Program of All-inclusive Care for the Elderly Enrolling Participants into the PACE Program Cindy Susee, APD PACE Policy Analyst February 2017
PACE Model PACE is a Medicare and Medicaid national program, currently in 31 states, that offers an array of health and wellness services in a consolidated all-inclusive service model. Medicare and Medicaid funds cover all medically necessary services. There are no co-pays or deductibles. Medicare recipients pay a monthly premium for the long-term care and drug benefits. Recipients can also pay privately for the PACE program if they do not qualify for Medicare or Medicaid.
PACE Model PACE services include but are not limited to: * Long-term Care * Primary Care * Laboratory Tests & Procedures * Emergency Medical Services * Hospital Care * Nursing Home Care * Palliative Care * Medication: Prescription & OTC * Medical Supplies * Medical Equipment * Adult Day Services * Transportation * In-Home Care * Dental Services * Mental Health Services * Social Services * Specialty Medical Care: Audiology/Optical/Podiatry * Therapeutic Services: Physical/Occupational/Speech/Recreational
PACE Eligibility and IDT The PACE Service Recipient is: 55 years old or older Living in a PACE service area Able to reside safely in the community At Nursing Home Level of Care (SPL 1-13) The PACE Interdisciplinary Team may include: Medical Doctors Registered Nurses Licensed Therapists Licensed Social Workers Therapeutic Aides Dieticians Other Relevant Healthcare Professionals
The PACE Participant & Care Team Together the Participant & Interdisciplinary Team: Develop a plan of care that is comprehensive and responsive to the individual s healthcare and social service needs. The PACE provider is responsible for meeting all of the healthcare and social service needs identified in the care plan.
PACE in Oregon The State of Oregon supports the expansion of the PACE program and PACE providers statewide. Currently, Providence ElderPlace is the only PACE provider in Oregon. Oregon PACE Service areas include Multnomah and Clatsop counties and parts of Washington, Tillamook and Clackamas Counties with over 1,200 participants.
ElderPlace Service Sites ElderPlace currently has 9 Health and Social Centers, including 3 that also offer housing. These Centers offer PACE participants comprehensive integrated care from an ElderPlace team of healthcare and social service professionals. If participants are unable to attend a Health and Social Center, their team will visit them at home. In addition to receiving healthcare services at the Center, participants have the opportunity to participate in social and recreational activities and include a nutritious lunch. Transportation is provided to and from ElderPlace Health and Social Centers and is available for medical appointments outside of the Center.
Referrals Prospective participants may be referred to Providence Intake Specialists at 503-215-6556 or 503-717-7150 (North Coast) Referrals may come from CMs, community sources (MDs) or others.
Marketing / Intake / Enrollment ElderPlace services can be provided in a Community Based Care, In-Home setting or a Nursing Facility (if participant is already enrolled in PACE). CM establishes financial eligibility and performs assessment. Providence s Intake Specialists provide information to prospective participants; screen for PACE eligibility; obtain signatures. Participant is enrolled by CM by the 1st of the month, unless s/he is new to Medicaid, in which case they may enroll weekly (on a Monday).
Enrollments Cont. If the participant is in a Medicare HMO (MedAdv.) or Medigap plan, they must disenroll from that plan. ElderPlace will call/and/or send an enrollment email to the CM stating the participant has or will be enrolled into PACE. Once notified of the date of enrollment, CMs should make every effort to update the case coding and complete the pay-in letter within 5 days of the notification, or by the compute deadline. LTCCNs should be notified that services are discontinued as of the date of PACE enrollment. It is very important to do reassessments timely. Expired assessments end the capitation payment.
PACE vs MCO/CCO PACE enrollments need to have their Benefit Plans updated to reflect PACE enrollment prior to the start of the month being enrolled. PACE is a prospective payment. When a reassessment is not updated timely, PACE participants are automatically disenrolled from PACE and automatically enrolled into a MCO/CCO. To avoid MMIS issues, try to complete new enrollments and assessments for PACE participants as early in the month as possible to avoid any preventable timing issues with billing and enrollment.
