CMS proposes changes to program for seniors dually eligible for Medicare, Medicaid

The agency has not issued a PACE-related rule since 2006

CMS last week proposed a rule intended to add greater flexibility to an integrated care program for beneficiaries who are dually eligible for Medicare and Medicaid.

PACE details

The Programs of All-Inclusive Care for the Elderly (PACE) first launched in 1983. To qualify for the program, a beneficiary must be dually eligible for Medicare and Medicaid, at least 55 years old, qualify for nursing facility-level services, and able to be treated in a community setting. The program integrates:

  • Acute care services;
  • Behavioral health services;
  • Long-term care;
  • Preventive care; and
  • Primary care.

Since 2011, PACE enrollment has increased by more than 60 percent. More than 34,000 beneficiaries now are enrolled in about 100 PACE organizations across 31 states. According to Home Health Care News, CMS has not issued a PACE-related rule since 2006.

Proposed rule details

The proposed rule would allow non-physician primary care providers to provide certain services to PACE beneficiaries in place of primary care physicians. In addition, the proposed rule would eliminate restrictions that bar individual care team members from serving in more than one role to deliver care.

The proposal also aims to simplify PACE's administrative and operational rules to expedite and automate the program's application process.

The proposed rule also seeks to bolster patient protections by:

  • Barring PACE organizations from hiring individuals with convictions for physical or sexual abuse, as well as drug or alcohol misuse, in capacities that could pose a risk to beneficiaries;
  • Clarifying that PACE organizations offering prescription drug coverage must comply with Medicare Part D requirements; and
  • Changing sanctions, enforcement actions, and terminations to keep PACE organizations accountable and reduce patient risk.

The proposed rule will be published in the Federal Register on Aug. 16 and remain open to public comment for 60 days.

Report: Dual-eligible programs costlier, more challenging than expected

Acting CMS Administrator Andy Slavitt in a blog post wrote that proposed rule's "goal ... is to strengthen beneficiary protections and provide PACE organizations with more administrative and operational flexibility so they can do what they do best—caring for our nation's most vulnerable individuals." He added that the agency hopes to increase participation in PACE (Baxter, Home Health Care News, 8/11; Dickson, Modern Healthcare, 8/11).

More than comfort: How home-based care can deliver on cost and quality goals

The ongoing trend toward value-based care has spurred significant innovations in home-based care. In a continued effort to provide high-quality, lower-cost care, pioneer organizations are now providing care traditionally delivered in hospitals and nursing homes in the home setting.

Join Advisory Board experts for a webconference on Thursday, August 25, to learn more about how these innovations help organizations meet the goals of value-based care by treating patients in a lower-cost setting, reducing avoidable utilization, and improving the quality of care.

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