PACE Hawaii Program

HAWAII ADMINISTRATIVE RULES

TITLE 17

DEPARTMENT OF HUMAN SERVICES

SUBTITLE 12

MED-QUEST DIVISION

CHAPTER 1746

PACE HAWAII PROGRAM

Subchapter 1 General Provisions

§17-1746-1 Purpose §17-1746-2 Definitions §17-1746-3 Reserved

Subchapter 2 PACE Program Requirements

§17-1746-4 PACE provider requirements §17-1746-5 Subcontracts §17-1746-6 to 17-1746-9 (Reserved)

Subchapter 3 PACE Program Services

§17-1746-10 PACE responsibilities §17-1746-11 Eligibility requirements §17-1746-12 Effective date of enrollment §17-1746-13 Effective date of disenrollment §17-1746-14 Waiver of other medicaid benefits §17-1746-15 Covered services §17-1746-16 Excluded services §17-1746-17 Grievances §17-1746-18 Quality assurances §17-1746-19 Reports and data §17-1746-20 Confidentiality

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§17-1746-1

SUBCHAPTER 1

GENERAL PROVISIONS

§17-1746-1 Purpose. The purpose of this chapter is to describe the PACE Hawaii Program, eligibility requirements, and services provided under the PACE Hawaii Program. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59) (Imp: HRS §346-14; 42 C.F.R. §434.20)

§17-1746-2 Definitions. For the purpose of this chapter: "Capitation payment" means the negotiated prepaid fixed dollar amount the department pays each month on behalf of each PACE enrollee to PACE whether or not the PACE enrollee receives services during the month covered by the payment. "Medicaid reimbursement" means the payment made to Medicaid providers for Medicaid services rendered to eligible recipients. "PACE" means the PACE Hawaii Program which is a demonstration project to provide an array of health related services within a capitation payment. "PACE enrollee" means an individual who voluntarily elects to receive services through the PACE provider. "PACE provider" means the Maluhia Long Term Care Health Center under the state department of health. "Subcontractor" means an organization or individual who has entered into a contract with PACE to provide medical or health related services for PACE participants. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59) (Imp: HRS §346-14; 42 C.F.R. §434.20)

§17-1746-3 (Reserved)

SUBCHAPTER 2

PACE PROVIDER REQUIREMENTS

§17-1746-4 PACE provider requirements. The PACE

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§17-1746-10

provider shall be part of the national On Lok Replication Project as authorized by the Secretary of the Department of Health and Human Services. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59) (Imp: §346-14; 42 C.F.R. §434.21)

§17-1746-5 Subcontracts. (a) A PACE provider that provides all or part of the required PACE services indirectly through a subcontractor shall enter into a written subcontract with the individual or organization. The written subcontract shall stipulate, at the minimum: (1) Name and address of the subcontractor; (2) Service to be provided by the subcontractor; (3) Conditions for payment; (4) Statement of functions and responsibilities of the PACE provider and the subcontractor; and (5) Other items agreed to by the PACE provider and the subcontractor. (b) The PACE provider shall submit the subcontract to the department for approval and commence the subcontract provisions after approval has been obtained from the med-QUEST division. (c) The PACE provider shall be responsible to the department for the provision of all PACE services. No subcontract between the PACE provider and the subcontractor shall terminate the legal responsibility of the PACE provider to the department. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59) (Imp: HRS §346-14; 42 C.F.R. §§434.20, 434.21)

§§17-1746-6 to 17-1746-9 (Reserved)

SUBCHAPTER 3

PACE PROGRAM SERVICES

§17-1746-10 PACE provider responsibilities. The PACE provider shall: (1) Inform the recipient of the recipient's right to voluntarily enroll and disenroll from PACE;

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§17-1746-10

(2) Indicate whether enrollment is continuous or time limited; (3) Explain the PACE enrollee's obligation to receive services through the PACE provider; (4) Describe the geographical service area of the PACE provider; (5) Provide a list of the scope of covered services and how these services may be obtained; (6) Explain under what conditions emergency services may be obtained. (7) Explain the PACE enrollee's grievance process; (8) Explain the reasons for termination from PACE; and (9) Limit enrollment into the PACE provider to no more than the total number of recipients and total dollar amount during a state fiscal year as specified in the contract between he department and the PACE provider. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-10) (Imp: HRS §346-14; 42 C.F.R. §§434.25, 434.26, 434.27, 434.32, 434.59)

§17-1746-11 Eligibility requirements. PACE services shall be provided to individuals who voluntarily elect PACE services in lieu of Medicaid services and who meet all of the following conditions: (1) Reside within the specified geographical service area of the PACE provider; (2) Is fifty-five years of age or older at the time of application; (3) Is not enrolled in the Hawaii QUEST program; (4) Is certified by the department's medical consultant as requiring acuity level A or acuity level C; (5) Is eligible for federally-funded medical assistance as determined by the department; and (6) Voluntarily elects to participate in PACE and signs the appropriate statement requesting PACE services. [Eff 01/29/96 ] (Auth: SLH 1922, Act 211; HRS §346-59; 42 C.F.R. §434.20) (Imp: HRS §346-14; 42 C.F.R. §§434.25, 434.26, 434.27)

