471 Neb. Admin. Code, ch. 37, § 001
This chapter regulates Nebraska's Program of All-Inclusive Care for the Elderly (PACE) provided under Nebraska Medicaid.
Appeal: The process by which a participant may seek and obtain a review and reversal with respect to enrollment denial; involuntary disenrollment; or non-coverage of, or nonpayment for, a service including denials, reductions, or termination of services.
External appeal: The State Administering Agency's or Medicare's formal appeal processes.
Grievance: A complaint, either written or oral, by participants, their family members, and/or representatives expressing dissatisfaction with service delivery or the quality of care furnished.
Internal appeal: A PACE organization's appeal process.
PACE organization: An entity that has a PACE program agreement in effect to operate a PACE program.
PACE program: A program of all-inclusive care for the elderly that is operated by an approved PACE organization and that provides comprehensive healthcare services to PACE participants in accordance with a PACE program agreement.
PACE program agreement: An agreement between a PACE organization, CMS, and the State Administering Agency for the operation of a PACE program.
Participant: An individual who is enrolled in a PACE program.
Premium: The monthly amount that a PACE organization charges a participant as determined by the participant's eligibility status for Medicare and Medicaid pursuant to 42 CFR 460.186.
State Administering Agency (SAA): The State agency responsible for administering the PACE program agreement. In Nebraska the SAA is the Nebraska Department of Health and Human Services, Division of Medicaid and Long-Term Care.
PACE is authorized by Sections 1894 and 1934 of the federal Social Security Act. Federal PACE regulations are located at 42 CFR, Part 460.
471 Neb. Admin. Code, ch. 37, § 001