N.M. Admin. Code § 8.315.2.13

Current through Register Vol. 35, No. 21, November 5, 2024

Section 8.315.2.13 - COVERED SERVICES

The PACE program is a partially capitated, community based service program. The PACE program will ensure access to a comprehensive benefit package of services to a frail population that meets nursing facility clinical criteria. The provider will provide all medicaid services that are included in a capitated rate. Medicare covered services will be reimbursed through a medicare capitated rate. The provider will provide medicare-eligible PACE participants with all medicare services that are included in the medicare capitated rate. Effective Janaury 1, 2006, upon the implementation of medicare part D prescription drug coverage, pharmacy costs for PACE medicare beneficiaries are covered by the medicare capitated rate. Pharmacy costs for medicaid only recipients would be covered by the medicaid only capitated rate.

A. Adult day health center: The focal point for coordination and provision of the majority of the PACE program services is the adult day health center. The adult day health center will include a primary care clinic and areas for therapeutic recreation, restorative therapies, socialization, personal care and dining. The center shall include the following areas:

(1) examination room(s);

(2) treatment room(s);

(3) therapy room(s);

(4) dining room(s);

(5) activity room(s);

(6) kitchen;

(7) bathroom(s);

(8) personal care room(s);

(9) administrative office(s);

(10) counseling office(s);

(11) pharmacy/medication room; and

(12) laboratory;

B. Interdisciplinary team: The interdisciplinary team is a critical element of the PACE program. The ongoing process of service delivery in this model requires the team to identify participant problems, determine appropriate treatment objectives, select interventions and evaluate efficiencies of care on an individual participant basis. The interdisciplinary team is composed of, but not limited to, the following members: Primary care physician, nurse, dietician, social worker, physical therapist, occupational therapist, speech therapist, recreational therapist or coordinator, day health center supervisor, home care liaison, health workers/aides, and drivers. Some of the interdisciplinary team members may be project staff and some may be contracted positions. All members must meet applicable state licensing and certification requirements and provide direct care and services appropriate to participant need.

C. Benefit package: The benefit package includes the following:

(1) a service delivery system that ensures prompt access to all covered services, including referral protocols, approved by the interdisciplinary team;

(2) access to medical care and other services, as applicable, 24 hours per day, seven days a week, 365 days per year; all care and services shall be available and shall be provided at such times and places, including the participants home or elsewhere, as are necessary and practical;

(3) access to an acute and comprehensive benefit package of services, including, but not limited to:

(a) interdisciplinary assessment and treatment planning;

(b) social work services;

(c) nutritional counseling;

(d) recreational therapy;

(e) meals;

(f) restorative therapies, including physical therapy, occupational therapy and speech therapy;

(g) home care (personal care, nursing care and disposable medical supplies), see 8.325.9 NMAC, Home Health Services;

(h) transportation, see 8.324.7 NMAC, Transportation Services and Lodging;

(i) drugs and biologicals; effective January 1, 2006, pharmacy costs are reimbursed by medicare for medicare beneficiaries; pharmacy costs for medicaid-only recipients are reimbursed by medicaid through the medicaid-only capitated rate; see 8.324.4 NMAC, Pharmacy Services, and Subsection D of 8.310.2.12 NMAC, Medical Services Providers;

(j) prosthetics, medical supplies and durable medical equipment, corrective vision devices such as eyeglasses and lenses, hearing aids, dentures and repairs and maintenance for these items; see 8.324.8 NMAC, Prosthetics and Orthotics; 8.310.6 NMAC, Vision Care Services; 8.324.6 NMAC, Hearing Aids and Related Evaluations; 8.310.7 NMAC, Dental Services; 8.324.5 NMAC, Durable Medical Equipment and Medical Supplies;

(k) behavioral health services, 8.310.8 NMAC, Mental Health Professional Services and 8.315.3 NMAC, Psychosocial Rehabilitation Services;

(l) nursing facility services which include, but are not limited to, the following: semi-private room and board, physician and skilled nursing services, custodial care, personal care and assistance, biologicals and drugs, physical, speech, occupational and recreational therapies, if necessary, social services, and medical supplies and appliances, see 8.312.2 NMAC, Nursing Facilities; 8.311.4 NMAC, Outpatient Psychiatric Services and Partial Hospitalization; 8.325.8 NMAC, Rehabilitation Service Providers; 8.324.4 NMAC, Pharmacy Services; Subsection D of 8.310.2.12 NMAC, Medical Services Providers; 8.324.5 NMAC, Durable Medical Equipment and Medical Supplies; and

(m) urgent care services.

(4) coordinating access for the following services:

(a) primary care services including physician and nursing services;

(b) medical specialty services, including but not limited to: anesthesiology, audiology, cardiology, dentistry, dermatology, gastroenterology, gynecology, internal medicine, nephrology, neurosurgery, oncology, ophthalmology, oral surgery, orthopedic surgery, otorhinolaryngology, plastic surgery, pharmacy consulting services, podiatry, psychiatry, pulmonary disease, radiology, rheumatology, surgery, thoracic and vascular surgery, urology; see 8.301.2 NMAC, General Benefit Description; 8.310.2 NMAC, Medical Services Providers; 8.311.2 NMAC, Hospital Services; 8.310.5 NMAC, Anesthesia Services; 8.324.6 NMAC, Hearing Aids and Related Evaluations; 8.310.7 NMAC, Dental Services; and 8.310.6 NMAC, Vision Care Services;

(c) laboratory and x-rays and other diagnostic procedures; see 8.324.2 NMAC, Laboratory Services;

(d) acute inpatient services, including but not limited to, the following: ambulance, emergency room care and treatment room services, semi-private room and board, general medical and nursing services, medical surgical/ intensive care/coronary care unit as necessary, laboratory tests, x-rays and other diagnostic procedures, drugs and biologicals, blood and blood derivatives, surgical care, including the use of anesthesia, use of oxygen, physical, speech, occupational, and respiratory therapies, and social services; see 8.301.2 NMAC, General Benefit Description; 8.324.8 NMAC, Prosthetics and Orthotics; 8.324.10 NMAC, Ambulatory Surgical Center Services; and 8.310.5 NMAC, Anesthesia Services; 8.324.2 NMAC, Laboratory Services; 8.324.4 NMAC, Pharmacy Services; Subsection D of 8.310.2.12 NMAC, Medical Services Providers; 8.325.8 NMAC, Rehabilitation Service Providers; and

(e) hospital emergency room services.

(5) in area emergency care; all medicaid reimbursable emergency services included in the capitated rate will be reimbursed by the PACE program to a non-affiliated provider when these services are rendered within the PACE program geographic service area; these emergency services will be reimbursed by the PACE program only until such time as the participant's condition permits travel to the nearest PACE program-affiliated facility;

(6) out-of-area emergency care that is provided in, or en route to, a hospital or hospital emergency room, in a clinic, or physician's office, or any other site outside of the PACE program service area; covered services included in the capitation rate will be paid by the PACE program when rendered in and out-of-area medical emergency, but only until such time as the participants condition permits travel to the nearest PACE program-affiliated facility.

N.M. Admin. Code § 8.315.2.13

8.315.2.13 NMAC - Rp, 8 NMAC 4.MAD.777.4, 12-1-06, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024