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§17-1746-15

§17-1746-12 Effective date of enrollment. An eligible individual shall be enrolled into PACE effective the month in which the application to the PACE provider is received. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59; 42 C.F.R. §434.20) (Imp: HRS §346-14; 42 C.F.R. §§434.25, 434.26, 434.27)

§17-1746-13 Effective date of disenrollment. Disenrollment from PACE shall be effective midnight of the last day of the month in which the individual is terminated by the PACE provider due to ineligibility. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59; 42 C.F.R. §434.20) (Imp: HRS §346-14; 42 C.F.R. §§434.25, 434.26, 434.27)

§17-1746-14 Waiver of other Medicaid benefits. (a) An individual who elects PACE shall waive all rights to Medicaid payments for services that are equivalent to PACE services. (b) Medicaid payments may be made for other Medicaid covered services unrelated to services available under PACE. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59; 42 C.F.R. §434.20) (Imp: HRS §346-14; 42 C.F.R. §434.25, 434.26, 434.27)

§17-1746-15 Covered services. (a) Services available to PACE enrollees shall be negotiated by the department and the PACE provider. The cost of providing PACE services and the administrative costs for the PACE provider shall be included in the capitation payment. (b) The covered services may be provided by the PACE provider either directly or indirectly through subcontractual arrangements in accordance with the provisions set forth in this chapter. (c) At the minimum, PACE services shall include: (1) Multidisciplinary team to assess, develop, implement and evaluate the treatment plan of each participant enrolled in PACE; (2) Adult day health services of which the core services include health related services, nursing services, maintenance therapies, social work services, recreational therapy, and dietary services;

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§17-1746-15

(3) Primary medical care including consultation, routine care, preventive health care, and physical examinations; (4) Occupational therapy or physical therapy or both when prescribed by the multidisciplinary team; (5) Audiology services when referred by the multidisciplinary team; (6) Optometry services when referred by the multidisciplinary team; (7) Dental care as determined by the PACE provider dentist and approved by the multidisciplinary team; (8) Podiatry services; (9) Speech therapy; (10) Home care services; (11) Prescription drug services; (12) Durable medical equipment; (13) Non-emergency medical and non-medical transportation; and (14) Acuity level A and acuity level C nursing facility care. (d) Prior authorization requirements applicable to fee for service providers shall be waived for PACE when such services are furnished by PACE to the PACE enrollees. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §434.21)

§17-1746-16 Excluded services. The following services shall not be paid for under the capitated rate: (1) Inpatient hospital care provided under Medicaid; (2) Ambulance or emergency transportation or both as provided under Medicaid; (3) Laboratory and X-rays, including tests ordered as part of the routine care, physical examinations or preventive care, physical examinations or preventive care provided by the PACE provider; (4) Medical specialists; (5) Home health services provided under Medicaid; (6) Any services which have not been authorized by the multidisciplinary team, even if the service is listed as a covered benefit;

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§17-1746-19

(7) Services rendered in a non-emergency setting or for a non-emergency reason without the PACE provider authorization; (8) Prescription drugs not prescribed by the PACE provider; (9) Cosmetic surgery unless required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction following mastectomy; (10) Experimental, medical, surgical, or other health procedures not generally available in the Hawaii area; (11) Gender alteration procedures; (12) Family planning; (13) Maternal care and pediatrics; (14) Service in any hospital for the treatment of tuberculosis or chronic medically uncomplicated drug dependency or alcoholism; and (15) Any services rendered outside of the United States. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59) (Imp: HRS §346-14; 42 C.F.R. §434.20)

§17-1746-17 Grievances. The PACE provider shall establish an internal grievance policy and procedure to hear and adjudicate complaints by PACE enrollees. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §434.32)

§17-1746-18 Quality assurance. The PACE provider shall develop and implement an internal quality assurance program to ensure provision of adequate and appropriate medical and related services and to safeguard against inappropriate and under utilization of medical and related services. [Eff 01/29/96 ] (Auth: SLH 1992, Act 211; HRS §346-59; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §434.34)

§17-1746-19 Reports and data. (a) The PACE provider shall maintain a system which makes readily available to health professionals of PACE all information pertinent to the care and management of each PACE enrollee.

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§17-1746-19

(b) The PACE provider shall make any of the PACE records available to the department or its representatives, Department of Health and Human Services, and other authorized federal and state agencies. (c) The PACE provider shall be required to maintain client records for a minimum of three (3) years after date of discharge from PACE. [Eff 01/29/96 ] (Auth: SLH 1992; Act 211; HRS §346-59; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §§434.6, 434.20, 434.21, 434.23, 434.53)

§17-1746-20 Confidentiality. (a) The PACE provider shall develop and implement written policies and procedures that govern access to, duplication of, and dissemination of information from the PACE enrollee's record or records with explicit written consent by the PACE enrollee. (b) Access to such information without the PACE enrollee's consent shall be limited pursuant to section 346-14, HRS. [Eff 01/29/96 ] (Auth: HRS §346-59; 42 C.F.R. §431.10) (Imp: HRS §§346-10, 346-14; 42 C.F.R. §431.10)

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