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From Health Law Daily, August 12, 2016

CMS sets ‘PACE’ with proposals for community-based elderly care program

By Bryant Storm, J.D.

Strengthened beneficiary care and greater administrative flexibility are the goals of a CMS Proposed rule to revise The Programs of All-Inclusive Care for the Elderly (PACE) program. In an advance release of the Proposed rule, CMS proposed changes to the program that would allow for better care coordination, increased compliance protections, greater flexibility through increased use of non-physician practitioners, and more frequent information sharing between CMS, state administering agencies, and PACE organizations. The Proposed rule is set to publish in the Federal Register on August 16, 2016. CMS is accepting comments on the proposal through October 17, 2016.

PACE. The PACE program is a managed care service delivery model that provides care in a community setting for frail, elderly individuals who are assessed as being eligible for nursing home placement according to Medicaid standards. Most individuals that are eligible under the PACE program are dually eligible for Medicare and Medicaid benefits.

Compliance. Under the Proposed rule, PACE organizations would be required to develop compliance oversight requirements for monitoring and auditing their organization for adherence to CMS regulations. PACE organizations would also be required to develop measures to prevent and detect program fraud and abuse.

Beneficiary protections. The Proposed rule’s beneficiary protections include changes to the composition of the interdisciplinary team used by PACE. CMS is proposing to allow team members to fill more than one role on the team—something they are not currently permitted to do. The Proposed rule also proposes to allow non-physician primary care practitioners to provide some services in the place of primary care physicians. The changes are designed to drive efficiencies, while ensuring that PACE organizations continue to meet the needs and preferences of their patients. Additionally, the Proposed rule would require that PACE organizations offering qualified prescription drug coverage comply with Medicare Part D prescription drug program requirements. CMS is also proposing to strengthen termination and sanction rules so that the agency can hold PACE organizations accountable for noncompliance.

Administrative flexibility. To improve flexibility, the Proposed rule proposes to modify the PACE Program Agreement, which is the contract between CMS, state administering agencies, and PACE organizations. CMS is requesting comments on whether current policies and procedures under the Program Agreement should remain. CMS is also proposing to streamline the development of the PACE Program Agreements and allow for more frequent information sharing between the agency and PACE organizations. Additionally, as more Medicaid programs move towards Managed Care, CMS is proposing to require that the PACE Program Agreement include the Medicaid capitation rates as well as the methodology used to calculate the Medicare capitation rate in order to lead to proper calculation of PACE Medicaid capitation rates.

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