Mo. Code Regs. tit. 13 § 70-8.010

Current through Register Vol. 49, No.12, June 17, 2024

Section 13 CSR 70-8.010 - Program of All-Inclusive Care for the Elderly

PURPOSE: This rule establishes the requirements for agencies contracting to provide services to eligible participants through the MO HealthNet Division's (MHD) Program of All-Inclusive Care for the Elderly (PACE).

(1) Purpose and Scope. This rule implements the Program of All-Inclusive Care for the Elderly (PACE). PACE provides comprehensive, community-based, acute, and long-term care services to participants who meet certain eligibility requirements, meet the criteria for level of care (LOC), and who can be served safely in the community. PACE is jointly funded and administered by the Centers for Medicare & Medicaid Services (CMS) and the state administering agency (SAA) as defined in section (2) of this rule.

(2) Definitions. For purposes of this regulation, the following words and phrases are defined as follows:

(A) "Interdisciplinary team" shall refer to the interdisciplinary team defined in 42 CFR 460.102 and in the program agreement;

(B) "Level of care (LOC)" shall refer to the level of care provided in a nursing facility, as established by the State of Missouri;

(C) "PACE organization (PO)" shall refer to the entity that provides services to participants under a PACE program agreement with CMS and the SAA;

(D) "Participant" shall refer to a person who receives services through the PACE organization;

(E) "Program agreement" shall refer to an agreement between a PACE organization, CMS, and the state administering agency for the operation of a PACE program; and

(F) "State administering agency (SAA)" shall refer to the Missouri Department of Social Services, MO HealthNet Division (MHD).

(3) Eligibility Criteria.

(A) To be eligible for PACE services, a participant must-

1. Be at least fifty-five (55) years of age;

2. Reside within a PACE organization's service area;

3. Meet the state's level of care requirements;

4. At the time of initial enrollment, reside in a non-institutional setting (e.g., house, apartment) without jeopardizing the participant's health or safety;

5. Agree to obtain all health-related services only through the PACE organization during the participant's period of enrollment in PACE;

6. Not be enrolled in one (1) or more of the following (or will discontinue being enrolled in one (1) or more of the following upon enrollment in PACE):

A. A Medicaid managed-care program other than PACE;

B. A hospice program;

C. A Medicaid 1915(c) home and community-based services (HCBS) waiver program;

D. A nursing facility certified by MHD while MHD is covering the person's nursing facility expenses; or

E. A health home;

7. Not reside in a state mental institution or an intermediate care facility for the intellectually disabled; and

8. Not be in a MO HealthNet coverage penalty period for a transfer of property under 42 U.S.C. 1396p(c).

(4) Enrollment Process.

(A) The PO shall develop and adhere to an enrollment process to be approved by the division.

(B) Completion of enrollment documentation and notifications is the responsibility of the PO in accordance with the division-approved enrollment process.

(5) Disenrollment Process.

(A) The PO shall develop and adhere to a disenrollment process to be approved by the division.

(B) For each participant who is voluntarily or involuntarily disen-rolled, the PO shall-

1. Continue to provide for the necessary services to the participant through the last day of enrollment;

2. Create a discharge plan to help the participant obtain necessary transitional care through appropriate referrals to other Medicaid or Medicare service providers; and

3. Provide the medical records of the participant within five (5) business days after receipt of release of information.

(6) Provider Qualifications.

(A) In order to qualify as a PO, a prospective PO shall-

1. Meet all CMS requirements outlined in the application process through CMS;

2. Enroll as a MO HealthNet provider with the Missouri Medicaid Audit and Compliance Unit (MMAC).

A. Any providers with which the PO contracts for the provision of MO HealthNet-covered services shall also enroll with MMAC; and

3. Shall complete and submit a feasibility study to be approved by the division.

(7) Provider Responsibilities.

(A) The PO shall be responsible for completing the SAA LOC assessment tool with the participant and/or authorized representative, and submitting the determination to the division.

1. The PO shall include with the determination that it submits to the division any supplemental documentation that the PO used to support its assessment.

(B) The PO shall be responsible for enrollment of the participant into PACE services, pursuant to federal and state law.

(C) The PO shall meet all applicable requirements under federal, state, and local law that are relevant to the PACE program and to MO HealthNet providers.

(D) The PO shall adhere to all terms outlined in the PACE program agreement between CMS, the division, and the PO.

(8) Capitation Payment.

(A) The division shall issue to the PO a monthly capitation payment for each PACE-enrolled MO HealthNet participant, and the PO shall assume full financial risk for that participant's care.

(B) The PO shall deliver a comprehensive service package, including all Medicare and Medicaid-covered services, as well as those additional services specified in the PACE program agreement.

(C) The PO shall consolidate the delivery of care by linking Medicaid and Medicare funding through the pooling of all capitation payments.

(9) Termination of the PACE Program Agreement.

(A) The division may terminate a PACE program agreement at any time for cause as outlined in the PACE program agreement.

1. Termination for cause include but is not limited to uncorrected deficiencies in the quality of care furnished to participants, the PACE organization's failure to comply substantially with conditions for a PACE program, or non-compliance with the terms of the program agreement.

(B) In the event of termination of the PACE program agreement, the PO may seek review of the department's action pursuant to section 208.156, RSMo.

(10) Annual Behavioral Health Screenings.

(A) The PO shall conduct annual behavioral health screenings. The PO shall conduct the Short Michigan Alcoholism Screening Test - Geriatric Version (SMAST-G) for every participant.

(B) In addition to the screening test identified in subsection (A) of this section, the PO shall determine which additional annual screening is appropriate for the participant in collaboration with the interdisciplinary team. The PO shall choose one (1) of the following assessments:

1. Rating Anxiety in Dementia (RAID) for participants with dementia; or

2. Geriatric Anxiety Scale - 10 Item Version (GAS-10) for cognitively normal participants.

(11) Provider Reporting.

(A) The PO shall provide to the division a list of all contracted and employed providers, in an easily readable and accessible format, by close of business on the last business day of each quarter (last business day of March, June, September, and December).

(B) The list of providers shall include the following details:

1. Provider/organization legal name;

2. National Provider Identifier (NPI) number; and

3. The effective date on which the provider enrolled with the PO.

(12) Provider Service Areas.

(A) The PO shall designate its service area in the application process through CMS.

1. A service area is made up of the county, zip code(s), street boundaries, census tract, block, or tribal jurisdictional area, as applicable, in which a participant must live in order to receive services from any given PO. The division may require that the service area be made up of one of these types of geographic areas.

2. A PO shall have the exclusive use of its designated service area.

3. The service area shall be established in the program agreement.

13 CSR 70-8.010

Adopted by Missouri Register February 1, 2023/Volume 48, Number 3, effective 3/31/2023