20 CAR Part 640 — Program for All-Inclusive Care for the Elderly (PACE) Provider Manual

Chapter XV

Subchapter B

20 CAR pt. 640 Program for All-Inclusive Care for the Elderly (PACE) Provider Manual {#sec-20-car-pt.-640 omnilex-key=us-ar-regs-official--title-20-part-640--20 CAR pt. 640}

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-1 SECTION II - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) CONTENTS

200.000 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) GENERAL INFORMATION

200.100 Program Description 200.200 PACE Terms and Definitions 201.000 PACE Applicant Requirements 201.200 Violations, Sanctions, Civil Money Penalties, Suspension, and Termination 201.300 State Monitoring Activities for PACE Organizations 201.400 Emergency Preparedness 201.500 Infection Control 201.600 Office of Medicaid Inspector General 202.000 PACE Administrative Requirements 202.100 Interdisciplinary Team 202.200 Participant Rights 202.300 Restraints 202.400 Marketing 203.000 PACE STAFF PARTICIPATION REQUIREMENTS 203.100 PACE Staff Participation Requirements 203.200 Qualifications of PACE Staff with Direct Participant Contact 203.300 Training for PACE Staff with Direct Participant Contact 210.000 PROGRAM ELIGIBILITY 210.100 Scope 210.200 Program Participant Eligibility Requirements 210.300 Evaluation Referral 210.400 Independent Assessment and Level of Care Determination 210.500 Enrollment with PACE Organization 210.600 Person-Centered Plan of Care 210.700 Service Determination Process 210.800 Service Determination Approvals and Denials 220.000 PROGRAM SERVICES 220.100 Non-covered Services 220.200 Covered Services

200.000 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) GENERAL INFORMATION

200.100 Program Description 9-1-26 A. The Program of All-Inclusive Care for the Elderly (PACE) is a comprehensive health and social services program that helps older adults, who need nursing home level of care, remain in their homes and communities. It is a joint Medicare/Medicaid program that provides and coordinates primary, acute, and long-term care for qualifying beneficiaries who are fifty-five (55) years of age or older. PACE relies on an interdisciplinary team approach to care management and comprehensive service delivery.

1. Social and medical services are provided primarily in a PACE center but are supplemented by in-home and referral services as needed by the PACE Organization (see section 202.000).
2. Pursuant to Arkansas Code Annotated §20-10-801 (14) a licensed, certified PACE Program is exempted from any additional or separate home healthcare licensing requirements.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-2 3. Pursuant to 42 CFR Part 460, PACE providers must be in compliance with all federal regulations. B. PACE is designed to meet the following aims:

1. Enhance the quality of life and autonomy for frail, older adults.
2. Maximize dignity of, and respect for, older adults.
3. Enable frail, older adults to live in the community as long as medically and socially feasible.
4. Preserve and support the older adult’s family unit. C. PACE provides pre-paid, capitated, comprehensive health care services The PACE assumes full financial risk. The PACE program must provide all the authorized care and services covered by Medicare and Medicaid, as well as additional medically-necessary care and services for program participants, as per 42 CFR §460.92. D. PACE is a State option under Arkansas Medicaid and is operated by the Division of Aging, Adult, and Behavioral Health Services (DAABHS). Further programmatic information and guidelines for PACE are outlined by the Centers for Medicare and Medicaid Services (CMS) in their Programs of All-Inclusive Care for the Elderly (PACE) Manual online. 200.200 PACE Terms and Definitions 9-1 -26

Contract Year The term of a PACE Program Agreement between the PACE Organization, DAABHS, and CMS, which is a calendar year that ends on December 31. A PACE Organization’s initial contract year may last anywhere from 19 to 30 months as determined by CMS, but will end on December 31 st . PACE Center A facility which includes a primary care clinic and areas for therapeutic recreation, restorative therapies, socialization, personal care, and dining, and which serves as the focal point for coordination and provision of most PACE services. PACE Organization A provider that has a PACE Program Agreement in effect to operate a PACE program in the state. PACE Program Agreement An agreement between a PACE Organization, DAABHS, and CMS for the operation of a PACE program. PACE Service Area The designated area (zip-code specific) where a PACE Organization is permitted to provide services. This should not overlap with another PACE Organization. Participant A beneficiary who is enrolled in a PACE program.

201.000 PACE Applicant Requirements 9-1 -26 A. A PACE Organization is a not-for-profit, for-profit, or public entity that is primarily engaged in providing PACE services. The following characteristics must also apply to a PACE organization:

1. Have a governing body, or a designated person functioning as a governing body, that includes participant representation;
2. Be able to provide the complete PACE service package regardless of frequency or duration of services;

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-3 3. Have a physical site and staff to provide primary care, social services, restorative therapies, personal care and supportive services, nutritional counseling, recreational therapy, and meals; 4. Have a defined service area; 5. Have safeguards against conflict of interest; 6. Have demonstrated fiscal soundness; 7. Have a formal Participant Bill of Rights; and 8. Have a process to address grievances and appeals. B. A provider must meet all of the following participation requirements to qualify as a PACE Organization that operates a PACE program under Arkansas Medicaid:

