PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Aging and Adult Services)
Original Notice.
Preproposal statement of inquiry was filed as WSR 99-11-051.
Title of Rule: New rules for program of all-Inclusive care for the elderly (PACE), WAC 388-71-0800 What is PACE? WAC 388-71-0805 What services does PACE cover? WAC 388-71-0810 Who provides these services? WAC 388-71-0815 Where are these services provided? WAC 388-71-0820 How do I qualify for Medicaid-funded PACE services? WAC 388-71-0825 What are may appeal rights? WAC 388-71-0830 Who pays the PACE provider? WAC 388-71-0835 How do I enroll into the PACE program? WAC 388-71-0840 How do I disenroll from the PACE program? WAC 388-71-0845 What are my rights as a PACE participant?
Purpose: To adopt rules on a new long-term care option, PACE.
Statutory Authority for Adoption: RCW 74.04.057, 74.08.090, 74.09.520, and 74.39A.030.
Statute Being Implemented: RCW 74.09.520, 74.08.390.
Summary: Rules define the PACE program, the types of services covered, and who is eligible for services under this program.
Reasons Supporting Proposal: Necessary to notify the public their options and rights under this new long-term care program.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Brooke Buckingham, 600 Woodland Square Loop, Lacey, WA, (360) 493-2544.
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: The rule is intended to formalize procedures and program criteria, so that: (1) Clients receiving services from program will be aware of their rights, and (2) persons authorizing services will be using standard protocols.
Proposal Changes the Following Existing Rules: [No information supplied by agency.]
No small business economic impact statement has been prepared under chapter 19.85 RCW. A small business economic impact statement is not required because the rule does not impact small businesses.
RCW 34.05.328 applies to this rule adoption. The rules do meet the definition of "significant legislative rule," but DSHS is exempt from preparing a cost benefit analysis under RCW 34.05.328 (5)(b)(vii).
Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on August 10, 1999, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Paige Wall by July 30, 1999.
Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by August 10, 1999.
Date of Intended Adoption: September 9, 1999.
June 29, 1999
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2572.3(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.
(5) 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.
(6) 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.
(7) Before the provider can disenroll you from the PACE program, the department must review and approve all proposed involuntary disenrollments.
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Reviser's note: The typographical errors in the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 388-71-0845
What are my rights as a PACE participant?
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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