Sec. 560-X-53-.06 - Services For Participants

ยง 560-X-53-.06. Services For Participants

(1) Services provided under PACE must include all Medicaid and Medicare services and covered items, as well as any services for each participant determined to be necessary by the Interdisciplinary Team. Provided services must include comprehensive medical, health, and social services for acute and long term care. Services may be provided directly by the PO or by a subcontractor, and must be available 24 hours a day. For guidelines for required services for Medicare and Medicaid Participants, refer to 42 CFR 460, Subpart F.

(2) Enrolled participants must receive their services through the PO. The services are to be provided at the PACE Center, the participant's home, and inpatient facilities. Attendance at a Center is based on the needs and preferences of each participant. A participant may not be discriminated against in receiving services based on race, ethnicity, national origin, religion, sec, age, sexual orientation, mental/physical disability, or source of payment.

(3) A PO must operate at least one PACE center in its service area. The facility is to have sufficient space to ensure routine attendance by participants and to provide adequate services for the participants. If the center does not fulfill these needs, the PO must increase the number of staff and services at the center as needed. If an additional center is needed, it must meet the same requirements as the initial center.

(4) Services to be provided include, but are not limited to, the following:

(a) Primary Care, to include physician and nursing services;

(b) Hospital Care;

(c) Medical Specialty Services;

(d) Prescription Drugs;

(e) Dentistry;

(f) Nursing Home Care;

(g) Personal Care;

(h) Physical Therapy;

(i) Adult Day Care;

(j) Nutritional Counseling;

(k) Social Services;

(l) Laboratory and X-Ray Services;

(m) Transportation.

(5) An emergency care plan for inpatient and outpatient services must be established and maintained by each PO so that emergency care is provided when needed. The plan must ensure that CMS, AMA, and participants are held harmless if the PO does not make payments for the care provided. Emergency care is to be provided when services are needed immediately due to an injury or sudden illness and care cannot be provided timely by the PO or a contract provider, causing risk of permanent damage to the participant's health. Requirements and guidelines for emergency services are located in 42 CFR 460.100.

(6) Excluded services under the PACE program include:

(a) Any service, including a required service that has not been authorized by the Interdisciplinary Team, unless it is an emergency service;

(b) Private room and private duty nursing services, unless medically necessary, in an inpatient facility;

(c) Non-medical items or charges for personal convenience (telephone, radio, television) in an inpatient facility, unless the item(s) have been included as part of the participant's care plan by the Interdisciplinary Team;

(d) Cosmetic surgery, unless it is required to improve the function of a malformed part of the body resulting from an accidental injury or for reconstruction following a mastectomy;

(e) Experimental medical, surgical, or other health procedures;

(f) Services furnished outside of the United States (refer to 42 CFR 460.96 for exceptions).

(Emergency rule effective May 1, 1991. Permanent rule effective August 14, 1991. New Rule: Filed November 10, 2011; effective December 15, 2011.)

Author: Linda Lackey, Medicaid Administrator, LTC Project Development Unit.

Statutory Authority: State Plan, Attachment 2.2-A, Attachment 3.1-A and Supplement 3; 4 2 CFR 460 Subpart F.

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