1. Submit a Notice of Intent to Apply (NOIA) PACE form to the Division of Aging and Adult Services as a letter of intention to establish or expand a PACE Program;
2. Obtain an Adult Day Health Care facility license; a. Adhere to all regulations established for the licensure of Adult Day Health Care (ADHC) facilities in Arkansas, overseen by the Division of Provider Services & Quality Assurance (DPSQA). b. Refer to ‘Rules and Regulations for Adult Day Health Care Providers’ for more information. Guidance is subject to periodic revisions as warranted.
3. Submit a PACE Provider Application and be approved by both Arkansas’ Division of Aging and Adult Services and the Centers for Medicare and Medicaid Services (CMS), as per 42 CFR §460.18; a. A PACE provider’s past performance will be considered when determining approval or denial of new or expansion applications. b. Submitting a completed PACE provider application to DAABHS after submitting it to CMS, or failing to submit it to DAABHS altogether, may result in the denial or delay of the application’s approval. c. A PACE Provider Application is also required for a pre-existing PACE Organization that seeks to expand its service area or add a new PACE Center (42 CFR 460.12(d)).
4. Execute a PACE Program Agreement, which acts as a three-party contract governing provider operations signed by the PACE provider, Division of Aging and Adult Services, and CMS; and
5. Complete the Medicaid provider participation and enrollment requirements contained within Section 140.000 of this Medicaid manual. C. A provider may request a waiver of certain regulatory requirements along with their PACE Provider Application. The purpose of the waiver is to provide for reasonable flexibility in adapting the PACE model to the needs of particular organizations (such as those in rural areas).
6. A provider should follow guidelines set forth in 42 CFR 460.26 for submission and evaluation of waiver requests. Note: Click here for more information on the PACE Provider Application. Note: Click here for more information on the PACE Program Agreement.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-4 201.200 Violations, Sanctions, Civil Money Penalties, Suspension, and Termination 9-1 -26 A. CMS may impose any of the sanctions as specified in 42 CFR 460.40 if CMS determines that a PACE organization commits programmatic violations. B. CMS may suspend Medicare payment to the PACE organization and may deny payment to the State for medical assistance for services furnished under the PACE program agreement for one or more program violations as specified in 42 CFR 460.42. C. CMS may impose civil money penalties up to the maximum amounts specified by federal law as specified in 42 CFR 460.46. D. CMS in consultation with DAABHS, may take one or more of the following actions as specified in 42. CFR 460.48:

1. Condition the continuation of the PACE program agreement upon timely execution of a corrective action plan.
2. Withhold some or all payments under the PACE program agreement until the organization corrects the deficiency.
3. Terminate the PACE program agreement. 201.300 State Monitoring Activities for PACE Organizations 9-1 -26 A. DPSQA, or its vendor, conducts independent site visits annually, or as needed, in addition to CMS site visits, to compliance with regulations, state and federal laws. B. DPSQA, or its vendor, is responsible for conducting an exit conference with the PACE Organization to discuss any review findings, provide technical assistance in developing corrective action plans, and to assist the PACE Organization in their efforts to implement the required corrections. C. The PACE Organization must be licensed by the Arkansas Department of Human Services, Division of Provider Services and Quality Assurance, as an Adult Day Health Care. CMS can conduct an audit at any point after the first year of the trial period. At the conclusion of the Three-year trial period, CMS in cooperation with DAABHS, continues to conduct reviews, as appropriate, of the PACE Organization considering the quality-of- service provision by the PACE Organization and compliance with all state and federal requirements. D. The PACE Organization is required to disclose to current PACE participants and potential PACE participants information specific to the PACE Organization’s performance and contract compliance deficiencies, in a manner specified by CMS (42 CFR §460.198). E DPSQA, or its vendor, upon annual inspection will review the following, in addition to ensuring a PACE provider is meeting the requirements of an Adult Day Health provider:
4. The PACE organization’s physical environment to ensure a safe, sanitary, functional, accessible, and comfortable environment;
5. Suitable space and equipment to provide primary medical care and suitable space for treatment, restorative therapies, therapeutic recreation, socialization, dining and personal care;
6. Suitable meeting space for personnel to conduct team meetings and for participant’s caregivers, and visitors;
7. Spaces which provide participant privacy and dignity during the delivery of services;

