PACE Plus Act

To improve access to the Program of All-Inclusive Care for the Elderly, and for other purposes. 1. Short title This Act may be cited as the Program of All-Inclusive Care for the Elderly Plus Act PACE Plus Act 2. PACE expansion grant program (a) Definitions In this section: (1) Area agency on aging The term area agency on aging 42 U.S.C. 3002 (2) CMS The term CMS (3) For-profit PACE provider The term for-profit PACE provider section 501(c)(3) (4) PACE pilot site The term PACE pilot site (A) has been approved to provide services in a geographic service area that is, in whole or in part, a rural area or an underserved urban area; and (B) has received a grant under subsection (b). (5) PACE program The term PACE program Social Security Act 42 U.S.C. 1395eee(a)(2) (6) PACE provider The term PACE provider Social Security Act 42 U.S.C. 1395eee(a)(3) (7) Rural area The term rural area Social Security Act 42 U.S.C. 1395ww(d)(2)(D) (8) Secretary The term Secretary (9) Underserved urban area The term underserved urban area 42 U.S.C. 254e (b) Site development assistance program (1) Site development assistance (A) In general The Secretary shall establish a process and criteria to award grants to qualified PACE providers that have been approved to serve a rural area or an underserved urban area. (B) Requirements for participating PACE providers To be eligible for a grant under subparagraph (A), a PACE provider shall demonstrate to the Secretary that the provider has a plan to partner with— (i) each area agency on aging serving the area that the provider is approved to serve; or (ii) if there is no area agency on aging serving such area, the applicable State Unit on Aging. (C) Amount per award A grant awarded under subparagraph (A) to any individual PACE pilot site shall not exceed $1,000,000. (D) Number of awards Not more than 30 PACE pilot sites shall be awarded a grant under subparagraph (A). (E) Use of funds Funds made available under a grant awarded under subparagraph (A) may be used for the following expenses only to the extent such expenses are incurred in relation to establishing or delivering PACE program services in a rural area or underserved urban area: (i) Feasibility analysis and planning. (ii) Interdisciplinary team development. (iii) Development of a provider network, including contract development. (iv) Development or adaptation of claims processing systems. (v) Preparation of special education and outreach efforts required for the PACE program. (vi) Development of any special quality of care or patient satisfaction data collection efforts. (vii) Purchase or lease of a building. (viii) Modifications to a building. (ix) To cover the cost of reinsurance during the grant period. (x) Establishment of a working capital fund to sustain fixed administrative, facility, or other fixed costs until the provider reaches sufficient enrollment size. (xi) Startup and development costs incurred prior to the approval of the PACE pilot site’s PACE provider application, new center application, or service area expansion application by CMS. (xii) Any other efforts determined by the PACE pilot site to be critical to its successful startup, as approved by the Secretary. (F) Site development grant eligibility (i) Grant eligibility A PACE provider shall only be eligible to receive a grant under this subsection if the provider is not a for-profit PACE provider. (ii) Limitation on eligibility to providers in 3-way PACE program agreements A PACE provider shall not be eligible for a grant under this subsection unless the provider has entered into an agreement, consistent with sections 1894 and 1934 of the Social Security Act ( 42 U.S.C. 1395eee (2) Technical assistance program The Secretary shall establish a technical assistance program to provide— (A) outreach and education to State agencies and provider organizations interested in establishing and expanding PACE programs in rural areas or underserved urban areas; and (B) technical assistance necessary to support PACE pilot sites. (3) Appropriation There is appropriated to the Secretary $30,000,000 to carry out this subsection, to remain available until expended. (c) Evaluation of PACE providers serving rural or underserved urban service areas Not later than 60 months after the date of enactment of this Act, the Secretary shall submit a report to Congress, including the Special Committee on Aging of the Senate and the Committee on Finance of the Senate, containing an evaluation of the experience of PACE pilot sites in rural areas and underserved urban areas. (d) State expansion grants (1) In general The Secretary shall establish a process and criteria to award State expansion grants to qualified State agencies in States that do not currently have PACE providers. (2) Amount per award A State expansion grant awarded under subparagraph (A) to any State agency shall not exceed $100,000. (3) Use of funds Funds made available under a State expansion grant awarded under paragraph (1) may be used for the following expenses only to the extent such expenses are incurred in relation to establishing a PACE program in the State: (A) Expenditures related to the development of a