A PACE organization shall furnish comprehensive medical,
health, and social services that integrate acute and long-term care.
(1)
Required services. The
PACE benefit package for all enrollees, regardless of the source of payment,
must include the following:
a. All
Medicare-covered items and services.
b. All Medicaid-covered items and services as
specified in 441-Chapters 78, 81, 82, 85, and 90. Medicaid benefit limitations
and conditions relating to amount, duration, scope of services, deductibles,
copayments, coinsurance, or other cost sharing do not apply to PACE
services.
c. Other services
determined necessary by the enrollee's interdisciplinary team to improve or
maintain the enrollee's overall health status.
(2)
Excluded services. The
following
services are excluded from coverage under
PACE:
a. Any service that is not authorized by the
enrollee 's interdisciplinary team, even if it is a required service, unless it
is an emergency service.
b. In an
inpatient facility:
(1) A private room and
private-duty nursing services unless medically necessary; and
(2) Nonmedical items for personal
convenience, such as telephone charges and radio or television rental, unless
specifically authorized by the interdisciplinary team as part of the enrollee's
plan of care.
c.
Cosmetic surgery. "Cosmetic surgery" does not include surgery that is required
for improved functioning of a malformed part of the body resulting from an
accidental injury or for reconstruction following mastectomy.
d. Experimental medical, surgical, or other
health procedures.
e. Services
furnished outside the United States, except in accordance with 42 CFR Sections
424.122 and
424.124 as amended to September 29, 1995, or as otherwise permitted
under the Iowa Medicaid program.
(3)
Service delivery. The
PACE organization must establish and implement a written plan to furnish care
that meets the needs of each
enrollee in all care settings 24 hours a day,
every day of the year.
a.
Provision
of services. PACE services must be furnished in at least:
(1) The PACE center,
(2) The enrollee's home, and
(3) Inpatient facilities.
b.
PACE center
operation. A
PACE organization must ensure accessible and adequate
services to meet the needs of its enrollees. The
interdisciplinary team shall
determine the frequency of each
enrollee's attendance at a
PACE center, based
on the needs and preferences of the
enrollee.
(1) A PACE organization must operate at least
one PACE center either in or contiguous to its defined service area. A PACE
center must be certified as an adult day services program pursuant to Iowa Code
chapter 23 ID and the department of elder affairs' rules at 321-Chapter
24.
(2) If necessary to maintain
sufficient capacity to allow routine attendance by enrollees, a PACE
organization must add staff or develop alternate PACE centers or service sites.
If a PACE organization operates more than one center, each alternate PACE
center must offer the full range of services and have sufficient staff to meet
the needs of enrollees.
(4)
Minimum services furnished at a
PACE center. At a minimum, the following
services must be furnished at
each primary or alternate
PACE center:
a.
Primary care, including physician and nursing services.
b. Social services.
c. Restorative therapies, including physical
therapy and occupational therapy.
d. Personal care and supportive
services.
e. Nutritional
counseling.
f. Recreational
therapy.
g.
Meals.
(5)
Primary care. Primary medical care must be furnished to an
enrollee by a
PACE primary care physician. Each primary care physician is
responsible for:
a. Managing an enrollee's
medical situations; and
b.
Overseeing an enrollee's use of medical specialists and inpatient care.
(6)
Out-of-network emergency care. A
PACE organization must pay
for out-of-network emergency care when the care is needed immediately because
of an injury or sudden illness and the time required to reach the
PACE
organization or one of its
contract providers would cause risk of permanent
damage to the
enrollee's health.
a.
Definitions. As used in this subrule, the following
definitions apply:
"Emergency medical condition" means a
condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent lay person with an average
knowledge of health and medicine could reasonably expect the absence of
immediate medical attention to result in any of the following:
1. Serious jeopardy to the health of the
enrollee.
2. Serious impairment to
bodily functions of the enrollee.
3. Serious dysfunction of any bodily organ or
part of the
enrollee.
"Emergency services" means inpatient and
outpatient services that are needed to evaluate or stabilize an emergency
medical condition and are furnished by a qualified emergency services provider
other than the PACE organization or one of its contract providers, either
inside or outside the PACE organization's service area.
"Post stabilization care" means services
provided subsequent to an emergency that a treating physician views as
medically necessary after an emergency medical condition has been stabilized
but that do not meet the definition of emergency services.
"Urgent care" means care that is provided to
an enrollee outside the service area because the enrollee believes that an
illness or injury is too severe to postpone treatment until the enrollee
returns to the service area but that does not meet the definition of emergency
services because the enrollee's life or functioning is not in severe
jeopardy.
b.
Plan. A
PACE organization must establish and maintain a
written plan to handle out-of-network emergency care. The plan must ensure that
CMS, the
department, and the
enrollee are held harmless if the
PACE
organization does not pay for out-of-network emergency
services. The plan must
provide for the following:
(1) An on-call
provider available 24 hours per day to address enrollee questions about
out-of-network emergency services and to respond to requests for authorization
of out-of-network urgent care and post stabilization care following emergency
services.
(2) Coverage of
out-of-network urgent care and post stabilization care when either of the
following conditions is met:
1. The PACE
organization has approved the services.
2. The PACE organization has not approved the
services because the PACE organization did not respond to a request for
approval within one hour after being contacted or because the PACE organization
cannot be contacted for approval.
c.
Explanation to enrollee.
The organization must ensure that the
enrollee or caregiver, or both,
understand:
(1) When and how to access
out-of-network emergency services, and
(2) That no prior authorization is
needed.