Case Manager Responsibility CMs still need to do yearly redeterminations and assessments. Monthly K Waiver phone calls are not required, but regular monitoring is. CMs should contact the PEP Social Worker prior to reassessments to collaborate. Once the assessment is complete a copy needs to be sent to ElderPlace. ElderPlace conducts semi-annual care conferences (IDTs) lasting approximately 15 minutes each. CMs are highly encouraged to participate. Ask about conference availability. Narrate everything!
Facility Payment / Pay-In ElderPlace pays the facility (the 512 is not used for the facility payment). Participant pays Room & Board (R&B) directly to the facility and keeps PIF amount. EP can apply to become a participant s rep payee. Calculate pay-in on total income, minus R&B and PIF. Send the 541 (Notice of Responsibility). Advise that payment goes to the local branch office (payable to APD) and R&B goes to the facility.
Facility Payment / Pay-In Send 001N to the participant with instructions to sign and return to CM. Send EP the 001N (CAPS assessment), 003N (client details) and a copy of the pay-in letter. For In-home, also include 546N and 598N. The 001N does not need to be signed by PEP or the facility. Copy of the pay-in letter goes in the participants file. The local office is responsible for tracking participants payments on a spreadsheet (not in SFMU). If a pay-in is not received, CMs should contact the participant. Then notify the EP SW asking if they can remind the participant that they are required to make their monthly payment for services or they may be closed and lose their PACE services.
Pay-In Options Participants can have their bank issue an automatic check and mail them to OFS or do an online payment by clicking on this link and then PACE Pay-in: https://apps.oregon.gov/ecommerce/dhsoha/eps/ Questions about whether a payment has been received? Contact: APD.ClientReceipting@dhsoha.state.or.us OFS is working on sending out a monthly report of all PACE liability payments that have been received.
Pay-In Tracking A report for the online payment system goes out to Branches twice a month. When a payment is made for PACE (OFS or Local Office), the information needs to be added to the narrative that a payment has been received. Currently, each Local Office/Branch/County keeps track of Pay-In payments for each participant.
Coding If there is an open in-home liability on SFMU, close it. If there is an open 512, close it the day before enrollment into PEP. Example: 512 close day Sept. 14, 2015; Oregon Access/UCMS PACE enrollment begin date = Sept. 15, 2015 If the participant is moving, change the address, phone and possible living situation in ORACCESS Person Details. This is important as failing to do so may cancel enrollment (FIPS codes must match).
Coding - CAPS End the current Benefit a day prior to the PAC Benefit date of enrollment and start a PAC Benefit using the date of enrollment. Then add PEP as the provider by searching using the name Providence ElderPlace. Provider number will be #005673.
Coding CMS Go to the Benefits Overview Medical tab. Choose SUPL, date of enrollment and change/add case descriptors with enrollment begin date: Change: APD Case Descriptor (service) to PAC Add: NID as case descriptor Remove: CBF, if appropriate Integrate by using the Mainframe Icon on the title bar and choosing CMS Note: If a PACE participant is admitted to a NF, PEP is responsible for the payment to the NF as long as the client remains enrolled. Do not set up a POC for EP participants.
Enrollment Checklist
Disenrollment Voluntary disenrollment: May be initiated by the participant at any time without cause. Involuntary disenrollment: May occur if Participant fails to pay client contribution (pay in or service contribution); or Engages in disruptive or threatening behavior (must be approved by CO); or No longer meets eligibility criteria. Participant must be given reasonable notice.
Disenrollment If a PACE participant wishes to disenroll, the CM should narrate the conversation and contact the ElderPlace social worker. They will talk with the participant to determine the reason for their request and will then notify the worker to disenroll. Disenrollment generally takes effect on the last day of the month in which the paperwork was completed. CM should then discuss waivered service options with the participant to be effective the first of the following month.
Disenrollment If a CM closes a participants Medicaid Eligibility they will be disenrolled from PACE. What is the protocol for CM disenrolling in regard to Fed Guidelines and 30 day notice? According to the 3 way agreement (CMS, DHS and EP), a 30 day notice of intent to disenroll must be sent. DHS contract states DHS will notify PEP when a participants fails to pay their share of the PACE costs. PACE participant will be disenrolled effective the last day of the full calendar month after EP provides a 30 day notice of Disenrollmnent to the PACE participant.
