Section 471-37-004 - PACE BENEFITS004.01 Benefits The PACE benefit package for all participants, regardless of source of payment, shall include the following:
1. All Medicare-covered items and services;2. All Medicaid-covered items and services as specified in Nebraska's approved Medicaid State Plan; and3. Other services determined necessary by the PACE organization's interdisciplinary team to improve and maintain the participant's overall health status.004.02 Benefit Conditions If a Medicare beneficiary or Medicaid recipient chooses to enroll in the PACE program, the following conditions apply:
1. Medicare and Medicaid benefit limitations and conditions relating to amount, duration, scope of services, deductibles, copayments, coinsurance, or other cost-sharing do not apply (Note: Participants who have been determined to have a Medicaid share of cost remain responsible to meet their share of cost as per 469 NAC 4); and2. The participant, while enrolled in the PACE program, shall receive all Medicare and Medicaid benefits, as well as other services determined necessary by the PACE organization interdisciplinary team, solely through the PACE organization.004.03 Excluded Benefits The following services are excluded from coverage under PACE:
1. Any service that is not authorized by the interdisciplinary team.2. In an inpatient facility, a private room and private duty nursing services, unless medically necessary, as well as non-medical items for personal convenience unless specifically authorized by the interdisciplinary team as part of the participant's plan of care.3. Cosmetic surgery, not including surgery that is required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction following mastectomy.4. Experimental medical, surgical, or other health procedures.5. Services furnished outside of the United States, including the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands, except under particular circumstances and as permitted under the Medicaid State Plan.471 Neb. Admin. Code, ch. 37, § 004