By Rebecca Mayo, J.D.
CMS has updated the Programs of All-Inclusive Care for the Elderly (PACE) to provide flexibility for PACE organizations and state agencies to expand programs and provide greater access to participants.
The Programs of All-Inclusive Care for the Elderly (PACE) have been updated and modernized in a new final rule that reflects updates in best practices in caring for frail and elderly individuals. Enrollment in PACE has increased by over 120 percent since 2011 and CMS hopes that the final rule will provide greater operational flexibility and allow for expansion of the program to more states and increase access for participants. The final rule, set to publish in the Federal Register on June 3, 2019, aims to strengthen protections and improve care for PACE participants while also providing administrative flexibility and regulatory relief for PACE organizations.
PACE. The PACE program provides comprehensive medical and social services to certain frail, elderly individuals who qualify for nursing home care but, at the time of enrollment, can still live safely in the community. PACE is a model of managed care that includes the provision of adult day health care and interdisciplinary team (IDT) care management, though which access to and allocation of all health services is managed. Physician, therapeutic, ancillary, and social support services are furnished at the participant’s residence or at a PACE center. Hospital, nursing home, home health, and other specialized services are generally furnished under a contract. More than 45,000 older adults are currently enrolled in more than 100 PACE organizations (POs) in 31 states and most participants are dually-eligible for Medicare and Medicaid benefits.
Proposed rule. In an August 2016 proposed rule, revisions and updates were proposed to reflect changes in the practice of caring for the frail and elderly and changes in technology that have occurred since the policies were finalized in the 2006 final rule. The PACE program has proven successful in keeping frail, older individuals in community settings, however revising some regulatory provisions to afford more flexibility to PACE organizations and state administering agencies will encourage the expansion of the program to more states and increase access for participants, which will in turn enhance the program’s effectiveness and reduce costs. Key provisions include permitting one individual to fill two separate roles on the IDT if the individual has the appropriate licenses and qualifications for both roles and permitting the primary care provider that is required for each IDT to include nurse practitioners, physician assistants and community based-physicians.
Provisions of the final rule. The final rule includes important patient protections such as clarifying that POs offering qualified prescription drug coverage must comply with Medicare Part D prescription drug program requirements unless the requirement has been waived. CMS’ ability to hold POs accountable for providing quality care and protect PACE participants from harm is strengthened through enforcement provisions which include sanctions and civil money penalties. Language was also added excluding individuals with a conviction for a criminal offense relating to physical, sexual or drug or alcohol abuse or use from employment at POs in any capacity where their contact with patients would pose a potential risk.
The final rule mostly incorporates the provisions of the proposed rule, although there were slight modifications. The final rule clarifies the timeframes for applications and the waiver submission process. It also revises the text to specify expectations for agent/broker training. The term "primary care" is revised to include services furnished by a primary care provider and nursing services. Appropriate members of the IDT must still conduct the in-person assessments, however unscheduled reassessments may be performed using remote technology in certain circumstances. The provisions relating to the compliance oversight program which require Pos to identify, respond to and correct non-compliance and fraud, waste and abuse, are finalized. And the Medicaid caption rate is revised to provide for reasonable, appropriate and attainable costs that are required under the PACE program agreement for the operation of the PO for the time period and population covered.
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