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-5 5. Proof that there are life safety code inspections from the fire marshal, Department of Health, and other required state agency inspections; 6. The PACE organization must provide evidence of a federal Clinical Laboratory Improvement Amendment (CLIA) exemption if the center is performing waived laboratory services on site or in the home, e.g., glucose meter testing, urine testing, fecal occult blood testing, blood testing, cholesterol screening or hemoglobin or hematocrit testing; 7. In addition, the PACE organization must meet all applicable Federal, State, and local laws and regulations, which include the Americans with Disabilities Act and Section 504 of the Rehabilitation Act; 8. A PACE organization must perform the manufacturer’s recommended maintenance on all equipment as indicated in the manufacturer’s written recommendations. This maintenance may be performed by PACE staff or contracted entities and in compliance with the contract; 9. The PACE organization is required to have trained personnel, drugs, and emergency equipment immediately available at every PACE center at all times to adequately support participants until Emergency Medical Services (EMS) responds to the PACE center; 10. Each PACE center is required to have at least one staff member who has been trained in cardio-pulmonary resuscitation (CPR) and will be on site during the hours that participants are in attendance; 11. The PACE organization must have a written plan and procedure for handling emergency situations that may arise including, but not limited to, cardiac arrest, choking and seizure activity in accordance with 42 CFR 460.100; 12. PACE center must have a documented plan to obtain Emergency Medical Services from sources outside the PACE center when needed. At least annually, a PACE organization must test, evaluate, and document the effectiveness of its emergency and disaster plans to ensure and maintain appropriate responses to the situations and needs that may arise from both medical and nonmedical emergencies; 13. The minimum emergency equipment that must be on the premises and immediately available includes: portable oxygen, airways, suction, and emergency drugs; 14. A PACE center must meet the applicable provisions of the 2000 edition of the Life Safety Code (LSC) of the National Fire Protection Association that apply to the type of setting in which the center is located; 15. A PACE provider must have an Emergency Preparedness Plan and an Infection Control Plan. 201.400 Emergency Preparedness 9-1 -26 In accordance with 42 CFR 460.84, the PACE organization must establish and maintain an emergency preparedness program that meets the federal requirements. The PACE organization must establish, implement, and maintain documented procedures to manage medical and non-medical emergencies and disasters that are likely to threaten the health and safety of participants, staff, or the public. The Disaster Plan must address the organization’s arrangements for emergency food, nutritional supplements, and potable water supplies. 201.500 Infection Control 9-1 -26 The PACE organization must, as specified in 42 CFR 460.74, establish, implement, and maintain a documented infection control plan that ensures a safe and sanitary environment and prevents and controls the transmission of disease and infection.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-6 A. An infection control plan must include, but is not limited to:

1. procedures to identify, investigate, control, and prevent infections in every PACE center and in each participant’s place of residence;
2. procedures to record any incidents of infection; and
3. procedures to analyze the incidents of infection, to identify trends and develop corrective actions related to the reduction of future incidents. PACE organizations are required to follow accepted policies and standard procedures with respect to infection control, including, at the least, the standard precautions developed by the Center for Disease Control and Prevention (CDC). PACE organizations are expected to establish written policies and procedures for the investigation, control, and prevention of infections including: B. An OSHA Exposure Control Plan which includes the Universal Precautions and Bloodborne Pathogen exposure procedures for staff;
4. Vaccinating participants and staff against diseases of particular concern for the PACE participant and the center’s geographic location, e.g., influenza and pneumonia;
5. Initial and ongoing health screening and vaccinations for staff and participants in accordance with OSHA regulations (staff) and CDC guidelines for tuberculosis, Hepatitis B and other communicable diseases;
6. Written plans and procedures for the investigation, evaluation, resolution, and reporting of all incidences of staff and participant infection;
7. Written plans and procedures for maintaining records of staff and participant infections to include post-exposure evaluation, training records, and participant and staff surveillance reports. Written plans and procedures for reporting required communicable diseases to the appropriate state and local officials;
8. Plans and procedures for staff providing direct care to patients with infection(s);
9. Provision of adequate facilities and supplies necessary for infection control to include:
   1. Hand washing facilities and supplies;
   2. Laundry facilities and supplies;
   3. Isolation facilities and supplies;
10. Written plans and procedures for addressing how laundry will be handled. If the service is contracted out, written agreements to comply with the requirements;
11. Written plans and procedures for the ongoing monitoring of the contractual agreement provisions for laundry and waste disposal;
12. Written plans and procedures for the appropriate handling and disposal of all waste products including blood and urine specimens for outside lab tests and other biohazardous wastes. C. DPSQA, or its vendor, is responsible for conducting an exit conference with the PACE Organization to discuss any review findings, provide technical assistance in developing corrective action plans, and to assist the PACE Organization in their efforts to implement the required corrections. D. The PACE Organization must be licensed by the Arkansas Department of Human Services, Division of Provider Services and Quality Assurance, as an Adult Day Health Care. CMS can conduct an audit at any point after the first year of the trial period. At the conclusion of the Three-year trial period, CMS in cooperation with DAABHS, continues to conduct reviews, as appropriate, of the PACE Organization considering the quality-of-

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-7 service provision by the PACE Organization and compliance with all state and federal requirements. E. The PACE Organization is required to disclose to current PACE participants and potential PACE participants information specific to the PACE Organization’s performance and contract compliance deficiencies, in a manner specified by CMS (42 CFR §460.198). 201.600 Office of Medicaid Inspector General 9-1 -26 A. A PACE Organization must have a formal process in place to gather information and must be able to respond in writing to a request from CMS or DAABHS for information regarding:

1. Persons with criminal convictions.
2. A PACE Organization must not employ individuals or contract with organizations or individuals: a. Who have been excluded from participation in the Medicare or Medicaid programs; b. Who have been convicted of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or health care programs, or social service programs under title XX of the Social Security Act; or c. In any capacity where an individual’s contact with participants would pose a potential risk because the individual has been convicted of physical, sexual, drug, or alcohol abuse.
3. Direct or indirect interest in contracts. No member of the PACE Organization’s governing body or any immediate family member may have a direct or indirect interest in any contract that supplies any administrative or care-related service or materials to the PACE Organization. 202.000 PACE Administrative Requirements 9-1 -26 A. In addition to participation requirements listed in Section 201.000, a PACE Organization must adhere to all PACE Administrative Requirements as outlined in 42 CFR Part 460 Subpart E, including:
4. PACE Organizational Structure;
5. PACE governing body and participant advisory committee;
6. Compliance oversight requirements;
7. Program integrity;
8. Physical environment;
9. Infection control;
10. Fiscal soundness; and
11. Emergency Preparedness. 202.100 Interdisciplinary Team 9-1 -26 A. The PACE Organization must establish an Interdisciplinary Team (IDT), composed of members that are qualified to fill the roles described below, at each PACE Center to comprehensively assess and meet the individual needs of each participant (42 CFR 460.102):
12. Primary Care Provider;
13. Registered Nurse;

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-8 3. Master’s-level social worker; 4. Physical therapist; 5. Occupational therapist; 6. Recreational therapist or activity coordinator; 7. Dietitian; 8. Home Care Coordinator; 9. Personal Care Aide or their representative; 10. Driver or their representative; and 11. PACE Center Manager. B. The PACE Organization must assign each participant to an Interdisciplinary Team (IDT) functioning at the PACE Center that the participant attends.

1. The IDT is responsible for:
   1. Assessing the needs of each PACE participant;
   2. Developing a Plan of Care;
   3. Providing and coordinating care that meets the needs of each participant
   across all care settings, twenty-four (24) hours a day, every day of the year (42 CFR 460.98); d. Monitoring the participant’s Plan of Care and making updates as needed; and e. Reviewing and determining the necessity of recommended services from a hospital, emergency department, or urgent care provider, within forty-eight (48) hours of the participant’s discharge, to determine if the service will appropriately meet the participant’s social, emotional, physical, and medical needs. 202.200 Participant Rights 9-1 -26 A. A PACE Organization must have a written participant bill of rights designed to protect and promote the rights of each participant. Those rights include, at a minimum, the rights specified below (42 CFR 460.112):
2. Respect and nondiscrimination;
3. Right to treatment;
4. Information disclosure, including but not limited to:
   1. Right to have all treatment options explained in a culturally competent manner.
   2. Right to receive information regarding palliative, comfort, or end-of-life care
   services.
5. Choice of providers;
6. Participation in treatment decisions, including, but not limited to: a. Right to receive all care and services needed to improve or maintain the participant's health condition and attain the highest practicable physical, emotional, and social well-being. b. Right to access emergency health care services when and where the need arises without prior authorization by the PACE interdisciplinary team.
7. Confidentiality of health information; and
8. Complaints, requests, and appeals.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-9 B. The PACE Organization must inform a participant or their representative, upon enrollment, in writing, of their rights and responsibilities, and all rules and regulations governing participation. It is required to:

1. Have the participant’s rights written and displayed in English in a prominent place in the PACE Center; and
2. Have the participant’s rights available in other principal languages of the community in which the PACE organization is located, as determined by the state. C. The PACE organization must protect and provide for the exercise of the participant’s rights, including:
3. Have established documented procedures to respond to and rectify a violation of a participant’s rights; and
4. Comply with requirements through the CMS complaints tracking module, address and resolve complaints received by CMS against the PACE organization within the required timeframes (42 CFR 460.119). D. Grievance Processes- Each PACE Organization must have formal written procedures to promptly identify, document, investigate, and resolve all medical and non-medical grievances in accordance with the requirements (42 CFR §460.120).
5. A grievance is a complaint, either oral or written, expressing dissatisfaction with service delivery or the quality of care furnished, regardless of whether remedial action is requested. Grievances may be between participants and the PACE Organization or any other entity or individual through which the PACE Organization provides services to the participant. All grievances must be remediated.
6. Medicare recipients have the right to file a written complaint with the quality improvement organization (QIO) with regard to Medicare covered services. 202.300 Restraints 9-1 -26 The PACE organization must limit use of restraints to the least restrictive and most effective method available. The term restraint includes either a physical restraint or a chemical restraint (42 CFR 460.114). A. A physical restraint is any manual method or physical or mechanical device, materials, or equipment attached or adjacent to the participant’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body. B. A chemical restraint is a medication used to control behavior or to restrict the participant’s freedom of movement and is not a standard treatment for the participant’s medical or psychiatric condition. C. If the interdisciplinary team determines that a restraint is needed to ensure the participant’s physical safety or the safety of others, the use must meet the following conditions:
7. Be imposed for a defined, limited period of time, based upon the assessed needs of the participant.
8. Be imposed in accordance with safe and appropriate restraining techniques.
9. Be imposed only when other less restrictive measures have been found to be ineffective to protect the participant or others from harm.
10. Be removed or ended at the earliest possible time.
11. The condition of the restrained participant must be continually assessed, monitored, and reevaluated.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-10 202.400 Marketing 9-1-26 A. PACE Organizations that publicize their programs must include in their public marketing materials:

1. An adequate description of the enrollment and disenrollment policies and requirements;
2. PACE enrollment procedures;
3. Description of benefits and services;
4. Premiums;
5. Information on the restriction of services; Materials must state clearly that PACE participants may be liable for the costs of out-of-PACE program agreement services; and
6. Other information necessary for prospective participants to make an informed decision about enrollment. B. Marketing information must be free of material inaccuracies, misleading information, or misrepresentations. C. Marketing information must be furnished in English and any other principal languages of the community in which the PACE Organization is located, as determined by the State. This includes Braille, when necessary. D. Marketing materials must be approved by CMS and DAABHS before distribution by the PACE Organization, including any revised or updated materials. Materials will be given a 45-day review period. If not disapproved within the review period, the organization can distribute it. E. More details about marketing regulations can be found in 42 CFR 460.82.

