WSR 03-09-091

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(     Aging and Disability Services Administration)

[ Filed April 18, 2003, 4:26 p.m. ]

     Original Notice.

     Preproposal statement of inquiry was filed as WSR 02-18-082.

     Title of Rule: Amendments to program of all-inclusive care for the elderly (PACE), WAC 388-71-0800, 388-71-0805, 388-71-0810, 388-71-0815, 388-71-0820, 388-71-0825, 388-71-0835, 388-71-0840, and 388-71-0845.

     Purpose: To amend and clarify PACE program requirements and add specific additional options under PACE rules.

     Statutory Authority for Adoption: RCW 74.04.057, 74.08.090, 74.09.520.

     Statute Being Implemented: RCW 74.04.057, 74.09.520, 74.09.523.

     Summary: The proposed rules amend and clarify PACE program requirements; makes PACE program requirements consistent with federal PACE regulations (42 C.F.R. Part 460) and updates WAC references; and adds medicaid covered mental health and substance abuse treatment services to the PACE service package.

     Reasons Supporting Proposal: Adds clarity to rules and makes PACE program requirements consistent with federal PACE regulations.

     Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Kristi Knudsen, P.O. Box 45600, Olympia, WA 98504-5600, (360) 725-2537, knudskl@dshs.wa.gov.

     Name of Proponent: Department of Social and Health Services, governmental.

     Rule is not necessitated by federal law, federal or state court decision.

     Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose, Summary, and Reasons Supporting Proposal above.

     Proposal Changes the Following Existing Rules: See Purpose, Summary, and Reasons Supporting Proposal above.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has found that changes to these rules will not adversely affect any small businesses.

     RCW 34.05.328 does not apply to this rule adoption. The proposed rules concern client financial or medical eligibility, and under RCW 34.05.328 (5)(b)(vii) these amendments are exempt from requirements of this statute.

     Hearing Location: Blake Office Park East, Rose Room, 4500 10th Avenue S.E. (behind Goodyear Courtesy Tire), Lacey, WA 98503, on May 27, 2003, at 10:00 a.m.

     Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by May 23, 2003, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

     Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., May 27, 2003.

     Date of Intended Adoption: Not earlier than May 28, 2003.

April 14, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3218.3
AMENDATORY SECTION(Amending WSR 99-19-048, filed 9/13/99, effective 10/14/99)

WAC 388-71-0800   What is PACE?   (1) PACE, which stands for the program of all-inclusive care for the elderly, is a managed care program that provides:

     (a) All Medicaid and Medicare services in a comprehensive((,)) and coordinated ((acute medical and long-term care services)) manner 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)) sections 1934 and 1894 of the Social Security Act and is administered by the department. The laws allow the department to expand home and community-based care options for the frail elderly population.

[Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0800, filed 9/13/99, effective 10/14/99.]


AMENDATORY SECTION(Amending WSR 99-19-048, filed 9/13/99, effective 10/14/99)

WAC 388-71-0805   What services does PACE cover?   Under their contract with the department, the PACE provider develops ((a care)) an individualized plan of care, as defined in 42 CFR 460.106, that integrates necessary long-term care ((and acute)), medical services, mental health services, and alcohol and substance abuse treatment 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)) Care coordination;

     (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)) Primary medical care;

     (b) Vision care;

     (c) Hospice care;

     (d) Restorative therapies, including 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)) Immunizations and vaccinations;

     (m) Emergency room visits and inpatient hospital stays.

     (3) The care plan may also include any other services determined necessary by the interdisciplinary team to improve and maintain the client's overall health status.

[Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0805, filed 9/13/99, effective 10/14/99.]


AMENDATORY SECTION(Amending WSR 99-19-048, filed 9/13/99, effective 10/14/99)

WAC 388-71-0810   Who provides these services?   (1) A PACE ((multidisciplinary)) interdisciplinary team, with the help of the client, family, and ((caseworker)) department case manager, develops and delivers necessary long-term care ((and acute)) medical services((. Members of the team may include)), mental health services, and alcohol and substance abuse treatment services. The PACE interdisciplinary team is composed of at least the following members:

     (a) Primary care ((physicians and nurses)) physician;

     (b) Registered nurse;

     (c) Social worker;

     (d) Physical therapists;

     (((c) Home care workers;

     (d) Social workers;

     (e) Transportation coordinators))

     (e) Occupational therapist;

     (f) Recreation therapist or activity coordinator;

     (g) Dietitian;

     (h) PACE center manager;

     (i) Home care coordinator;

     (j) Personal care attendant;

     (k) Van driver or his or her representative.

