Program of All-Inclusive Care for the Elderly

PURPOSE: This rule establishes the requirements for agencies contracting to provide services to eligible participants through the MO HealthNet Division’s (MHD) Program of All-Inclusive Care for the Elderly (PACE). PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Purpose and Scope. This rule implements the Program of All-Inclusive Care for the Elderly (PACE). PACE provides comprehensive, community-based, acute, and long-term care services to participants who meet certain eligibility requirements, meet the criteria for level of care (LOC), and who can be served safely in the community. PACE is jointly funded and administered by the Centers for Medicare & Medicaid Services (CMS) and the state administering agency (SAA) as defined in section (2) of this rule. (2) Definitions. For purposes of this regulation, the following words and phrases are defined as follows: (A) “Interdisciplinary team” shall refer to the interdisciplinary team defined in 42 CFR 460.102. This rule hereby incorporates by reference and makes a part of this rule 42 CFR 460.102 as published by the Office of the Federal Register, 800 North Capitol St. NW, Suite 700, Washington, DC 20408, and which is located on the website of the U.S. Government Publishing Office at https://www.govinfo.gov/app/collection/CFR, October 1, 2023. This rule does not incorporate any subsequent amendments or additions; (B) “Level of care (LOC)” shall refer to the level of care provided in a nursing facility, as established by the State of Missouri; (C) “PACE organization (PO)” shall refer to the entity that provides services to participants under a PACE program agreement with CMS and the SAA; (D) “Participant” shall refer to a person who receives services through the PACE organization; (E) “Program agreement” shall refer to an agreement between a PACE organization, CMS, and the state administering agency for the operation of a PACE program; and (F) “State administering agency (SAA)” shall refer to the Missouri Department of Social Services, MO HealthNet Division (MHD). (3) Eligibility Criteria. (A) To be eligible for PACE services, a participant must— 1. Be at least fifty-five (55) years of age; 2. Reside within a PACE organization’s service area; 3. Meet the state’s level of care requirements; 4. At the time of initial enrollment, reside in a non-institutional setting (e.g., house, apartment) without jeopardizing the participant’s health or safety; 5. Agree to obtain all health-related services only through the PACE organization during the participant’s period of enrollment in PACE; 6. Not be enrolled in one (1) or more of the following (or will discontinue being enrolled in one (1) or more of the following upon enrollment in PACE): A. A Medicaid managed-care program other than PACE; B. A hospice program; C. A Medicaid 1915(c) home and community-based services (HCBS) waiver program; D. A nursing facility certified by MHD while MHD is covering the person’s nursing facility expenses; or E. A health home; 7. Not reside in a state mental institution or an intermediate care facility for the intellectually disabled; and 8. Not be in a MO HealthNet coverage penalty period for a transfer of property under 42 U.S.C. 1396p(c). (B) The PACE program is available to eligible Medicaid participants receiving MO HealthNet under a federally funded MO HealthNet eligibility category. The eligible MO HealthNet Medicaid Eligibility (ME) codes can be found in the MO HealthNet Provider Manual and include— 1. E2, 01, 03, 04, 11, 12, 13, 14, 15, 16, 85, and 86; 2. A participant may also have ME 55 or ME 82, but these codes shall be in conjunction with one (1) of the ME codes listed above; and 3. This rule hereby incorporates by reference and makes a part of this rule the PACE Provider Manual as published by the MO HealthNet Division, 615 Howerton Ct., Jefferson City, MO 65109, and which is located on the website of the Missouri Department of Social Services at https://mydss.mo.gov/mhd/ provider-manuals, September 1, 2023. This rule does not incorporate any subsequent amendments or additions. (4) Eligibility Review. (A) The PO shall complete a full eligibility review of all potential enrollees. A full eligibility review includes the following steps: 1. Verification of ME code using the eMOMED system; 2. Verification of spenddown eligibility and spenddown amount via eMOMED; and 3. Review of the Department of Health and Senior Services’ (DHSS) Cyber Access system for the presence of a Healthcare Home enrollment or an HCBS care plan. If either is present, the enrollment(s) must end if the participant enrolls in PACE. (B) The PO shall ensure all eligibility criteria are met at time of enrollment. This shall include— 1. Requesting the termination of Healthcare Home enrollment; and 2. Verifying HCBS care plan is closed. (5) Enrollment Process. (A) The PO shall develop and adhere to an enrollment process to be approved by the SAA. (B) Completion of enrollment documentation and notifications is the responsibility of the PO in accordance with the SAA-approved enrollment process. (6) Disenrollment Process. (A) The PO shall develop and adhere to a disenrollment process to be approved by the SAA. (B) For each participant who is voluntarily or involuntarily disenrolled, the PO shall— 1. Continue to provide for the necessary services to the participant through the last day of enrollment; 2. Create a discharge plan to help the participant obtain necessary transitional care through appropriate referrals to other Medicaid or Medicare service providers; and 3. Provide the medical records of the participant within five (5) business days after receipt of a legally compliant release of information. (7) Provider Qualifications. (A) In order to qualify as a PO, a prospective PO shall— 1. Meet all CMS requirements outlined in the application process through CMS; 2. Enroll as a MO HealthNet provider with the Missouri Medicaid Audit and Compliance Unit (MMAC). A. Any providers with which the PO contracts for the provision of MO HealthNet-covered services shall also enroll with MMAC; and 3. Shall complete and submit a feasibility study to be approved by the SAA. (8) Provider Responsibilities. (A) The PO shall be responsible for completing the SAA LOC assessment tool with the participant and/or authorized representative and submitting the determination to the SAA. The SAA LOC Assessment tool is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at https://mydss.mo.gov/ mhd/forms, April 30, 2022. This rule does not incorporate any subsequent amendments or additions. 