current through Register Vol. 50, No. 11, November 20, 2024

Section XXIII-901 - Violations

A. Sanctions may be imposed against a PACE organization if it commits one of the following violations:

1. fails to provide medically necessary items and services to a participant that are covered PACE services, and that failure has adversely affected (or has substantial likelihood of adversely affecting) the participant;

2. involuntarily disenrolls a participant in violation of 42 CFR 460.164;

3. discriminates in the enrollment or disenrollment of Medicare beneficiaries or Medicaid participants, or both, who are eligible to enroll in a PACE program on the basis of a participant's health status or need for health care services;

4. engages in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment, except as permitted by Section 460 150, by Medicare beneficiaries or Medicaid participants whose medical condition or history indicates a need for substantial future medical services;

5. imposes charges on participants enrolled under Medicare or Medicaid for premiums in excess of the premiums permitted;

6. misrepresents, falsifies, or fails to disclose information that is furnished to:

a. CMS or the state under this Part XXIII; or

b. an individual or any other entity under this Part XXIII;

7. prohibits or otherwise restricts a covered health care professional from advising a participant who is a patient of the professional about the participant's health status, medical care, or treatment for the participant's condition or disease, regardless of whether the PACE program provides benefits for that care or treatment, if the professional is acting within his or her lawful scope of practice;

8. operates a physician incentive plan that does not meet the requirements of Section 1876(i)(8) of the Social Security Act; or

9. employs or contracts with any individual who is excluded from participation in Medicare or Medicaid under Section 1128 or Section 1128A of the Social Security Act (or with any entity that employs or contracts with that individual) for the provision of health care, utilization review, medical social work, or administrative services.

La. Admin. Code tit. 50, § XXIII-901

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:249 (February 2004), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 50403 (3/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, Title XIX of the Social Security Act, and 42 CFR 460 et seq.