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Final Rule Updates CMS PACE Program


 

Final Rule Updates CMS PACE Program

CMS recently updated regulations for Programs for All-Inclusive Care for the Elderly (PACE) to strengthen protections for participants and allow more operational flexibility for providers. PACE seeks to provide comprehensive, whole person care to some of the nation's most vulnerable citizens, allowing them to stay in their homes.

Although still a small part of overall senior care from the Centers for Medicare & Medicaid Services, PACE organizations (POs) have doubled over the last decade from 63 to 124. Today, more than 45,000 older adults are enrolled in programs across 31 states, including Tennessee. PACE programming combines medical, social and long-term care services for frail individuals, allowing them to continue living in their homes and communities instead of being institutionalized.

PACE organizations provide services in the home, community and PACE center. Participants might be required to use a physician in the PACE network, but the PO contracts with numerous area specialists and support service providers. Most PACE participants are dually eligible for Medicare and Medicaid benefits.

To qualify, an individual must be age 55 or over, live in a service area where there is a PACE organization, be eligible for skilled nursing care but be able to live safely in the community with some supports in place. A capitated program, the interdisciplinary team of providers can use the fixed amount of funding to deliver whatever type of services an individual might need instead of only providing those reimbursable under Medicare or Medicaid fee-for-service plans.

A recent final rule, released at the end of May, made the first updates to the program since 2006. According to a CMS spokesperson, the National PACE Association (NPA) and POs have requested updates and changes to the PACE program for more than a decade. Their comments have focused primarily on providing more administrative flexibility and ensuring that PACE requirements align with today's standards of care and practice.

"This rule is the first major update to the PACE program since 2006 and reflects updates to best practices in caring for frail and elderly individuals, as well as changes in technology," said the spokesperson. For example, the update allows for the use of electronic communication and the automation of certain processes.

Additionally, the rule revises and updates PACE requirements for application and waiver procedures, enforcement action and administrative requirements, participant rights, quality assessment and performance improvement, participant enrollment and disenrollment, federal and state oversight and monitoring, data collection, and reporting requirements, among other issues.

"The finalized changes provide greater operational flexibility, remove redundancies and outdated information, and codify existing practice," said the spokesperson. "For example, we are implementing a more flexible approach to the composition of the interdisciplinary team that is central to the coordinated care participants receive from PACE organizations in order to allow the team to better meet participants' needs. Now, one individual will be able to fill two separate roles on the interdisciplinary team in certain circumstances, which will strengthen the ability of the PACE organization to provide more seamless care and better tailor care to individual participants." Prior to the final rule, team members could only fulfill one role on the care team.

In order to expand access to PACE, the spokesperson said CMS is finalizing a number of other flexibilities, including allowing certain non-physician primary care providers to deliver some care in place of a physician where appropriate. Other regulation changes are focused on increasing participant protections by:

  • Clarifying POs that are offering qualified prescription drug coverage must comply with Part D requirements unless the requirement has been waived,
  • Implementing changes to enforcement action authority to enable CMS to hold POs accountable for non-compliance,
  • Increasing transparency and making the regulations more comprehensible for participants and providers,
  • Adding language to help ensure individuals with a criminal conviction for offenses related to physical, sexual or substance abuse or use could not be employed in any capacity where their might pose a potential risk.

Additionally, the final rule codified an existing practice by CMS of relying on automated review systems for processing initial applications to become a PACE organization or for existing POs to expand. For more information on the PACE program or how to apply to become a PACE provider, please go online to NashvilleMedicalNews.com and click on the PACE Fact Sheet.

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Tags:
CMS, Community-based Care, Medicaid, Medicare, PACE, Programs of All-Inclusive Care for the Elderly
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