471 NAC 37-001. INTRODUCTION: This chapter regulates Nebraska’s Program of All-Inclusive Care for the Elderly (PACE) provided under Nebraska Medicaid

37-001 INTRODUCTION: This chapter regulates Nebraska’s Program of All-Inclusive Care for the Elderly (PACE) provided under Nebraska Medicaid. 37-001.01 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. 37-001.02 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.