capitated payment rate model, including appropriate risk adjustment, for making payments to PACE providers under a PACE program agreement. (B) Expenditures on any other efforts determined by the State Medicaid agency to be critical to the successful implementation of a PACE program in the State, as approved by the Secretary. (4) Appropriation There are appropriated to the Secretary $2,000,000 to carry out this subsection, to remain available until expended. (e) Amounts in Addition to Payments under Social Security Act Any amounts paid under the authority of this section to a PACE provider shall be in addition to payments made to the provider under section 1894 or 1934 of the Social Security Act 42 U.S.C. 1395eee 3. Two-way PACE program agreements (a) Medicare Section 1894(a)(4) of the Social Security Act ( 42 U.S.C. 1395eee(a)(4) Beginning January 1, 2022, with respect to a PACE provider operating in a State that has not entered into an agreement described in the previous sentence as of such date, such term shall include an agreement, consistent with this section and regulations promulgated to carry out this section, between such a PACE provider and the Secretary for the operation of a PACE program in such State by the provider under this section alone. (b) Medicaid Section 1934 of the Social Security Act ( 42 U.S.C. 1396u–4 (1) in subsection (a)(4), by adding at the end the following new sentence: Beginning January 1, 2022, with respect to a PACE provider operating in a State that has not entered into an agreement described in the previous sentence as of such date, such term shall include an agreement, consistent with section 1894 and regulations promulgated to carry out such section, between such a PACE provider and the Secretary for the operation of a PACE program in such State by the provider under such section 1894 alone. (2) by adding at the end the following new subsection: (k) Application to PACE providers in 2-Way PACE program agreement States (1) In general In the case of a State described in the second sentence of subsection (a)(4), the Secretary shall administer the preceding provisions of this section with respect to PACE programs offered by PACE providers under PACE program agreements described in such sentence to PACE program eligible individuals who are eligible for benefits under part A, or enrolled under part B, of title XVIII. (2) Assessment of need of nursing home level of care (A) In general For purposes of the administration of this section pursuant to this subsection, the determination under subsection (a)(5)(B) of whether an individual requires the level of care required under the State plan for coverage of nursing facility services shall be made by an independent entity based on a level of care assessment tool used by the State to determine whether an individual requires such level of care. (B) Independent entity defined In this subsection, the term independent entity (i) is not the PACE provider operating the PACE program involved; (ii) is not owned or controlled by, or an employee of, such PACE provider; (iii) does not receive any differential payment (such as a bonus) for identifying individuals who are PACE program eligible individuals under the PACE program agreement involved; and (iv) is free of any other conflict of interest (as defined by the Secretary) between the entity and the PACE provider operating the PACE program involved. . 4. Anytime enrollment in PACE (a) In general (1) Any time enrollment and effective date Section 1894(c)(5) of the Social Security Act ( 42 U.S.C. 1395eee(c)(5) (C) Any time enrollment and effective date of enrollment (i) Any time enrollment A PACE program eligible individual may enroll in a PACE program at any time during a month. (ii) Effective date Subject to clause (iii), the enrollment of a PACE program eligible individual in a PACE program shall be effective on the date the PACE provider operating the PACE program receives an enrollment agreement signed by such PACE program eligible individual with respect to such PACE program. (iii) Special rule in the case of dual eligible beneficiaries In the case of a PACE program eligible individual who is eligible for benefits under this title and title XIX, clause (i) shall only apply if the State in which such individual resides has made an election under section 1934(c)(5)(C) to permit PACE program eligible individuals enroll in a PACE program at any time during a month in such State. . (2) Prorated payments Section 1894(d) of the Social Security Act ( 42 U.S.C. 1395eee(d) (4) Prorated payments In the case of a PACE program eligible individual enrolled in a PACE program operated by a PACE provider with an enrollment effective date that is not the first day of a month, the capitation amount that would otherwise be made under this subsection to the PACE provider for such individual for the first month in which such individual is so enrolled shall be prorated accordingly. . (b) Conforming amendments (1) Anytime enrollment and effective date Section 1934(c)(5) of the Social Security Act ( 42 U.S.C. 1396u–4(c)(5) (C) State option to permit any time enrollment and effective date of enrollment (i) Any time