203.000 PACE STAFF PARTICIPATION REQUIREMENTS

203.100 PACE Staff Participation Requirements 9-1-26 A. A provider must meet the following requirements to serve as a PACE Organization's staff (employee or contractor):

1. Be legally authorized (active license, registration, or certification in good standing) to practice in Arkansas and only act within the scope of his or her licensed authority. a. See specific Certification or Licensure Manual for specific provider types.
2. Successfully pass the background and registry checks and searches required by Ark. Code Ann. §§ 20-33-213 and 20-38-101 et seq. 203.200 Qualifications of PACE Staff with Direct Participant Contact 9-1-26 A. Each member of the PACE Organization's staff (employee or contractor) that has direct contact with participants must meet all the following conditions (42 CFR 460.64):
3. Have one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience, must receive appropriate training from the PACE Organization on working with a frail or elderly population.
4. Meet a standardized set of competencies, as described in Section 202.201 for the specific position description established by the PACE Organization, before working independently.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-11 3. Have all immunizations up to date before engaging in direct participant contact. 4. Be medically cleared of communicable disease, and specifically determined free of active Tuberculosis, prior to providing direct care. a. Staff must be cleared for communicable diseases based on a physical examination performed by a licensed physician, nurse practitioner, or physician assistant. b. A PACE Organization may alternatively choose to perform an individual risk assessment for symptoms and exposure (must meet requirements specified in 42 CFR 460.64(a)(5)(iii)) to determine when a physical exam would be required for staff. Results of risk assessment must be reviewed by RN, physician, nurse practitioner, or physician assistant. 5. PACE Center staff must follow additional staffing regulations outlined in ‘Rules and Regulations for Adult Day Health Care Providers,’ the licensure manual for Adult Day Health Care (ADHC) facilities in Arkansas. Guidance is subject to periodic revisions as warranted. 203.300 Training for PACE Staff with Direct Participant Contact 9-1-26 A. A PACE Organization must ensure all its employees and contracted staff providing direct care to participants demonstrate the skills necessary for performance of their position (42 CFR §460.71).

1. The PACE Organization must provide all staff with an orientation that includes, at a minimum, the organization’s mission, philosophy, policies on participant rights, emergency plan, ethics, the PACE Program, and any policies related to the job duties.
2. The provider must develop a competency evaluation program that identifies those skills, knowledge, and abilities that must be demonstrated by direct participant care staff. a. Training shall be appropriate to job function and shall include but is not limited to the ADHC’s licensure manual for training.
3. The competency program must be evidenced as completed before performing participant care and on an on-going basis by qualified professionals.
4. Certification of the satisfactory completion of the competency program must be in the personnel files of all staff.

210.000 PROGRAM ELIGIBILITY

210.100 Scope 9-1-26 Arkansas Medicaid will pay qualified PACE Organizations a fixed monthly payment per enrolled Medicaid participant for comprehensive services delivered to those who meet the PACE eligibility requirements of this Medicaid manual. Medicaid payment is conditional upon compliance with this manual, manual update transmittals, and official program correspondence. 210.200 Program Participant Eligibility Requirements 9-1-26 A. Participation in PACE is available to individuals fifty-five (55) years of age and older who live in a PACE Service Area, meet nursing home level of care as determined by Division of Aging and Adult Services, can live safely in a community setting without risking health or safety, and agree to forgo their usual sources of care to receive all services through the PACE Organization.

1. Additional eligibility requirements include:

Program of All-Inclusive Care for the Elderly (PACE) Section II

Section II-12

1. Having proof of residency in the State of Arkansas;
2. Being a US citizen or legal alien;
3. Having proof of a valid Social Security Number;
4. Meeting Intermediate I-S, I-A, II-B, or III-C nursing facility level of care; and
5. Meeting one of the following medical criteria, as assessed by a DHS

Registered Nurse:

i. Unable to perform at least one (1) of the three (3) activities of daily living

(ADLs) of transferring or locomotion, eating, or toileting without extensive

assistance or total dependence upon another person;

ii. Unable to perform at least two (2) of the three (3) activities of daily living

(ADLs) of transferring or locomotion, eating, or toileting without limited

assistance from another person;

iii. Primary or secondary diagnosis of Alzheimer’s disease or related

dementia and cognitively impaired so as to require substantial

supervision from another individual; or

iv. Diagnosed medical condition which requires monitoring or assessment at

least once a day by a licensed medical professional and if left untreated,

would be life threatening.

Note: Individuals diagnosed with serious mental illness (SMI) or an intellectual

disability are not eligible for PACE unless their medical needs are unrelated

to their SMI/DD diagnosis and they meet the other qualifying criteria.

2. Medicare beneficiaries meeting the above requirements agree to participate in PACE

by paying monthly premiums equal to the Medicaid capitation amount, but no

deductibles, coinsurance, or any other type of Medicare or Medicaid cost-sharing.

