Or. Admin. Code § 411-045-0040

Current through Register Vol. 63, No. 11, November 1, 2024

Section 411-045-0040 - PACE Marketing and Informational Requirements

(1) The PACE program may inform the general public of its program through appropriate informational activities and media. The PACE program must ensure that prohibited marketing activities as defined in 42 CFR 460.82 are not conducted by its employees or its agents.

(2) PACE programs will ensure that all staff who have contact with potential PACE participants are fully informed of PACE program policies, including enrollment, disenrollment and grievance policies and the provision of language and sign language interpreter services including providers who have bilingual capacity.

(3) PACE programs will develop informational materials for potential PACE participants in accordance with the following standards:

(a) PACE programs will provide informational materials sufficient for eligible PACE participants to make an informed decision about applying for enrollment. Information on participating providers must be made available from the program, upon request to potential enrollees, and must include enrollment requirements, benefits and services, locations of PACE centers, and choice of centers and PCPs, list of specialists, fees and other charges;

(b) PACE programs will produce printed informational materials that, at a minimum will include, the Marketing brochures, Participant Handbook, Enrollment Agreement, Disenrollment forms, and Denial of Services notices. These informational materials will be culturally sensitive and in the primary language of each substantial population (35 households) of non-English speaking PACE applicants and participants and in alternate forms for all vision impaired PACE applicants and participants. Alternate forms may include, but are not limited to, audio tapes, closed-captioned videos, large type and Braille;

(c) No written information will be provided to potential PACE participants that has not been approved by the Department. Approval or denial will be granted within 30 days of receipt by the Department. No response in 30 days constitutes approval. Any written communication by the PACE program or its subcontractors and providers that is intended solely for PACE participants and pertains to requirements to receive care at service sites or benefits must be approved by the Department prior to distribution; and

(d) PACE programs will provide written notice to affected PACE participants of any significant changes in program or service sites that impacts the PACE participants' ability to access care or services from PACE providers. Such notice will be provided to PACE participants or their representatives at least 14 calendar days prior to the effective date of that change, or as soon as possible, if the provider has not given the PACE program sufficient notification to meet the 14 days notice requirement. The Department will review and approve such materials within two working days of receipt by the Department.

(4) Participant Handbook Materials:

(a) The Participant Handbook will be made available as described above and will be distributed within 14 calendar days of the PACE participant's effective date of coverage with the PACE program;

(b) At a minimum the information in the Participant Handbook will contain the following elements:

(A) Location(s) and office hours of the PACE program;

(B) Telephone number(s) to call for more information and telephone numbers relating to information listed below;

(C) Choice and use of PCPs and policies on changing PCPs;

(D) How to access urgent care services and advice;

(E) How and when to use emergency services including ambulance;

(F) Information on the grievance process, including confidentiality and requesting an administrative hearing;

(G) How to access interpreter services including sign interpreters;

(H) PACE participant rights and responsibilities;

(I) PACE participant's possible responsibility for charges including Medicare deductibles and coinsurances if he or she goes outside of the PACE program for non-emergent care, obtain non-covered services or services not authorized by the Interdisciplinary Team (IDT);

(J) A clear statement that level of care decisions (i.e., whether or not a participant needs continuing nursing home care or may be discharged to a community based facility), are determined by the participant's Interdisciplinary Team after consulting with the participant and their family. The participant may appeal that decision but does not have the choice of remaining at a particular level of care unless the level of care warrants such and is approved by the Interdisciplinary Team;

(K) Information on the availability of social services and assistance in placement in community based housing and facilities;

(L) How to obtain specialty care, mental health and chemical dependency services;

(M) Information on Advance Directives and Physician Order for Life Sustaining Treatment ( POLST);

(N) How to obtain copies of the participant's records (and that the participant may be charged a reasonable copying fee);

(O) How to obtain non-emergent ambulance services and other medical transportation to appointments, as appropriate;

(P) Explanation of covered and non-covered services;

(Q) How to obtain prescriptions; and

(R) The PACE program's confidentiality policy.

(c) The Participant Handbook will be reviewed by the PACE program for accuracy at least yearly and updated with new or corrected information as needed to reflect the PACE program's internal changes and regulatory changes. If changes impact the PACE participant's ability to use services or benefits, the updated materials will be distributed to all PACE participants after approval by the Department.

(5) PACE programs will offer orientation to the PACE program to new participants in person within 30 days of enrollment.

Or. Admin. Code § 411-045-0040

SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01; SPD 2-2005, f. & cert. ef. 1-4-05

Stat. Auth.: ORS 410.090

Stats. Implemented: ORS 410.070