Oversight of PACE Organizations and Providers

PURPOSE: This rule establishes a process of cooperation between the MO HealthNet Division (MHD) and Program of All-Inclusive Care for the Elderly (PACE) organizations and their providers to safeguard against unnecessary and inappropriate utilization of care and services provided to PACE participants. (1) Scope. This rule implements the oversight and compliance requirements for the Program of All-Inclusive Care for the Elderly (PACE). (2) Definitions. For purposes of this regulation, the following words and phrases are defined as follows: (A) “Electronic medical records” (EMR) are defined at 13 CSR 70-3.210(1) Electronic Retention of Records; (B) “PACE organization” (PO) shall refer to the entity that provides services to participants under a PACE program agreement with CMS and the SAA; (C) “Participant” shall refer to a person who receives services through the MO HealthNet Division (MHD) and the PACE organization; and (D) “State administering agency” (SAA) shall refer to the Missouri Department of Social Services, MO HealthNet Division (MHD), which for purposes of this rule includes Missouri Medicaid Audit and Compliance (MMAC). (3) Oversight Process. (A) The PACE organization shall cooperate with the SAA’s evaluation, oversight, and ongoing monitoring. The PACE organization’s cooperation shall include the following: 1. Permitting the SAA access to inspect any physical locations involved with the PACE organization’s services; 2. Giving the SAA access to the PO’s electronic medical records for five (5) consecutive days each month as determined by the SAA for focused reviews. A. The PO will have ten (10) business days after notification by email to provide access to the PO’s EMR for its focused review; 3. Providing the SAA with copies of any requested records regarding the PACE organization and services offered to PACE participants through file transfer protocol (FTP) or encrypted email within five (5) business days of the request; and 4. Conducting an annual audit which the SAA may conduct remotely and on-site. A. A remote audit may include but not be limited to a review of participant files, grievance and appeals logs, call logs, service logs, changes to policies and procedures, and personnel files. B. An on-site audit may include but not be limited to observations of participants in any settings, and observations and reviews of compliance with policies and procedures. (B) The PO will be referred to MMAC for any suspected cases of fraud, waste, and abuse. (4) The PACE organizations and their providers shall comply with the provisions of 13 CSR 70-3.030 and are subject to 13 CSR 65-2. AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sections 208.152 and 208.153, RSMo Supp. 2024.* Original rule filed May 16, 2024, effective Dec. 30, 2024. *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.