enrollment A State may elect to permit a PACE program eligible individual to enroll in a PACE program at any time during a month. (ii) Effective date Pursuant to a State election made under clause (i), the enrollment of a PACE program eligible individual in a PACE program shall be effective on the date the PACE provider operating the PACE program receives an enrollment agreement signed by such PACE program eligible individual with respect to such PACE program. . (2) Prorated payments Section 1934(d) of the Social Security Act ( 42 U.S.C. 1396u–4(d) (3) Prorated payments If a State elects under subsection (c)(5)(C) to permit enrollment at any time during a month, in the case of a PACE program eligible individual enrolled in a PACE program operated by a PACE provider with an enrollment effective date that is not the first day of a month, the State shall prorate the capitation amount that would otherwise be made under this subsection to the PACE provider for such individual for the first month in which such individual is so enrolled. . (c) Effective date The amendments made by this section shall take effect on January 1, 2022. 5. Improving access to and affordability of PACE programs for Medicare beneficiaries who are not dual eligible beneficiaries through flexibility in rate setting for services not covered by Medicare (a) In general Section 1894 of the Social Security Act ( 42 U.S.C. 1395eee (j) Flexibility in establishing premiums for Medicare PACE participants who are not also entitled to benefits under a State Medicaid program (1) Codification of authority to charge a monthly capitation amount for non-Medicare services Subject to the succeeding provisions of this subsection, a PACE program operated by a PACE provider under a PACE program agreement in any State may charge a Medicare-only PACE program eligible individual (as defined in paragraph (4)(A)) who is enrolled in such PACE program a monthly capitation payment amount for the provision of non-Medicare services (as defined in paragraph (4)(B)) under the PACE program. (2) Determination of monthly capitation payment amount (A) In general Notwithstanding section 460.186 of title 42, Code of Federal Regulations (or any successor regulation), the monthly capitation payment amount that may be charged under paragraph (1) shall be determined by the PACE provider operating the PACE program. Such monthly capitation payment amount shall be based on assessments conducted on the Medicare-only PACE program eligible individual who is enrolled in such PACE program by the PACE program interdisciplinary team and shall take into account the health status of such individual. In determining the monthly capitation amount for a Medicare-only PACE program eligible individual under this paragraph, a PACE provider may take into account the services determined necessary for the individual by the PACE program interdisciplinary team based upon their assessment of the individual. A determination described in the preceding sentence shall not be construed as limiting the responsibility of the PACE provider to meet any unforeseen needs or provide for any required services for such individual. (B) Authority to adjust monthly capitation amount (i) In general Subject to clause (ii) and paragraph (3), the monthly capitation payment amount that may be charged under paragraph (1) to a Medicare-only PACE program eligible individual enrolled in a PACE program for non-Medicare services may increase or decrease based on assessments conducted on such individual. Any change in the monthly capitation payment amount charged to such an individual shall take effect beginning with the first day of the first month that begins after the month during which the plan of care is developed for such individual based on such an assessment. (ii) Limitation on frequency of increase The monthly capitation payment amount that may be charged under paragraph (1) to such an individual may not increase more frequently than once per calendar quarter. (3) Beneficiary protections (A) Disclosure of premium rate structure A PACE provider shall disclose to Medicare-only PACE program eligible individuals the capitation payment amounts that may be charged under this section to such individuals for non-Medicare services under the PACE program operated by such PACE provider under this section— (i) prior to enrollment of such individual in such PACE program, and (ii) periodically, and upon request of such individual, after enrollment. (B) Assessment instrument (i) In general The Secretary shall develop an assessment instrument for use by PACE programs with respect to Medicare-only PACE program eligible individuals under this subsection. (ii) Requirement for disclosure of assessment instrument The monthly capitation payment amount charged under paragraph (1) to a Medicare-only PACE program eligible individual for non-Medicare services shall be based on an assessment of such individual conducted by the PACE provider (using the assessment instrument developed by the Secretary under clause (i)), accounting for health status and corresponding needs. (iii) Requirement for disclosure of assessment instrument The assessment instrument used