3. Individuals not eligible for Medicaid or Medicare who meet the above requirements

agree to participate in PACE by paying private premiums.

210.300 Evaluation Referral

9-1 -26

A. A beneficiary may be initially referred to PACE by a PACE Organization or DHS

Registered Nurse, however an outside referral is not required to apply.

B. Beneficiaries apply for PACE through their local Division of County Operations (DCO)

office for a determination of financial eligibility.

C. The local DCO office will refer the beneficiary for an independent assessment,

determination of financial eligibility notwithstanding.

210.400 Independent Assessment and Level of Care Determination

9-1 -26

A. For individuals new to PACE, the individual must receive an Independent Assessment via

the Arkansas Independent Assessment (ARIA) instrument, administered by a DHS-

appointed Independent Assessment Contractor. The ARIA determines the individual’s

functional needs eligibility.

1. The Division of County Operations (DCO) registered nurse determines the potential enrollee’s nursing facility level of care via the DHS-704 based on the results of the Independent Assessment.
2. The DCO registered nurse notifies the PACE Organization when all requirements have been met. B. For renewing PACE participants, a Division of Aging and Adult Services registered nurse completes an annual evaluation (Medical Needs Assessment Form DMS-703) to evaluate the potential enrollee’s nursing facility level of care.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-13

1. To be eligible for PACE, beneficiaries must have a Medical Needs Assessment indicating they require Intermediate I-S, I-A, II-B, or III-C nursing facility level of care.
2. The Division of Aging and Adult Services’ registered nurse must certify that an assessment has been completed and that it is safe for the participant to live in the community.
3. The Division of Aging and Adult Services’ registered nurse notifies the local Division of County Operations (DCO) office and the PACE Organization when all requirements have been met. 210.500 Enrollment with PACE Organization 9-1 -26 A. If the potential participant meets the eligibility requirements and wants to pursue enrollment with the PACE Organization, they must sign an enrollment agreement with the PACE Organization that serves their Service Area. For more details on the contents of the enrollment agreement, see 42 CFR 460.154.
4. Enrollment in PACE results in disenrollment from any other Medicare or Medicaid prepayment plan or optional benefit. See 42 CFR 460.154(i).
5. The PACE Organization is required to complete its own intensive assessment that includes a minimum of one (1) home visit for enrollment.
6. The potential enrollee is required to complete one (1) visit to the PACE Center, unless otherwise approved by CMS.
7. At the time of enrollment, the PACE Organization is required to do the following: a. Verify whether the participant is dually eligible for Medicare and Medicaid and whether the participant has Medicare Part A, Part B, or both; b. Remind participants that unless they are dually eligible, they will need to continue to pay their Medicare Part A premium (if not free), Part B premium (if not eligible for State coverage), and Part D premium, if applicable; and c. Identify payers that are primary to Medicare, determine the amounts payable by those payers, and coordinate benefits to Medicare participants with the benefits of primary payers. B. Involuntary Disenrollment
8. Involuntary disenrollments are to be handled pursuant to federal law.
9. Refer to 42 C.F.R. 460.164, 460.166 and 460.172. 210.600 Person-Centered Plan of Care 9-1 -26 A. After the individual is enrolled, the PACE Organization’s Interdisciplinary Team (IDT) is responsible for individualized assessment, treatment planning, and care delivery. The IDT must meet the following requirements for the Plan of Care:
10. Complete an initial, in-person, comprehensive assessment by the following members promptly following the beneficiary’s enrollment:
    1. Primary care physician;
    2. Registered nurse;
    3. Master’s-level social worker;
    4. Physical therapist;
    5. Occupational therapist;
    6. Recreational therapist or activity coordinator;
    7. Dietitian; and

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-14 h. Home care coordinator. 2. Develop, evaluate, and, if necessary, revise the comprehensive Person-Centered Plan of Care for the participant (42 CFR §460.106). a. The Interdisciplinary Team must complete the initial Plan of Care within thirty (30) calendar days of the participant's date of enrollment. b. The Interdisciplinary Team must involve the participant and their family members or circle of natural supports in the development of the Plan of Care. The PACE Organization should document beneficiary and/or family approval of the Plan of Care. c. The Plan of Care must explain different treatment options, provide written information of those options, and obtain written consent prior to initiating any palliative, comfort, or end-of-life care services. d. At least once every one hundred eighty (180) calendar days from the date the latest Plan of Care was finalized, the Interdisciplinary Team must complete a semi-annual Plan of Care evaluation, and if necessary, revisions to each participant's Plan of Care. 3. For requests from the participant, or their representative or caregiver, to initiate, modify, or continue a service during the development of the initial Person-Centered Plan of Care, the IDT must: a. Document the request; and b. Discuss the request during the care planning meeting and either: i. Approve the requested service and incorporate it into the participant's initial Plan of Care; or ii. Document the rationale for not approving the service in the initial Plan of Care. 4. Additional in-person Assessments and Treatment Plans corresponding to the overall Person-Centered Plan of Care must be completed, as applicable, by the: a. Physical therapist; b. Occupational therapist; c. Dietitian; and d. Home care coordinator. B. Change of Condition