Grievance Process Grievances are handled internally by the PACE organization. Appeals are also handled by the PACE organization. If an appeal is denied, the participant may request an Administrative Hearing with the State.
Administrative Hearing If a PACE participant disagrees with a decision to approve, deny, reduce or close a benefit or service they may ask for an Administrative Hearing. When the participant requests a hearing, either verbally or in writing, the CM is to fill out top portion of form 0443. If the hearing request is made face to face, ask the participant to sign the 0443; however it is not required. Admin Hearing Protocols can be found at: http://www.dhs.state.or.us/spd/tools/hearing/hearings %20Request%20PROTOCOLS%20SEPTEMBER%20 2015.pdf
Collaboration and Communication PACE is a partnership, not just between participants and the program, but with the Local Offices, Providence ElderPlace and Central Office. We all share the same goal of enhancing the quality of life for Oregon s aging population!
PACE
Courtesy Assessments CM visits consumer and completes a 4 ADL assessment. No client details are needed. Narrative is written for clarification as to why the courtesy assessment was done and date completed. Fax 002N to ElderPlace contact ElderPlace distributes a list to branches on PACE private pay participants. An annual assessment is completed.
Deeming 42 CFR 460.160(b) Furthermore, the State Administering Agency (SAA) may deem a participant who no longer meets the State Medicaid nursing facility level of care requirements to continue to be eligible for the PACE program if, in the absence of continued coverage under the program, the SAA determines the participant reasonably would be expected to meet the nursing facility level of care requirement in the next six months. The SAA must establish the criteria to use in making the determination of deemed continued eligibility and the criteria used to make the determination of continued eligibility must be specified in the program agreement. These criteria must be applied in reviewing the participant s medical record and plan of care. The SAA, in consultation with the PACE organization, may make a determination of deemed continued eligibility based on review of the participant s medical record and plan of care.
Risk Assessment Everyone consumer receives a risk assessment. However, if the individual is PACE, the assessment is performed by ElderPlace.
Paid Family Caregiver (PFCG) Caregiver and setting identified by the participant is credentialed for caregiver reimbursement by PEP. Independent credentialed caregiver is compensated by PEP to provide personal ADL and IADL care to a designated participant. PFCG will receive payment when criminal background, Medicare and Medicaid Fraud Check and contractual agreements are complete. PFCG is reimbursed monthly equivalent to ACH Medicaid rate structure.
MAGI Clients If an individual is on MAGI, they are eligible for PACE. Use the work-around D4 case. When using D4 work-around, you don t use any KPS coding. If they have no income, APD pays the R&B monthly via 437 with a B8 code. There is no client liability for a MAGI individual.
Direct/Indirect For PACE participants, CMs don t need to do direct/indirect case management contacts, since PACE isn t a K-plan.
In Home Maintenance Allowance OAR 411-045-0050 (4)(c) The Department provides for the calculation of any applicable spend-down liability and for post-eligibility treatment of income for Medicaid participants in the same manner as the Department treats spend-down liability and posteligibility income for individuals receiving Medicaid home and community-based services (OAR 461-160- 0620).
PACE & Moving Costs If PACE enrolled, PEP will assist with visiting homes and planning the move. In terms of the actual moving, it depends on whether the person qualified for special needs whether PEP would cover the cost. Either way, PEP will assist in coordinating unless there is involved family to help.
Special Needs To be eligible for a special need item, clients must have no other available resources in the community or in their natural support system to meet the need. To be eligible for a special need item, clients must not be eligible for the item through Medicare, Medicaid or any other medical coverage.
Behavioral Support Services ElderPlace has their own internal Health Team for behavioral supports.
Social Worker Contact Social Worker contacts change as do Case Managers. Please let PEP know when there is a change of caseloads within your Branch. If you are needing to know who the Social Worker is for your participant, please contact the PACE site Social Worker.
PACE Resources Key contacts: Providence Intake Specialists at 503-215-6556 or for North Coast 503-717-7150 Jeannie Frederick, Marketing & Enrollment Manager at 503-215-3741 or jeannie.frederick@providence.org Cindy Susee, PACE Analyst, APD at 503-945-6448 or Cynthia.susee@dhsoha.state.or.us. PACE Oregon Toll-free: 1-844-224-7223