Or. Admin. Code § 411-045-0020

Current through Register Vol. 63, No. 12, December 1, 2024

Section 411-045-0020 - Program Administration

(1) A PACE program must be, or be a distinct part of, one of the following:

(a) An entity of a city, county, state, or tribal government;

(b) A private, not-for-profit entity organized for charitable purposes under section 501(c)(3) of the Internal Revenue Code or 1986; or

(c) A PACE for-profit demonstration program that has been approved by CMS.

(2) The PACE program's service area must be approved by both the Department and CMS.

(3) The PACE program must employ a program director who is responsible for oversight and administration of the program.

(4) The PACE program must employ a medical director who is responsible for the delivery of participant care as well as the performance of the quality improvement program.

(5) The PACE program must notify the Department in writing 90 days before changes in organizational structure, including ownership, take effect. The Department must approve such changes in advance.

(6) A PACE program must have an identifiable governing body (e.g. a board of directors) with full legal authority and responsibility for the following:

(a) Governance and operation;

(b) Development of policies consistent with the mission;

(c) Management and provision of all services;

(d) Establishment of personnel;

(e) Fiscal operations; and

(f) Quality improvement program.

(7) A PACE program must provide training to maintain and improve the skills and knowledge of staff members in each of the PACE positions.

(8) PACE programs are responsible for payment of all covered services. Such services should be billed directly to the PACE program. PACE programs may require providers to obtain pre-authorization to deliver covered services other than emergency services.

(9) Payment by the PACE program to providers for covered services is a matter between the PACE program and the provider, except as follows:

(a) Pre-Authorizations:

(A) PACE programs must have written procedures for processing valid pre-authorization requests received from any provider;

(B) Authorizations for prescription drugs must be completed and the pharmacy notified within 24 hours. If an authorization for a prescription cannot be completed within the 24 hours, the PACE program must provide for the dispensing of at least a 72-hour supply if the medical need for the drug is immediate. The PACE program shall notify providers of such determination within 2 working days of receipt of the request; and

(C) PACE programs will notify PACE participants of a denial of an authorization request within five working days from the final determination using the Department approved client notice format.

(b) Claims Payment:

(A) PACE programs must have written procedures for processing claims submitted for payment from any source;

(B) PACE programs must pay or deny at least 90% of valid claims within 45 calendar days of receipt and at least 99% of valid claims within 60 calendars days of receipt. PACE programs shall make an initial determination on 99% of all claims submitted within 60 calendar days of receipt; and

(C) PACE programs must provide written notification of determinations when such determinations result in a denial of payment for services, for which the PACE participant may be financially responsible. Such notice must be provided to the PACE participant and the treating provider within fourteen (14) calendar days of the final determination. The notice to the participant must be a Department-approved notice format and will include information on the PACE program's internal appeals process, and the Notice of Hearing Rights (DMAP 3030) will be attached. The notice to the provider must include the reason for the denial.

(c) PACE programs are responsible for payment of Medicare coinsurances and deductibles up to the Medicare or PACE program's allowable amount for covered services the PACE participant receives with authorized referrals and for urgent or emergency services from non-participating providers.

(d) PACE programs will pay transportation, meals and lodging costs for the PACE participant and any required attendant for out-of-state services (as defined in DMAP general rules) that the PACE program has arranged and authorized when those services are available within the state, unless otherwise approved by the Department.

(e) PACE programs will be responsible for payment of covered services provided by a non-participating provider that were not pre-authorized if the following conditions exist:

(A) It can be verified that the participating provider ordered or directed the covered services to be delivered by a non-participating provider;

(B) The covered service was delivered in good faith without the pre-authorization;

(C) It was a covered service that would have been pre-authorized with a participating provider if the PACE program's referral protocols had been followed; and

(D) The PACE programs will be responsible for payment to non-participating providers according to the PACE program's reimbursement policies.

(10) Under a PACE program agreement and 42 CFR 460.180, CMS makes a prospective monthly payment to the PACE organization of a capitation rate for each Medicare participant. Consistent with the requirements of 42 CFR 460.180, PACE programs are responsible for payment up to the PACE contracted rates for covered services the PACE participant receives for authorized referral care, and for urgent or emergency services received from non-contracted providers.

(11) Under the PACE program agreement and 42 CFR 460.182, the Department makes a prospective monthly payment to the PACE organization of a capitation rate for each Medicaid participant. The PACE program must accept the capitation payment as payment in full for Medicaid participants and may not bill, charge, collect or receive any other form of payment from the Department or from or on behalf of the participant, except as follows:

(a) Payment with respect to the applicable spend-down liability and any amounts due under the post-eligibility treatment of income;

(b) Medicare payment received from CMS or from other payors, in accordance with section (10) of this rule; or

(c) Adjustments related to enrollment and disenrollment of participants in the PACE program; and

(d) Fee for service payments by the Department or Medicare prior to the participant being capitated.

(12) A PACE program must meet the requirements stated in 42CFR Part 460, Programs of All Inclusive Care for the Elderly (PACE) except where these rules are at variance.

Or. Admin. Code § 411-045-0020

SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01; SPD 2-2005, f. & cert. ef. 1-4-05

Stat. Auth.: ORS 410.090

Stats. Implemented: ORS 410.070