1. When a change of condition is noted by any provider delivering services to the PACE participant, the Interdisciplinary Team must update the Plan of Care within fourteen (14) days from the actual status change.
2. Re-assessments and Treatment Plan changes are also completed when the PACE participant experiences a change in health or psycho-social condition. 210.700 Service Determination Process 9-1 -26 A. Service Determination Requests (42 CFR 460.121)
3. A Service Determination Request is a request made by a participant, their representative, or their caregiver to initiate a new service, modify an existing service, or continue coverage of a service that a PACE Organization is recommending being discontinued or reduced. a. Requests can be made orally or in writing to any employee or contractor of the PACE Organization that provides direct care to a participant, including transportation personnel. b. If a request is made prior to completing the development of the initial Person-

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-15 Centered Plan of Care, it is not considered a Service Determination Request. 2. The PACE organization must bring a Service Determination Request to the Interdisciplinary Team (IDT) as expeditiously as the participant's condition requires, but no later than three (3) calendar days from the time the request is made. a. If a member of the IDT is able to approve the Service Determination Request in full at the time the request is made, the PACE Organization: i. Must provide oral or written notice of decision to approve a service determination request to the participant, in understandable language. The approval should include the conditions of the approval, including when the participant may expect to receive the approved service. ii. Must follow recordkeeping requirements established in Part B below. iii. Does not need a full IDT review. b. In all other cases, the full IDT must review and discuss each Service Determination Request and decide to approve, deny, or partially deny the request based on that review. i. IDT will consider all relevant information when evaluating a request, including, but not limited to, the findings and results of any reassessments. c. The IDT may extend the timeframe for review and notification by up to five (5) calendar days if either of the following occur: i. The participant or their representative request the extension; or ii. The IDT needs additional information from an individual, not directly employed by the PACE Organization, that may change the interdisciplinary team's decision to deny a service. d. The participant or their representative must be notified of any extension in review timeframe either orally or in writing, no later than twenty-four (24) hours after the IDT decides to extend the review timeframe. e. If the IDT fails to provide the participant with timely notice of the resolution of the request, or does not furnish the services required by the revised Person- Centered Plan of Care, this constitutes an adverse decision. The participant's request must be automatically processed by the PACE organization as an appeal (42 CFR 460.121(l)). B. Recordkeeping

1. The PACE organization must establish and implement a process to document, track, and maintain records related to all processing requirements for Service Determination Requests received both orally and in writing.
2. These records must be available to the IDT to ensure that all members remain alert to pertinent participant information. C. Reassessments based on a Service Determination Request
3. If the IDT expects to deny or partially deny a Service Determination Request, the appropriate members of the IDT must conduct an in-person Reassessment before the IDT makes a final decision.
4. IDT members performing the Reassessment evaluate whether the requested service is necessary to meet the participant's medical, physical, emotional, and social needs.
5. The IDT may conduct a Reassessment prior to approving a Service Determination Request, either in-person or through the use of remote technology, if the team determines that a Reassessment is necessary.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-16 210.800 Service Determination Approvals and Denials 9-1 -26 A. Notice of decision to approve a Service Determination Request

1. If the interdisciplinary team (IDT) decides to approve a Service Determination Request, it must provide the participant or representative either oral or written notice of the determination.
2. The approval must explain the conditions of the approval in understandable language, including when the participant may expect to receive the approved service. B. Notice of decision to deny a Service Determination Request (42 CFR 460.121(j))
3. If the IDT decides to deny or partially deny a service, it must provide the participant or representative both oral and written notice of the determination.
4. Notice of any denial must: a. State the specific reason(s) for the denial, including why the service is not necessary to maintain or improve the participant's overall health status, taking into account the participant's medical, physical, emotional, and social needs, and the results of the Reassessment(s) in understandable language. b. Inform the participant or representative of his or her right to appeal the decision. c. Describe the standard and expedited appeals processes, including the right to, and conditions for, obtaining expedited consideration of an appeal of a denial of services. d. For a Medicaid participant, inform the participant of both of the following: i. His or her right to continue receiving disputed services during the appeals process until issuance of the final determination. ii. The conditions for continuing to receive disputed services. C. Appeals
5. An appeal to a PACE Organization is a participant's action taken with respect to the PACE Organization's noncoverage of, or nonpayment for, a service including denials, reductions, or termination of services. Refer to Appendix R in the PACE Program Agreement.
6. A request to initiate, modify, or continue a service must first be processed as a service determination request under Section 210.700 before the PACE organization can process an appeal under this section.
7. See further details on a PACE Organization’s Appeals Process (42 CFR 460.122).
8. Additional appeal rights under Medicare or for those dually eligible for Medicare and Medicaid can be found 42 CFR 460.124.
9. Medicaid Administrative Reconsideration and Appeals: a. Medicaid allows only one (1) reconsideration of an adverse decision. Reconsideration requests must be submitted in accordance with Section 160.000 Section 1 of this Medicaid Manual. b. When the State Medicaid Agency or its designee denies a reconsideration request or issues any adverse decision, the beneficiary may appeal and request a fair hearing. A request for a fair hearing must be submitted in accordance with Sections 160.000, 190.000, and 191.000 of Section 1 of this Medicaid Manual.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-17 220.000 PROGRAM SERVICES

