Iowa Admin. Code r. 441-88.23 - PACE program agreement
An entity that has been approved by the
(1)
Content and terms of agreement.
a.
Required content. A PACE
program agreement must include the following information:
(1) A designation of the service area of the
PACE organization 's program, identified by county. The department and CMS must
approve any change in the designated service area .
(2) The PACE organization 's commitment to
meet all applicable requirements under federal, state, and local laws and
regulations, including provisions of the Civil Rights Act, the Age
Discrimination Act, and the Americans with Disabilities Act.
(3) The effective date and term of the
agreement.
(4) A description of the
organizational structure of the PACE organization and information on the
organization's administrative contacts.
(5) An enrollee bill of rights approved by
CMS and an assurance that the listed rights and protections will be
provided.
(6) A description of the
process for handling enrollee grievances and appeals.
(7) A statement of the PACE organization 's
policies on eligibility, enrollment, voluntary disenrollment, and involuntary
disenrollment.
(8) A description of
the services available to enrollees.
(9) A description of the PACE organization 's
quality assessment and performance improvement program.
(10)A statement of the levels of performance
required in CMS standard quality measures.
(11) A statement of the data and information
required by the department and CMS to be collected on enrollee care.
(12)The Medicaid capitation rate and the
methodology used to calculate the Medicare capitation rate .
(13)A description of procedures that the PACE
organization will follow if the PACE program agreement is terminated, including
how the organization will:
1. Inform
enrollees, the community, CMS , and the department , in writing, about the
organization's termination and transition procedures.
2. Initiate contact with income maintenance
staff in the local department office and assist enrollees in obtaining
reinstatement of conventional Medicare and Medicaid benefits.
3. Transition enrollees' care to other
providers.
4. Terminate marketing
and enrollment activities.
b.
Optional content. An
agreement may:
(1) Provide additional
requirements for individuals to qualify as PACE enrollees in accordance with
subparagraph 88.84(1)"a"(5).
(2) Contain any additional terms and
conditions agreed to by the parties.
(2)
Duration of agreement. A
PACE program agreement shall be effective for a contract year but may be
extended for additional contract years in the absence of a notice by a party to
terminate.
(3)
Enforcement
of agreement. If the department determines that the PACE organization
is not in substantial compliance with requirements of the federal PACE
regulations or of this division, the department may take one or more of the
following actions:
a. Condition the
continuation of the PACE program agreement upon timely execution of a
corrective action plan.
b. Withhold
some or all payments under the PACE program agreement until the PACE
organization corrects the deficiency.
c. Terminate the PACE program
agreement .
(4)
Termination of agreement by the department .
a.
Grounds for termination.
The department may terminate a PACE program agreement at any time for cause,
including but not limited to the following circumstances:
(1) Termination due to uncorrected
deficiencies. The department may terminate a PACE program agreement if both of
the following circumstances exist:
1. The
department has determined through a review pursuant to subrule 88.87(4) that
the PACE organization has significant deficiencies in the quality of care
furnished to enrollees or has failed to comply substantially with the
conditions for a PACE organization or PACE program under this division, the
federal PACE regulations , or the terms of its PACE program agreement .
2. The PACE organization has failed to
develop and successfully initiate a plan to correct the deficiencies within 30
days of the date of receipt of a written notice of deficiencies, as confirmed
by certified mail, or has failed to continue implementation of the corrective
action plan.
(2)
Termination due to health and safety risk. The department may terminate a PACE
program agreement if the department determines that the PACE organization
cannot ensure the health and safety of its enrollees. This determination may
result from the identification of deficiencies that the department determines
cannot be corrected.
b.
Notice and opportunity for hearing. Except as provided in
paragraph "c" of this subrule, before terminating an
agreement, the department shall furnish the PACE organization with the
following:
(1) A reasonable opportunity to
develop and implement a corrective action plan to correct the deficiencies that
are the basis of the department 's determination that cause exists for
termination.
(2) Reasonable notice
and opportunity for hearing (including the right to appeal an initial
determination) before terminating the agreement.
c.
Immediate termination.
The department may terminate an agreement without invoking the procedures
described in paragraph "b" of this subrule if the department
determines that a delay in termination resulting from compliance with those
procedures before termination would pose an imminent and serious risk to the
health of the enrollees.
(5)
Termination of agreement by PACE
organization . A PACE organization may terminate an agreement after
timely notice issued as follows:
a. To CMS
and the department , 90 days before termination.
b. To enrollees, 60 days before termination.
(6)
Transitional
care during termination. A PACE organization whose PACE program
agreement is being terminated must provide assistance to each enrollee in
obtaining necessary transitional care by making appropriate referrals and
making the enrollee 's medical records available to new
providers.
Notes
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