Date of Adoption: September 13, 1999.

Purpose: Aging and adult services administration is adopting rules on a new long-term care option, PACE, to formalize options, criteria, and rights under the PACE program.

Statutory Authority for Adoption: RCW 74.04.057, 74.08.090, 74.09.520, and 74.39A.030.

Adopted under notice filed as WSR 99-14-066 on July 2, 1999.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 10, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 10, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 10, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 10, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

September 13, 1999

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

(1) PACE, which stands for the program of all-inclusive care for the elderly, is a managed care program that provides:

(a) Comprehensive, coordinated acute medical and long-term care services for a frail elderly population; and

(b) A home and community-based alternative to nursing facility care.

(2) PACE is a Medicare/Medicaid program, authorized under section 1934 of the Social Security Act and administered by the department. The laws allow the department to expand home and community-based care options for the frail elderly population.

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Under their contract with the department, the PACE provider develops a care plan that integrates necessary long-term care and acute medical services.

(1) The care plan includes, but is not limited to any of the following long-term care services:

(a) Case management, to access and monitor services;

(b) Home and community based services:

(i) Personal (in-home) care;

(ii) Residential care (e.g., boarding home, adult family home).

(c) And, if necessary, nursing facility care.

(2) The care plan may also include, but is not limited to the following medical services:

(a) Routine medical care;

(b) Vision care;

(c) Hospice care;

(d) Speech, occupational, and physical therapy;

(e) Oxygen therapy;

(f) Audiology (including hearing aids);

(g) Transportation;

(h) Podiatry;

(i) Durable medical equipment (e.g., wheelchair);

(j) Dental care;

(k) Pharmaceutical products;

(l) Shots.

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(1) A PACE multidisciplinary team, with the help of the client, family, and caseworker, develops and delivers necessary long-term care and acute medical services. Members of the team may include:

(a) Primary care physicians and nurses;

(b) Therapists;

(c) Home care workers;

(d) Social workers;

(e) Transportation coordinators.

(2) As needed, the PACE provider may subcontract with other qualified professionals to provide services.

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Most of the covered services are offered at the PACE site, which is a licensed adult day health center. The PACE team may also provide care in homes, hospitals, and nursing homes.

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To qualify for Medicaid-funded PACE services, you must apply for an assessment by contacting your local Home and Community Services office. A case worker will assess and determine whether you:

(1) Are age:

(a) Fifty-five or older, and blind or disabled as defined in WAC 388-15-202, Long-term care services--Definitions; or

(b) Sixty-five or older.

(2) Need nursing facility level of care as defined in WAC 388-97-235, titled Medical eligibility for nursing facility care. Note: If you are already enrolled, but no longer need nursing facility care, you might still be eligible for PACE services if the case manager reasonably expects you to need nursing facility care within the next six months;

(3) Live within the designated service area of the PACE provider, currently the central Seattle area; and

(4) Meet financial eligibility requirements. This means the department will assess your finances and determine if your income and resources fall within the limits set in WAC 388-513-1315, Eligibility determination--Institutional.

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If the department determines you are ineligible, but you disagree, you may appeal the department's decision. For more information on your appeal rights, refer to chapter 388-08 WAC, Practice and procedures--Fair hearing.

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Depending on your income and resources, you may be required to pay for part of the PACE services. The department's financial worker will determine what amount, if any, you must contribute if you decide to enroll. The department pays the PACE provider the remaining amount.

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Once you qualify for PACE, enrollment into the program is voluntary. However, before you can join, you must:

(1) Not be enrolled in any other medical coverage plan that purchases services on a prepaid basis (e.g., HMO); and

(2) Agree to receive services exclusively from the PACE provider.

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(1) You may voluntarily choose to disenroll from the PACE program. To do so, you must give the provider written notice. If you give notice:

(a) Before the fifteenth of the month, disenrollment is effective at the end of the month.

(b) After the fifteenth, disenrollment is not effective until the end of the following month.

(2) The PACE provider may also end services, if you:

(a) Move out of the designated service area;

(b) Exhibit violent or abusive behavior or fail to cooperate with the provider to the point where the provider cannot effectively or safely provide services;

(c) Refuse services and/or do not participate in your agreed-upon care plan;

(d) Fail to pay or make arrangements to pay your part of the costs after the thirty-day grace period;

(e) Become financially ineligible for Medicaid services, unless you choose to pay privately; or

(f) Are enrolled with a provider that loses its license and/or contract.

(3) For any of the above reasons, the provider must give you written notice, explaining that they are terminating benefits. If the provider gives you notice:

(a) Before the fifteenth of the month, then you may be disenrolled at the end of the month.

(b) After the fifteenth, then you may be disenrolled at the end of the following month.

(4) Before the provider can disenroll you from the PACE program, the department must review and approve all proposed involuntary disenrollments.

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You have a right to:

(1) Receive any information regarding your care under PACE;

(2) Participate in creating or changing your treatment plan;

(3) Receive confidential treatment;

(4) Disenroll at any time; and

(5) Voice grievances when a disagreement exists. For information on resolving a disagreement, refer to your contract with the PACE provider.

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