by the interdisciplinary team of the PACE program to evaluate the health and social status of PACE participants shall be disclosed to the individual prior to the assessment. (C) Process to seek review of assessments The Secretary shall establish a process for a Medicare-only PACE program eligible individual to seek review of any assessment conducted on the individual under this subsection. (4) Rule of construction Nothing in this subsection shall be construed to preclude the testing under section 1115A of a model to permit a PACE provider operating a PACE program to establish and charge monthly capitation payment amounts for the provision of non-Medicare services under the PACE program to Medicare-only PACE program eligible individuals under a rate structure established by such PACE provider for such purpose, including the use of an assessment instrument developed by the PACE program to assign such individuals to an appropriate rate category under such rate structure. (5) Definitions In this subsection— (A) the term Medicare-only PACE program eligible individual (B) the term non-Medicare services . (b) Effective date The amendment made by subsection (a) shall take effect on the date of the enactment of this Act, and apply with respect to capitation amounts that may be charged for months beginning on or after January 1, 2022. (c) Rule of construction Nothing in this section, or the amendments made by this section, shall be construed to modify or otherwise impact the following Medicare capitation rates that may be charged by PACE plans for PACE participants who are Medicare beneficiaries who are not both entitled to (or enrolled for) benefits under part A of title XVIII of the Social Security Act ( 42 U.S.C. 1395 (1) Part A only medicare beneficiary In the case of a Medicare beneficiary who is a PACE participant who is entitled to (or enrolled for) benefits under part A of such title XVIII but who is not enrolled for benefits under part B of such title, the Medicare Part B capitation rate under paragraph (b) of section 460.186 of title 42, Code of Federal Regulations (or any successor regulations). (2) Part B only medicare beneficiary In the case of a Medicare beneficiary who is a PACE participant who is enrolled for benefits under part B of such title XVIII but who is not entitled to (or enrolled for) benefits under part A of such title, the Medicare Part A capitation rate under paragraph (c) of such section 460.186 (or any successor regulations). 6. PACE site approval and expansion (a) In general Sections 1894(e) and 1934(e) of the Social Security Act ( 42 U.S.C. 1395eee(e) (8) Authority to submit applications at any time; timely consideration of applications (A) Authority to submit applications at any time (i) New PACE provider status An entity that seeks to become a PACE provider may submit an application for PACE provider status at any time. (ii) Service area expansion and addition of PACE center site To the extent the Secretary requires a PACE provider to submit an application to expand its service area or to add a PACE center site, a PACE provider may submit such an application at any time, subject to the requirements of section 460.12(d) of title 42, Code of Federal Regulations (relating to the first trial period audit), or any successor regulation. (iii) Assurances An application for PACE provider status under clause (i) or to add a PACE center site under clause (ii) shall include the following assurances: (I) An assurance that the required members of the interdisciplinary team are employees or contractors of the proposed PACE center or will be employees or contractors of the proposed PACE center by the time the PACE center becomes operational. (II) An assurance that— (aa) the PACE provider’s contracts for all contractors and contracted personnel will be executed by the time the proposed PACE center becomes operational; and (bb) executed contracts may include provisions for staffing levels to commensurate with enrollment to full projected census. (B) Deemed approval An application described in subparagraph (A) shall be deemed approved unless the Secretary, within 45 days after the date of the submission of the application to the Secretary, either denies such request in writing or informs the applicant in writing with respect to any additional information that is needed in order to make a final determination with respect to the application. After the date the Secretary receives such additional information, the application shall be deemed approved unless the Secretary, within 45 days of such date, denies such request. . (b) Effective date The amendments made by subsection (a) shall take effect on January 1, 2022. 