D.C. Mun. Regs. tit. 29, r. 29-8814

Current through Register Vol. 71, No. 43, October 25, 2024

Rule 29-8814 - SANCTIONS, ENFORCEMENT ACTIONS, AND TERMINATION

8814.1

If CMS determines that the PACE organization has committed any of the violations set forth at 42 CFR § 460.40(a), or CMS or DHCF makes a determination that could lead to a termination of the PACE program agreement under 42 CFR § 460.50, CMS has the authority to impose the following sanctions:

(a) Suspend enrollment of Medicare beneficiaries or suspend Medicare payment to the PACE organization, in accordance 42 CFR § 460.42;

(b) Impose civil money penalties, in accordance with 42 CFR § 460.46; or

(c) Pursue any other remedies authorized by federal or District law.

8814.2

If CMS, after consultation with DHCF, determines that the PACE organization is not in substantial compliance with program requirements, CMS or DHCF has authority to take one or more of the following actions:

(a) Condition the continuation of the PACE program agreement upon timely execution of a corrective action plan;

(b) Withhold some or all payments under the PACE program agreement until the PACE organization corrects the deficiency; or

(c) Terminate the PACE program agreement.

8814.3

CMS or DHCF has the authority to terminate a PACE program agreement at any time for cause, including, but not limited to the circumstances set forth in paragraphs (a) or (b) of this subsection:

(a) CMS or DHCF has authority to terminate a PACE program agreement if a determination is made that both of the following circumstances exist:

(1) Either:

(i) There are significant deficiencies in the quality of care furnished to participants; or

(ii) The PACE organization failed to comply substantially with conditions for a PACE program or PACE organization under 42 CFR Part 460 , or with terms of its PACE program agreement, including making payment to an individual or entity that is included on the preclusion list, defined at 42 CFR § 422.2.

(2) Within thirty (30) days of the date of the receipt of written notice of a determination made under § 8814.3(a)(1), the PACE organization failed to develop and successfully initiate a plan to correct the deficiencies or failed to continue implementation of the plan of correction.

(b) CMS or DHCF has authority to terminate a PACE program agreement if CMS or DHCF determines that the PACE organization cannot ensure the health and safety of its participants. This determination may result from the identification of deficiencies that CMS or DHCF concludes cannot be corrected.

8814.4

The PACE organization has authority to terminate a PACE program agreement after giving timely written notice to CMS, DHCF, and participants. Notice shall be timely if the PACE organization:

(a) Submits written notice to CMS and DHCF at least ninety (90) days before the proposed effective date of the termination; and

(b) Submits written notice to participants at least sixty (60) days before the proposed effective date of the termination.

8814.5

The PACE organization must develop a written plan detailing how, in the event of termination, the organization will complete the following actions:

(a) Give written notice to participants, the community, CMS, and DHCF about termination and transition procedures;

(b) Assist participants with reinstatement of conventional Medicare and Medicaid benefits;

(c) Transition participants' care to other providers; and

(d) End all marketing and enrollment activities.

8814.6

A PACE organization whose PACE program agreement is in the process of being terminated must assist each participant in obtaining necessary transitional care through appropriate referrals and making the participant's medical records available to new providers.

D.C. Mun. Regs. tit. 29, r. 29-8814

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