PACE Program Development

Chris van Reenen, NPA

MN PACE Summit

July 2004

Session Objectives

Identify milestones in PACE development

Review PACE provider application process, State plan amendment process and 3-way program agreement

Consider CMS and State roles in PACE development and implementation

Milestones in PACE Development

Understanding the PACE Model Organizational Assessment and

Decision-Making Planning and Development Program Operations

Step 1: Understanding the PACE Model

Gain understanding of PACE model and service requirements

Understand scope and extent of current PACE experience

Understand stages of development for initiating new PACE organization

Assess availability and cost of resources to assist in decision-making and start-up

Milestone: Organization’s governing bodycommits to in-depth self-assessment

Step 2: Organizational Assessment and Decision-Making

Assess federal and state regulatory requirements and implications for PACE

Describe critical factors for moving forward and assess need for outside support

Complete a business plan including recommendation to organization’s governing body

Step 2: Organizational Assessment and Decision-Making, cont.

Key topics to be included in decision-making plan: Environmental assessment/demand analysis Organizational structure and management Service area and site location Service arrangements/provider network Marketing and enrollment plan Start-up and operations plan Goals, risk assessment and exit strategy Financial analysis

Milestone: Organization commits resources to timeline andworkplan for start-up

Step 3: Planning and Development /PACE Provider Application

Secure financing and risk insurance Obtain approval of PACE provider

application Establish effective marketing strategies Establish an operational PACE Center

Milestone: PACE organization is

operational and initiates enrollment

PACE Provider Application Content

State assurances General Information & Organization

Service area Organizational structure Governing body Consumer Advisory Committee

PACE Administration Training program and competency assessment Contract services Physical environment, including PACE Center,

emergency readiness, infection control, transportation, dietary services

PACE Provider Application Content, cont.

Financial Financial statements Financial projections Insolvency plan Insurance arrangements

Marketing Copies of all marketing materials Marketing plan

PACE Services Service delivery plan PACE Centers Interdisciplinary team Participant assessment/reassessment Care planning

PACE Provider Application Content, cont.

Participants Rights Bill of rights Restraints Grievance and appeals processes

Quality Assessment & Performance Improvement QAPI plan External quality assessment and reporting

requirements Participant Enrollment & Disenrollment

Eligibility determination process Enrollment process and agreement Disenrollment processes

PACE Provider Application Content, cont.

Payment Medicare secondary payor Information to set up systems for payment

Data Collection, Record Maintenance & Reporting Medical records Confidentiality Data reporting

PACE Provider Application Process

Provider applicant drafts application and submits to State for review and comment

State submits final application to CMS with assurances

If application is complete, CMS activates 1st 90-day clock

CMS responds to State with approval, disapproval or request for add’l info (RAI)

PACE Provider Application Process, cont.

Provider applicant drafts response to RAI and submits to State for review and comment

State submits response to RAI to CMS State conducts on-site State Readiness

Review and forwards results to CMS 2nd 90-day clock begins – no later than

Day 90, CMS must approve (or deny) provider application

State Plan Amendment for PACE

State must amend its State Medicaid Plan to elect PACE as a voluntary state option

SPA and provider application processes can occur simultaneously

State must receive CMS approval of SPA before 3-way Program Agreement can be signed

PACE Program Agreement 3-way agreement signed by PACE

organization, CMS and State following approval of PACE provider application

Consists largely of elements of provider application, e.g., participant bill of rights, grievance and appeals procedures, eligibility and enrollment policies, QAPI program

PACE organization can now initiate operations

State and CMS Roles in PACE Development

State Role Site selection Licensing and certification requirements UPL(s) and Medicaid capitation rate(s)-setting Program eligibility requirements and

determination processes Medicaid enrollment and disenrollment systems Medicaid state plan amendment Reviews/submits PACE provider application and

participate in provider application process Participates in 3-way Program Agreement Medicaid contract, if necessary Ongoing oversight and monitoring

State and CMS Roles in PACE Development, cont.

CMS Role Responsible for development/implementation

of federal PACE regulatory requirements Implements Medicare payment methodology Reviews/approves PACE provider applications

and SPAs Medicare enrollment and disenrollment

systems Participates in 3-way program agreement Ongoing oversight and monitoring

For more information…

CMS Website (www.cms.gov/pace): PACE regulation (11/24/99 AND 10/1/02) PACE Provider Application PACE Program Agreement PACE State Plan Amendment information PACE State Readiness Review Tool HPMS Data Elements Solicitation for For-Profit Demonstration

NPA Website (www.npaonline.org)

Evolving Innovations

PACE in rural areas PACE programs working in

collaboration with housing

Regulatory flexibility for rural PACE organizations

The likelihood that PACE organizations serving rural areas will need flexibility in adapting the PACE model is recognized in both statute and regulation

§460.26 and §460.28 define the process by which existing and prospective PACE organizations can request waivers of specific regulatory requirements

Waiver requests can accompany a PACE provider application or be submitted independently

Requirements that CANNOT be waived without changing current

law Focus on frail elderly who require

nursing home level of care Delivery of comprehensive, integrated

acute and long-term care services Interdisciplinary team approach to care

management and service delivery Capitated, integrated financing Assumption of full financial risk

Additional provisions not subject to waiver

Nonprofit or public status of PACE organization

Elements of provider application process and PACE program agreement

Availability of health care services at PACE Center

Interdisciplinary team approach to care management

Comprehensive assessment & reassessment of health care needs

Participant rights

Types of flexibility that may be important in rural areas

Use of non-staff, community-based primary care physicians

Composition of PACE IDT Recognition that PACE Centers in

rural areas may not look like those in urban areas and be utilized differently

Use of alternative delivery settings Personnel requirements

Opportunities for flexibility in rural areas

Engage State and CMS partners in development of PACE in rural areas

Utilize “new” contracting opportunities

Utilize waiver process for regulatory flexibility

Pursue statutory changes as necessary and appropriate

CORE Act of 2004

Community Options for Rural Elders Act of 2004

Intended to “jumpstart” development of PACE in rural areas

Provides for start-up and development funding for rural PACE providers

Waive requirements of full-financial risk for initial 3-year period

Establishes formal technical assistance program for rural PACE providers

PACE and Senior Housing

As PACE programs mature and their enrollees age, access to supportive housing environments becomes increasingly important

Most PACE organizations have informal or formal links to senior housing

Federal Housing Programs

Section 202 (loan/grants) 350,000+ units Section 236 80,000 units

Section 8 (rent subsidy) Project based 260,000 units Tenant based (vouchers) 240,000 units

Public housing 600,000+ units Other 200,000+ units

Senior Housing Residents

Residents’ average age is about 80 years (Section 202/PHA)

90% of residents are older women living alone with less than $10,000 in annual income

Estimate 20-30% need supportive services to remain at home (3+ ADLs)

PACE and Senior Housing: Benefits in Collaboration

Residents: aging in place, quality care, future needs addressed

Housing: addressing needs of elderly residents, does not require direct involvement in provision of care

PACE: increased enrollment, continued community residence for enrollees, community visibility

HUD-HHS: opportunity for collaboration

PACE and Senior Housing: Relationships

Enrollment of frail residents in PACE Assist PACE enrollees to access

suitable and affordable housing Lease/own community space and/or

units Collaborate with development

Ownership and/or management Joint funding (housing/common space)

Co-location

PACE and Senior Housing: Co-location model

Example in Pittsburgh, PA -- Homestead