7. PACE pilot Section 1115A(b)(2) of the Social Security Act ( 42 U.S.C. 1315a(b)(2) (1) in subparagraph (B), by adding at the end the following new clause: (xxviii) National testing of a model for expanded eligibility for the Program of All-Inclusive Care for the Elderly as described in subparagraph (D). ; and (2) by adding at the end the following new subparagraph: (D) National testing of model for expanded eligibility for the program of all-inclusive care for the elderly In the case where the Secretary selects the model described in clause (ii) of this subparagraph for testing pursuant to clause (xxviii) of subparagraph (B), the following shall apply: (i) National testing (I) In general Subject to subclause (II), the Secretary shall design a demonstration that allows each PACE provider with an executed PACE agreement to develop and submit to the Secretary an application to begin testing expanded PACE eligibility for high-need and high-cost populations that are not otherwise eligible to participate in a PACE program within 1 year of the date on which the model is selected. (II) No effect on ongoing models or demonstration projects Nothing in this subparagraph shall affect the testing of any model under this subsection or any demonstration project under this Act that is implemented prior to the date of the enactment of this subparagraph. (ii) Model described The model described in this clause seeks to increase access to quality, integrated, care for high-need, high-cost individuals who are not otherwise eligible to participate in a PACE program in order to improve health and reduce cost. Under this model, participating PACE providers would— (I) be paid fixed, monthly capitated rates from both Medicare and the applicable State Medicaid agency for all services provided to each enrollee fitting the criteria of the PACE provider’s designated population; (II) partner with non-PACE providers, such as Area Agencies on Aging, Centers for Independent Living, local hospitals, and non-hospital providers such as physicians, behavioral health providers and other community-based organizations to effectively reach the PACE provider’s selected population; (III) adapt the PACE program model of care to appropriately serve the PACE provider’s selected population to integrate care and meet the unique needs of said population; and (IV) if the PACE provider is located in a State that has not yet served the selected population through a PACE program under section 1934, receive an up-front fixed payment to coordinate with the State to develop a capitated payment rate, with appropriate risk adjustment, for the PACE provider’s selected population. (iii) Requirements for participating PACE organizations In order to participate in the model, a PACE provider must— (I) conduct a survey or needs assessment of their service area to determine the most appropriate population with which to expand their services; (II) receive prior approval from the applicable State Medicaid agency to submit an application to participate in the model; and (III) following such survey or needs assessment and approval from the applicable State Medicaid agency, submit and receive approval of an application of expansion from the Secretary. (iv) Application A PACE provider’s application to participate in this model shall include the following information: (I) Results of the survey or needs assessment of their service area under clause (iii)(I) and an explanation of the expanded population the PACE organization will serve. (II) The types of services that the expanded population will require and the PACE provider's plan to implement these services. (III) How the PACE provider will achieve engagement and enrollment of the new population in the model, including how it will partner with non-PACE providers in the applicable service area. (IV) How the expanded population’s participation in the PACE program is intended to improve quality of care and health outcomes under the model. (V) Certification that the applicable State Medicaid agency has approved the PACE provider's application to participate in the model. (VI) Plans to coordinate with the State Medicaid agency to develop an initial capitated rate with appropriate risk adjustment. (VII) Plans for the PACE provider and the State Medicaid agency to review and adjust the Medicaid capitated rate on a biennial basis, as needed. (VIII) Any other information required by the Secretary. (v) Technical assistance The Secretary shall provide, or designate an entity to provide, technical assistance to participating PACE providers as they apply for and implement the model. (vi) Accounting for uncertainty In order for implementing PACE providers to receive unanticipated additional resources needed to implement the model, the Secretary shall establish procedures for the implementing PACE providers to submit to the Secretary a request for additional resources. (vii) Monitoring outcomes The Secretary, in conjunction with PACE providers and in consultation with States that have elected to expand PACE program eligibility under section 1934(l), shall develop a plan to— (I) annually monitor outcomes under the model, which may include financial, quality, access, and utilization outcomes; (II) annually monitor the health outcomes of the PACE provider’s expanded population; and (III) any other outcomes as determined by the Secretary. (viii) Reporting requirements (I) Report to congress Not less frequently than every 3 years (for the duration of the implementation of the model under this subparagraph), the Secretary shall submit to Congress a report on the implementation of the model under this subparagraph. The report shall include demographic information on the populations served under the demonstration, best practices for future implementation efforts and any other information the Secretary determines appropriate together with recommendations for such legislation and administrative action as the Secretary determines appropriate. (ix) Funding The Secretary shall allocate funds made available under subsection (f)(1) to design, implement, evaluate, and report on the model described in clause (ii) in accordance with this subparagraph. . 