1. The PO shall complete the LOC assessment accurately based on the resources provided by the SAA. If the PO does not complete the assessment accurately, the SAA may deny the LOC assessment. 2. The PO shall include with the determination that it submits to the SAA any supplemental documentation that the PO used to support its assessment. 3. For purposes of determining eligibility, the LOC determination is only valid for ninety (90) days from the date of assessment. (B) The PO shall be responsible for enrollment of the participant into PACE services, pursuant to federal and state law. (C) The PO shall meet all applicable requirements under federal, state, and local law that are relevant to the PACE program and to MO HealthNet providers. (D) The PO shall adhere to all terms outlined in the PACE program agreement between CMS, the SAA, and the PO. (E) The PO shall obtain and maintain access to the following systems to be used for eligibility reviews, secure file transmission, enrollments, and disenrollments: 1. eMOMED; 2. CyberAccess (HCBS tab); 3. A File Transfer Protocol (FTP) site as determined by the SAA; and 4. Additional systems as determined by the SAA. (9) Capitation Payment. (A) The SAA shall issue to the PO a monthly prospective capitation payment for each PACE-enrolled MO HealthNet participant, and the PO shall assume full financial risk for that participant’s care. (B) The PO shall deliver a comprehensive service package, including all Medicare and Medicaid-covered services, as well as those additional services specified in the PACE program agreement. (C) The PO shall consolidate the delivery of care by linking Medicaid and Medicare funding through the pooling of all capitation payments. (D) In the event that a PACE participant is placed in a skilled nursing facility indefinitely, the Family Support Division (FSD) shall determine if the participant will have a surplus pursuant to 13 CSR 40-2.200. If the participant has a surplus, the PO shall recoup that amount from the participant, and the SAA shall recoup that amount from the capitation payment each month. The steps for Medicaid eligibility recalculation and recoupment are as follows: 1. The PO shall notify the SAA via FTP that a participant is being placed in a skilled nursing facility for a time frame to exceed thirty (30) consecutive days; A. The PO shall include the participant’s name, departmental client number (DCN), date of birth, the name of the skilled nursing facility, and date the participant was or is being placed in the skilled nursing facility; B. Should the participant be discharged from the skilled nursing facility, the PO shall notify the SAA of the discharge date; and 2. The PO shall contact the FSD to initiate a determination of the participant’s surplus liability. (10) Termination of the PACE Program Agreement. (A) The SAA may, in addition to any actions taken by MMAC pursuant to state law, terminate a PACE program agreement at any time for cause as outlined in the PACE program agreement. 1. Termination for cause includes but is not limited to uncorrected deficiencies in the quality of care furnished to participants, the PACE organization’s failure to comply substantially with conditions for a PACE program, or noncompliance with the terms of the program agreement. (B) In the event of termination of the PACE program agreement, the PO may seek review of the department’s action pursuant to section 208.156, RSMo. (11) Annual Behavioral Health Screenings. (A) The PO shall conduct annual behavioral health screenings. The PO shall conduct the Short Michigan Alcoholism Screening Test – Geriatric Version (SMAST-G) for every participant. (B) In addition to the screening test identified in subsection (A) of this section, the PO shall determine which additional annual screening is appropriate for the participant in collaboration with the interdisciplinary team. The PO shall choose one (1) of the following assessments: 1. Rating Anxiety in Dementia (RAID) for participants with dementia; or 2. Geriatric Anxiety Scale – 10 Item Version (GAS-10) for cognitively normal participants. (12) Provider Reporting. (A) The PO shall provide to the SAA a list of all providers with whom the PO has a contractual agreement to provide services to the PO’s participants, in an easily readable and accessible format, by close of business on the last business day of each quarter (last business day of March, June, September, and December). (B) The list of providers shall include the following details: 1. Provider/organization legal name; 2. National Provider Identifier (NPI) number; and 3. The effective date on which the provider enrolled with the PO. (13) Provider Service Areas. (A) The PO shall designate its service area in the application process through CMS. 1. A service area is made up of the county, zip code(s), street boundaries, census tract, block, or tribal jurisdictional area, as applicable, in which a participant must live in order to receive services from any given PO. The SAA may require that the service area be made up of one (1) of these types of geographic areas. 2. A PO shall have the exclusive use of its designated service area. 3. The service area shall be established in the program agreement. AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2024.* Original rule filed Aug. 1, 2022, effective March 30, 2023. Amended: Filed Aug. 2, 2024, effective Feb. 28, 2025. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021, 2023, 2024; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.