Current through Register Vol. 35, No. 18, September 24, 2024
The PACE program is a partially capitated, community based
service program. The PACE program will ensure access to a comprehensive benefit
package of services to a frail population that meets nursing facility clinical
criteria. The provider will provide all medicaid services that are included in
a capitated rate. Medicare covered services will be reimbursed through a
medicare capitated rate. The provider will provide medicare-eligible PACE
participants with all medicare services that are included in the medicare
capitated rate. Effective Janaury 1, 2006, upon the implementation of medicare
part D prescription drug coverage, pharmacy costs for PACE medicare
beneficiaries are covered by the medicare capitated rate. Pharmacy costs for
medicaid only recipients would be covered by the medicaid only capitated
rate.
A. Adult day health center: The
focal point for coordination and provision of the majority of the PACE program
services is the adult day health center. The adult day health center will
include a primary care clinic and areas for therapeutic recreation, restorative
therapies, socialization, personal care and dining. The center shall include
the following areas:
(1) examination
room(s);
(2) treatment
room(s);
(3) therapy
room(s);
(4) dining
room(s);
(5) activity
room(s);
(6) kitchen;
(7) bathroom(s);
(8) personal care room(s);
(9) administrative office(s);
(10) counseling office(s);
(11) pharmacy/medication room; and
(12) laboratory;
B. Interdisciplinary team: The
interdisciplinary team is a critical element of the PACE program. The ongoing
process of service delivery in this model requires the team to identify
participant problems, determine appropriate treatment objectives, select
interventions and evaluate efficiencies of care on an individual participant
basis. The interdisciplinary team is composed of, but not limited to, the
following members: Primary care physician, nurse, dietician, social worker,
physical therapist, occupational therapist, speech therapist, recreational
therapist or coordinator, day health center supervisor, home care liaison,
health workers/aides, and drivers. Some of the interdisciplinary team members
may be project staff and some may be contracted positions. All members must
meet applicable state licensing and certification requirements and provide
direct care and services appropriate to participant need.
C. Benefit package: The benefit package
includes the following:
(1) a service delivery
system that ensures prompt access to all covered services, including referral
protocols, approved by the interdisciplinary team;
(2) access to medical care and other
services, as applicable, 24 hours per day, seven days a week, 365 days per
year; all care and services shall be available and shall be provided at such
times and places, including the participants home or elsewhere, as are
necessary and practical;
(3) access
to an acute and comprehensive benefit package of services, including, but not
limited to:
(a) interdisciplinary assessment
and treatment planning;
(b) social
work services;
(c) nutritional
counseling;
(d) recreational
therapy;
(e) meals;
(f) restorative therapies, including physical
therapy, occupational therapy and speech therapy;
(g) home care (personal care, nursing care
and disposable medical supplies), see 8.325.9 NMAC, Home Health
Services;
(h)
transportation, see 8.324.7 NMAC, Transportation Services and
Lodging;
(i) drugs and
biologicals; effective January 1, 2006, pharmacy costs are reimbursed by
medicare for medicare beneficiaries; pharmacy costs for medicaid-only
recipients are reimbursed by medicaid through the medicaid-only capitated rate;
see 8.324.4 NMAC, Pharmacy Services, and Subsection D of
8.310.2.12 NMAC, Medical
Services Providers;
(j)
prosthetics, medical supplies and durable medical equipment, corrective vision
devices such as eyeglasses and lenses, hearing aids, dentures and repairs and
maintenance for these items; see 8.324.8 NMAC, Prosthetics and
Orthotics; 8.310.6 NMAC, Vision Care Services;
8.324.6 NMAC, Hearing Aids and Related Evaluations; 8.310.7
NMAC, Dental Services; 8.324.5 NMAC, Durable Medical
Equipment and Medical Supplies;
(k) behavioral health services, 8.310.8 NMAC,
Mental Health Professional Services and 8.315.3 NMAC,
Psychosocial Rehabilitation Services;
(l) nursing facility services which include,
but are not limited to, the following: semi-private room and board, physician
and skilled nursing services, custodial care, personal care and assistance,
biologicals and drugs, physical, speech, occupational and recreational
therapies, if necessary, social services, and medical supplies and appliances,
see 8.312.2 NMAC, Nursing Facilities; 8.311.4 NMAC,
Outpatient Psychiatric Services and Partial Hospitalization;
8.325.8 NMAC, Rehabilitation Service Providers; 8.324.4 NMAC,
Pharmacy Services; Subsection D of
8.310.2.12 NMAC, Medical
Services Providers; 8.324.5 NMAC, Durable Medical Equipment
and Medical Supplies; and
(m) urgent care services.
(4) coordinating access for the
following services:
(a) primary care services
including physician and nursing services;
(b) medical specialty services, including but
not limited to: anesthesiology, audiology, cardiology, dentistry, dermatology,
gastroenterology, gynecology, internal medicine, nephrology, neurosurgery,
oncology, ophthalmology, oral surgery, orthopedic surgery, otorhinolaryngology,
plastic surgery, pharmacy consulting services, podiatry, psychiatry, pulmonary
disease, radiology, rheumatology, surgery, thoracic and vascular surgery,
urology; see 8.301.2 NMAC, General Benefit Description;
8.310.2 NMAC, Medical Services Providers; 8.311.2 NMAC,
Hospital Services; 8.310.5 NMAC, Anesthesia
Services; 8.324.6 NMAC, Hearing Aids and Related
Evaluations; 8.310.7 NMAC, Dental Services; and
8.310.6 NMAC, Vision Care Services;
(c) laboratory and x-rays and other
diagnostic procedures; see 8.324.2 NMAC, Laboratory
Services;
(d) acute
inpatient services, including but not limited to, the following: ambulance,
emergency room care and treatment room services, semi-private room and board,
general medical and nursing services, medical surgical/ intensive care/coronary
care unit as necessary, laboratory tests, x-rays and other diagnostic
procedures, drugs and biologicals, blood and blood derivatives, surgical care,
including the use of anesthesia, use of oxygen, physical, speech, occupational,
and respiratory therapies, and social services; see 8.301.2 NMAC,
General Benefit Description; 8.324.8 NMAC, Prosthetics
and Orthotics; 8.324.10 NMAC, Ambulatory Surgical Center
Services; and 8.310.5 NMAC, Anesthesia Services;
8.324.2 NMAC, Laboratory Services; 8.324.4 NMAC,
Pharmacy Services; Subsection D of
8.310.2.12 NMAC, Medical
Services Providers; 8.325.8 NMAC, Rehabilitation Service
Providers; and
(e)
hospital emergency room services.
(5) in area emergency care; all medicaid
reimbursable emergency services included in the capitated rate will be
reimbursed by the PACE program to a non-affiliated provider when these services
are rendered within the PACE program geographic service area; these emergency
services will be reimbursed by the PACE program only until such time as the
participant's condition permits travel to the nearest PACE program-affiliated
facility;
(6) out-of-area emergency
care that is provided in, or en route to, a hospital or hospital emergency
room, in a clinic, or physician's office, or any other site outside of the PACE
program service area; covered services included in the capitation rate will be
paid by the PACE program when rendered in and out-of-area medical emergency,
but only until such time as the participants condition permits travel to the
nearest PACE program-affiliated facility.