220.100 Non-covered Services 9-1-26 A. Medicare and Medicaid services delivered solely through the PACE Organization are the only benefits covered while the participant is enrolled in a PACE program (42 CFR 460.90). B. The following services are excluded from coverage under PACE:

1. Cosmetic surgery;
2. Experimental medical, surgical, or other health procedures; and
3. Services furnished outside the USA, except as permitted under the state’s Medicaid Plan. 220.200 Covered Services 9-1-26 The PACE benefit package for all participants, regardless of the source of payment, must include the following as prescribed by the Interdisciplinary Team (IDT) assessment:
   1. All Medicaid-covered services, as specified in the State's approved Medicaid plan.
   2. Interdisciplinary assessment and treatment planning.
   3. Primary care, including physician and nursing services.
   4. Social work services.
   5. Restorative therapies, including physical therapy, occupational therapy, and speech-
   language pathology services. F. Personal care and supportive services. G. Nutritional counseling. H. For more detailed policies on meal requirements and sanitary conditions, see 42 CFR 460.78. I. Recreational therapy. J. Transportation.
4. For more detailed policies on required safety, accessibility, and equipment; maintenance of vehicles; vehicle communication with PACE center; personnel training; and inclusion in any changes to the person-centered service plan, see 42 CFR 460.76.
   11. Meals as required by the interdisciplinary team’s plan of care.
   12. Medical specialty services including, but not limited to the following:
5. Anesthesiology;
6. Audiology;
7. Cardiology;
8. Dentistry;
9. Dermatology;
10. Gastroenterology;

Program of All-Inclusive Care for the Elderly (PACE) Section II

Section II-18

7. Gynecology;

8. Internal medicine;

9. Nephrology;

10. Neurosurgery;

11. Oncology;

12. Ophthalmology;

13. Oral surgery;

14. Orthopedic surgery;

15. Otorhinolaryngology;

16. Palliative Medicine

17. Plastic surgery;

18. Pharmacy consulting services;

19. Podiatry;

20. Psychiatry;

21. Pulmonary disease;

22. Radiology;

23. Rheumatology;

24. General surgery;

25. Thoracic and vascular surgery; and

26. Urology.

13. Laboratory tests, x-rays, and other diagnostic procedures.
14. Drugs and biologicals.
15. Prosthetics, orthotics, durable medical equipment, corrective vision devices, such as

eyeglasses and lenses, hearing aids, dentures, and repair and maintenance of these

items.

P. Acute inpatient care, including the following:

1. Ambulance;
2. Emergency room care and treatment room services;
3. Semi-private room and board;
4. General medical and nursing services;
5. Medical, surgical, intensive care, and the Coronary Care Unit;
6. Laboratory tests, x-rays, and other diagnostic procedures;
7. Drugs and biologicals;
8. Blood and blood derivatives;
9. Surgical care, including the use of anesthesia;
10. Use of oxygen;
11. Physical, occupational, respiratory therapies, and speech language pathology services; and
12. Social services.

Program of All-Inclusive Care for the Elderly (PACE) Section II Section II-19 Q. Nursing facility care, including the following:

1. Semi-private room and board;
2. Physician and skilled nursing services;
3. Custodial care;
4. Personal care and assistance;
5. Drugs and biologicals;
6. Physical, occupational, recreational therapies, and speech-language pathology, if necessary;
7. Social services; and
8. Medical supplies and appliances. R. Other services determined necessary by the IDT to improve and maintain the participant's overall health status.
9. Medications must be provided within twenty-four (24) hours of the Primary Care Provider’s order.
10. All services (other than medications) approved by the IDT must be set-up, scheduled, or arranged within seven (7) days of the approval. This does not include routine or preventative services.
11. Notwithstanding, all services and medications are to be provided as expeditiously as the participant’s health requires, so if needed, services must be provided more quickly than the timelines provided for in this section.
12. Contracted Services. S. The PACE organization must have a written contract with each outside organization, agency, or individual that furnishes administrative or care-related services not furnished directly by the PACE organization, including, at a minimum, the medical specialties listed previously in this Section (as per 42 CFR 460.70).
13. Contracts with medical specialists must be executed prior to enrollment of participants and must be maintained on an ongoing basis to ensure participants receive appropriate and timely access to all medically necessary care and services.
14. A PACE Organization is responsible for making all reasonable and timely attempts to contract with medical specialists. If at any time a PACE Organization is unable to directly contract or maintain a contract with a specific specialty, the PACE Organization must: a. Ensure care and services that would otherwise be provided to participants by a contracted specialist are provided and that the participant's needs are met through a different mechanism to include hospitalization; and b. Promptly report the contracting issue to CMS and DAABHS, including the attempts made to contract, the reason why the contract was not effectuated, and the PACE Organization's plan to provide access to the necessary services.
15. A PACE Organization is not required to have a contract with a particular medical specialty if the PACE Organization directly employs one (1) or more individuals prior to contracting, who are legally authorized, and, if applicable, board certified in the particular medical specialty. 4 For more information about contract requirements, the mandatory list of contractors that must be kept on file, see 42 CFR 460.70.

History

• History: Ark. R. 2025-3 (eff. June 1, 2025); Ark. R. 2026-113 (eff. September 1, 2026)