D.C. Mun. Regs. tit. 29, r. 29-8808

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-8808 - PACE SERVICES

8808.1

If a Medicare beneficiary or Medicaid beneficiary enrolls in PACE, the following conditions apply:

(a) The participant is not subject to Medicare and Medicaid benefit limitations and conditions relating to amount, duration, scope of services, deductibles, copayments, coinsurance, or other cost-sharing; and

(b) The participant, while enrolled in PACE, must receive Medicare and Medicaid benefits solely through the PACE organization.

8808.2

The PACE benefit package for all participants must include the following:

(a) All Medicare-covered items and services;

(b) All Medicaid-covered items and services, as specified in the District's approved Medicaid state plan; and

(c) Other services determined necessary by the interdisciplinary team to improve and maintain the participant's overall health status.

8808.3

The PACE benefit package for Medicare-enrolled participants must also meet the requirements at 42 CFR § 460.94.

8808.4

The following services are excluded from coverage under PACE:

(a) Any service that is not authorized by the interdisciplinary team, even if it is a required service, unless it is an emergency service;

(b) In an inpatient facility, private room and private duty nursing services (unless medically necessary), and nonmedical items for personal convenience such as telephone charges and radio or television rental (unless specifically authorized by the interdisciplinary team as part of the participant's plan of care);

(c) Cosmetic surgery, which does not include surgery that is required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction following mastectomy;

(d) Experimental medical, surgical, or other health procedures; and

(e) Services furnished outside of the United States, except when in accordance with 42 CFR §§ 424.122 and 424.124.

8808.5

The PACE organization must establish and implement a written plan to furnish care that meets the needs of each participant in all care settings twenty-four (24) hours a day, every day of the year.

8808.6

The PACE organization must furnish comprehensive medical, health, and social services that integrate acute and long-term care. These services must be furnished in at least the PACE center, the home, and inpatient facilities.

8808.7

The PACE organization may not discriminate against any participant in the delivery of required PACE services based on race, ethnicity, national origin, religion, sex, gender, age, sexual orientation, mental or physical disability, or source of payment.

D.C. Mun. Regs. tit. 29, r. 29-8808

Final Rulemaking published at 69 DCR 6400 (6/3/2022)