Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 37 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY
Section 471-37-001 - INTRODUCTION

001.01 Definitions

Appeal: The process by which a participant may seek and obtain a review and reversal with respect to enrollment denial; involuntary disenrollment; or non-coverage of, or nonpayment for, a service including denials, reductions, or termination of services.

External appeal: The State Administering Agency's or Medicare's formal appeal processes.

Grievance: A complaint, either written or oral, by participants, their family members, and/or representatives expressing dissatisfaction with service delivery or the quality of care furnished.

Internal appeal: A PACE organization's appeal process.

PACE organization: An entity that has a PACE program agreement in effect to operate a PACE program.

PACE program: A program of all-inclusive care for the elderly that is operated by an approved PACE organization and that provides comprehensive healthcare services to PACE participants in accordance with a PACE program agreement.

PACE program agreement: An agreement between a PACE organization, CMS, and the State Administering Agency for the operation of a PACE program.

Participant: An individual who is enrolled in a PACE program.

Premium: The monthly amount that a PACE organization charges a participant as determined by the participant's eligibility status for Medicare and Medicaid pursuant to 42 CFR 460.186.

State Administering Agency (SAA): The State agency responsible for administering the PACE program agreement. In Nebraska the SAA is the Nebraska Department of Health and Human Services, Division of Medicaid and Long-Term Care.

001.02 Legal Basis

PACE is authorized by Sections 1894 and 1934 of the federal Social Security Act. Federal PACE regulations are located at 42 CFR, Part 460.