Efficacy of the Programs of All- Inclusive Care for the Elderly (PACE) Study
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1 JOINT LEGISLATIVE OVERSIGHT COMMITTEE ON MEDICAID AND NC HEALTH CHOICE Efficacy of the Programs of All- Inclusive Care for the Elderly (PACE) Study Dave Richard Department of Health and Human Services April 10, 2018
2 Programs of All-Inclusive Care for the Elderly PACE is a capitated managed care program for frail, elderly adults who are enrolled in Medicaid, enrolled in Medicare, dually enrolled in Medicaid or Medicare, or able to pay privately. Program features a comprehensive service delivery system and integrated Medicare and Medicaid financing for beneficiaries enrolled in both programs. 2
3 PACE is a managed care model for the Elderly PACE organizations assume full financial risk for the costs of all medical care for their participants, including nursing home care, longterm care services, inpatient hospital services, outpatient hospital services, physician services, laboratory and radiology services, pharmacy, transportation, durable medical equipment (DME), and hospice services. 3
4 Program of All-Inclusive Care for the Elderly To be eligible for PACE an individual must: 55 years of age or older; Determined to need the level of care required under the Medicaid State Plan for coverage of nursing facility services; Reside in the PACE organization s service area; Able to live in a community setting at the time of enrollment without jeopardizing his or her safety; and Meet any additional criteria set forth in the program agreement. 11 PACE Organizations with 12 sites 36 counties have at least one zip code served by a PACE Organization 64 counties have no PACE access at this time Current enrollment is 2040 individuals 4
5 Next Steps for PACE growth in NC NC can consider expanding the capacity of existing PACE Organizations Zip code expansion Approval of alternative care setting Expansion of PACE to unserved and underserved areas in NC will require additional funding 5
6 Expanding PACE access Zip Code Expansion Will allow existing PACE Organizations to enroll individuals residing outside their current service areas. Alternative Care Setting (ACS) ACS allows PACE participants to receive some (but not all) PACE services at the alternative setting during usual and customary PACE center hours of operation. Services at an ACS should supplement and not replace services provided at the main PACE center Periodic visits to the main center are required 6
7 Next Steps for PACE regulatory reform Operationalize the recommendations that have been identified to address the duplication of regulatory monitoring by Centers for Medicare & Medicaid Services (CMS), Division of Medical Assistance (DMA), and Division of Aging & Adult Services (DAAS) Evaluate DMA and Division of Health Service Regulation (DHSR) rules regarding delivery of inhome services to verify duplication with CMS regulations 7
8 PACE Innovation Act Options Medicaid will investigate options for delivery of care under the PACE Innovation Act DMA will consult with CMS Coordination Office regarding the PACE Innovation Act Discuss strategies to adapt the PACE model of care to serve populations currently ineligible for PACE and diagnostic criteria other than nursing home level of care 8
9 Recommendations Study the expansion of the Long-Term Care Ombudsman (LTCO) program to assist PACE participants. LTCO assists residents of long term care facilities to exercise their rights and resolve grievances between the residents, families, and facilities Currently PACE participants and their families do not have comparable assistance to assist with grievances or complaints involving a PACE organization outside formal due process PACE Organizations manage all care for individuals 9
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