Programs of All-Inclusive Care for the Elderly: How Does it Work? LCDR Amy Hesselgesser, OTR Account Manager, Centers for Medicare & Medicaid Service s.

Programs of All-InclusiveCare for the Elderly: How Does it Work?

LCDR Amy Hesselgesser, OTRAccount Manager, Centers for Medicare & Medicaid Services

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Stay in the home you love, visit us for the care you need.

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National PACE Association , 2011

I was alone a lot of the time. Now I have a place to go where I have friends, I can keep my mind challenged

and always have someone to talk to.

3National PACE Association, 2011

Agenda

History of PACE PACE Services & EligibilityKey Program AreasCMS/State MonitoringQuestions

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PACE

What are Programs of All-inclusive Care for the Elderly (PACE)?PACE is a Medicare and Medicaid program for older adults and people over age 55 living with disabilities. The program provides community-based care and services to people who otherwise need nursing home level of care.

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PACE Regulations

PACE is governed by regulations at CFR 42, Part 460, and is a three way agreement:

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History

On Lok, first PACE Organization (PO), developed in 1979 in San Francisco, CA

1986 federal government expansion allowed up to ten POs nation wide

1997 Balanced Budget Act recognized PACE as a permanent CMS provider type

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Enrollment

Currently over 75 PACE organizations

Serves over 23,000 beneficiaries Located in rural and urban areas

in 29 states Twelve pilot sites offer veterans

care in collaboration with the VA

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Growth of PACE Programs

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Source: National PACE Association

GOAL

The PACE model provides: comprehensive medical and social

services to frail, low-income seniors.

PACE is intended to help seniors stay in their homes as long as possible.

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PACE Eligibility

Individuals who wish to participate must voluntarily enroll and:

Be at least 55 years of age. Live in the PACE service area. Be in need of nursing facility care as

defined by the State At the time of enrollment, be able to

safely live in a community setting.

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Eligibility

Once enrolled, participants must: get their medical care only

through PACE providers. out of network care must be

authorized by the PACE interdisciplinary team (IDT).

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How it works….

PACE organizations receive a fixed monthly payment per enrollee from Medicare and Medicaid.

In return, they are responsible for providing 100% of the health services their participants require.

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What it Looks Like……

PACE offers & manages all the medical, social and rehabilitative services their enrollees need to preserve or restore their independence, to remain in their homes and communities, and to maintain their quality of life.

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Focus on Preventive Care:

The PACE interdisciplinary team (IDT) provides:

treatment and preventive health care to keep seniors healthy and to avoid hospitalizations or nursing home visits.

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The Interdisciplinary Team

The Interdisciplinary Team (IDT) manages the care of the participant.

The IDT, by regulation, must consist of:Primary care physicians and nursesPhysical, occupational, and recreational therapistsSocial workers and Home Care CoordinatorsPersonal care attendantsDietitiansDriversPACE Center Manager

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Plan of Care

The IDT must perform participant assessments:

at enrollment every 6 months when a participant’s condition

changes upon participant request

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Plan of Care

Once the IDT assesses, they must develop a plan of care designed to meet the medical, physical, social and emotional needs of the participant.

The plan of care must reflect the

participants preferences for care.

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PACE Services

PACE regulations require PACE organizations to provide participants with all medically necessary services including prescription drugs, without any limitation or condition as to:

amount, duration, or scope and without application of deductibles, co-

payments, or coinsurance that would otherwise apply under Medicare or Medicaid.

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PACE Services

Minimum services provided in the PACE center:

primary care services social services restorative therapies (physical AND

occupational therapy) personal care and supportive services, nutritional counseling, recreational therapy, meals.

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Participant Costs

Participant Prescriptions Health Coverage

Medicare/Medicaid No cost No cost

Medicare-Only Premium only, no deductible or co-pay

Premium equivalent to State Capitation

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The Day Center

Services are provided in an adult day health center setting, but may also include in-home and other referral services that enrollees may need.

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Outside the Day Center

Transportation Home care Other services deemed necessary

by the Interdisciplinary Team

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Other Services

Other services include but are not limited to:

medical specialists laboratory other diagnostic services hospital nursing home care

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Excluded Services

Any service not authorized by the IDT EXCEPT emergency careExperimental procedures, cosmetic surgeryNon medical items for personal convenience

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Key Program Areas

The PACE Organization must:

have a governing board that includes community representation be able to provide the complete service package regardless of frequency or duration of services have a physical site to provide adult day services have a defined service area

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Key Program Areas

The PACE Organization must:

have safeguards against conflict of interest; have demonstrated fiscal soundness; have a formal Participant Bill of Rights, andmust demonstrate Interdisciplinary Team driven participant care.

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Quality Assessment/Performance Improvement (QAPI)

PACE organizations must have written QAPI performance improvement plans which identify:

Areas to improve the delivery of services/patient care

Plans to improve or maintain quality of care

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Examples of PACE QAPI initiatives

Utilization of services

Caregiver/participant satisfaction

Outcome measures derived from clinical data and non-clinical data

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CMS/State Monitoring

Technical Advisory Visits Trial Period Audits Routine Audits Focused Audits

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CMS/State Monitoring

PACE Organizations are required to report 9 quality indicators to CMS:

ImmunizationsGrievancesAppealsEnrollments/DisenrollmentsProspective EnrolleesReadmissionsEmergency CareParticipant DeathsUnusual Incidents

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Level II Reporting

PACE organizations are required to:

report serious events having adverse health outcomes to CMS and the State agency.

conduct an internal investigation and report the results to CMS via teleconference.

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Cost Effectiveness

Statistics vary by state. Some

report significant savings. No comprehensive evaluation of

PACE cost-effectiveness currently exists.

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Expansion

Barriers include:High start up costsMarketing challengesFinancial risksLack of standardized outcome measures

National PACE Association, 12/2010

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Do you want to know more about PACE?

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Questions

Dallas PACE Account ManagerLCDR Amy Hesselgesser, [email protected]

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What’s New at CMS: PCIP

Pre-Existing Condition Insurance Plan (PCIP)

Program

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Statutory Authority for PCIP

Section 1101 of the Affordable Care Act (ACA) requires that HHS establish a “temporary high risk health insurance pool program” Provides coverage for individuals with pre-existing conditions until the Health Insurance Exchanges are available in 2014

Law required establishment within 90 days of enactment

PCIP Offers Comprehensive Benefits…

Care in medical offices for treatment of illness or injuryEmergency servicesInpatient and outpatient hospital servicesInpatient and outpatient mental health and substance abuse servicesPrescription drugsHome health care and hospice servicesOutpatient laboratory and diagnostic servicesIn- and out-of-network benefits

…and Important Features for Consumers

First-dollar coverage for preventive careNo lifetime maximum on the amount the plan pays for enrollee’s careBenefits are available immediately when coverage begins, even for pre-existing conditionsThe ability to receive benefits at any qualified provider

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Eligibility for PCIP

A person applying for PCIP must:Reside within the service area of the PCIP;Be a U.S. citizen or reside in the U.S. legally;Have been without health coverage for a minimum of 6 months before applying; and Have a pre-existing condition, as defined by the PCIP and approved by HHS.*Rate must equal at least 200% of corresponding PCIP rate. Permitted for select applicants.

Applying for PCIP Coverage

In federally-run PCIP, apply for coverage by:

Mailing a paper application;Calling the call center to complete an application over the phone; or Filing out an online application at www.pcip.gov

State-run PCIP enrollment mechanisms vary

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For more information on the Pre-existing Condition Insurance Plan, please visit

http://www.pcip.gov