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

[Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0810, filed 9/13/99, effective 10/14/99.]


AMENDATORY SECTION(Amending WSR 99-19-048, filed 9/13/99, effective 10/14/99)

WAC 388-71-0815   Where are these services provided?   In general, 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 facilities, and community-based residential settings including adult family homes, assisted living facilities, and boarding homes.

[Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0815, filed 9/13/99, effective 10/14/99.]


AMENDATORY SECTION(Amending WSR 02-15-138, filed 7/22/02, effective 8/22/02)

WAC 388-71-0820   How do I qualify for Medicaid-funded PACE services?   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)) manager 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)) 388-511-1105, SSI-related eligibility requirements; or

     (b) Sixty-five or older.

     (2) Need nursing facility level of care as defined in WAC 388-71-0435(4), titled Am I eligible for COPES-funded services? Note: If you are already enrolled, but no longer need nursing facility care, you ((might)) may still be eligible for PACE services if the case manager reasonably expects you to need nursing facility care within the next six months in the absence of continued PACE coverage;

     (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)) 388-515-1505.

[Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.520. 02-15-138, § 388-71-0820, filed 7/22/02, effective 8/22/02. Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0820, filed 9/13/99, effective 10/14/99.]


AMENDATORY SECTION(Amending WSR 99-19-048, filed 9/13/99, effective 10/14/99)

WAC 388-71-0825   What are my appeal rights?   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)) 388-02 WAC, ((Practice and procedures--Fair hearing)) DSHS hearing rules and 42 CFR 460.124, Additional appeal rights under Medicare or Medicaid.

[Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0825, filed 9/13/99, effective 10/14/99.]


AMENDATORY SECTION(Amending WSR 99-19-048, filed 9/13/99, effective 10/14/99)

WAC 388-71-0835   How do I enroll into the PACE program?   Once you qualify for PACE, enrollment into the program is voluntary. However, before you can ((join)) participate, you must:

     (1) Contact your local PACE provider or local home and community services office.

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

     (((2))) (3) Agree to receive services exclusively ((from)) through the PACE provider and the PACE provider's network of contracted providers.

[Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0835, filed 9/13/99, effective 10/14/99.]


AMENDATORY SECTION(Amending WSR 99-19-048, filed 9/13/99, effective 10/14/99)

WAC 388-71-0840   How do I disenroll from the PACE program?   (1) You may ((voluntarily)) choose to voluntarily disenroll from the PACE program without cause at any time. To do so, you must give the PACE 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) You may also be involuntarily disenrolled from the program by the PACE provider ((may also end services)), if you:

     (a) Move out of the designated service area or are out of the service area for more than thirty consecutive days, unless the PACE provider agrees to a longer absence due to extenuating circumstances;

     (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)) Engage in disruptive or threatening behavior such that the behavior jeopardizes your health or safety, or the safety of others;

     (c) ((Refuse services and/or do not participate in your agreed-upon care plan)) Fail to comply with your plan of care or the terms of the PACE enrollment agreement;

     (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; or

     (g) No longer meet the nursing facility level of care requirement as defined in WAC 388-71-0435(4) and are not deemed PACE eligible.

     (3) For any of the above reasons, the PACE 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 PACE provider can involuntarily disenroll you from the PACE program, the department must review and approve all proposed involuntary disenrollments.

[Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0840, filed 9/13/99, effective 10/14/99.]


AMENDATORY SECTION(Amending WSR 99-19-048, filed 9/13/99, effective 10/14/99)

WAC 388-71-0845   What are my rights as a PACE ((participant)) client?   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)) Express grievances when a disagreement exists. For information on resolving a disagreement, refer to your contract with the PACE provider.

[Statutory Authority: RCW 74.04.057, 74.08.090, 74.09.520 and 74.39A.030. 99-19-048, § 388-71-0845, filed 9/13/99, effective 10/14/99.]

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