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 471-37-004 - PACE BENEFITS
Universal Citation: 471 NE Admin Rules and Regs ch 37 ยง 004
Current through March 20, 2024
004.01 Benefits
The PACE benefit package for all participants, regardless of source of payment, shall include the following:
1. All Medicare-covered items and
services;
2. All Medicaid-covered
items and services as specified in Nebraska's approved Medicaid State Plan;
and
3. Other services determined
necessary by the PACE organization's interdisciplinary team to improve and
maintain the participant's overall health status.
004.02 Benefit Conditions
If a Medicare beneficiary or Medicaid recipient chooses to enroll in the PACE program, the following conditions apply:
1. Medicare and Medicaid benefit limitations
and conditions relating to amount, duration, scope of services, deductibles,
copayments, coinsurance, or other cost-sharing do not apply (Note: Participants
who have been determined to have a Medicaid share of cost remain responsible to
meet their share of cost as per 469 NAC 4); and
2. The participant, while enrolled in the
PACE program, shall receive all Medicare and Medicaid benefits, as well as
other services determined necessary by the PACE organization interdisciplinary
team, solely through the PACE organization.
004.03 Excluded Benefits
The following services are excluded from coverage under PACE:
1. Any service that is not
authorized by the interdisciplinary team.
2. In an inpatient facility, a private room
and private duty nursing services, unless medically necessary, as well as
non-medical items for personal convenience unless specifically authorized by
the interdisciplinary team as part of the participant's plan of care.
3. Cosmetic surgery, not including surgery
that is required for improved functioning of a malformed part of the body
resulting from an accidental injury or for reconstruction following
mastectomy.
4. Experimental
medical, surgical, or other health procedures.
5. Services furnished outside of the United
States, including the Commonwealth of Puerto Rico, the Virgin Islands, Guam,
American Samoa, and the Northern Mariana Islands, except under particular
circumstances and as permitted under the Medicaid State Plan.
Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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