8. State option to expand eligibility for PACE program (a) In general Section 1934 of the Social Security Act ( 42 U.S.C. 1396u–4 (1) in subsection (a)(5)(B), by inserting , subsection (k), and subsection (l) subsection (c)(4) (2) by adding at the end the following new subsection: (l) State option To expand eligibility (1) In general A State described in paragraph (3) may, at the option of the State, deem individuals described in paragraph (2) to be PACE program eligible individuals for the purposes of this section without regard to the requirement under subsection (a)(5)(B) that a PACE program eligible individual require the level of care required under the State medicaid plan for coverage of nursing facility services. (2) Expansion of eligibility An individual is described in this paragraph if— (A) the individual meets the requirements of subparagraphs (A), (C), and (D) of subsection (a)(5); (B) the individual is unable to perform at least 2 (or such higher number as the State may establish) activities of daily living, as determined by the State; and (C) the individual's income does not exceed 150 percent of the poverty line (as defined in section 2110(c)(5)) or, if greater, the income level applicable for an individual who has been determined to require an institutional level of care to be eligible for nursing facility services under the State plan and with respect to whom there has been a determination that, but for the provision of such services, the individual would require the level of care provided in a hospital, a nursing facility, an intermediate care facility for the mentally retarded, or an institution for mental diseases, the cost of which could be reimbursed under the State plan. (3) States eligible for option A State shall only be eligible to exercise the option under this subsection if— (A) the State administering agency has entered into an agreement for the operation of a PACE program under this section (and section 1894, if applicable) among such agency, the Secretary, and a PACE provider; and (B) the State provides coverage under the State plan under this title (or a waiver of such plan) for long-term services and supports. (4) Enhanced FMAP Notwithstanding section 1905(b), in the case of a State that exercises the option under this subsection, the Federal medical assistance percentage applicable with respect to expenditures by such State on monthly payments made to PACE providers under a PACE program agreement under this section for individuals who are deemed to be PACE program eligible individuals in accordance with paragraph (2) shall be equal to 90 percent. . (b) Conforming amendment Section 1894(a)(5) of the Social Security Act ( 42 U.S.C. 1395eee(a)(5) and section 1934(l) subsection (c)(4) 9. Coordination with the Federal Coordinated Health Care Office Section 1934 of the Social Security Act ( 42 U.S.C. 1396u–4 (m) Coordination with the Federal Coordinated Health Care Office (1) State coordination with FCHCO The Director of the Federal Coordinated Health Care Office established under section 2602 of the Patient Protection and Affordable Care Act shall serve as a point of contact between State administering agencies and the Federal Government for purposes of implementing and operating a PACE program in a State, and shall coordinate with other relevant offices and staff of the Centers for Medicare & Medicaid Services involved in carrying out this section. (2) Annual report Not later than January 1, 2023, and annually thereafter, the Director of the Federal Coordinated Health Care Office shall submit to Congress a report on the demographics of the populations served by PACE programs operated under this section and section 1894. .

Summary: Program of All-Inclusive Care for the Elderly Plus Act or the PACE Plus Act This bill modifies requirements and establishes programs regarding Programs of All-Inclusive Care for the Elderly (PACE). PACE is a program under Medicare and Medicaid that provides in-home and community services for certain individuals as an alternative to nursing home care. The bill allows Medicare beneficiaries to enroll in a PACE program at any time and provides states with the option to allow Medicaid beneficiaries to do the same. Entities may also apply to become PACE providers at any time, upon specified assurances relating to staffing and other requirements. States that provide Medicaid coverage of long-term care may also choose to expand PACE eligibility for Medicaid beneficiaries who are unable to perform at least two activities of daily living and who meet other specified criteria. Additionally, the bill establishes and provides funds for grant programs for (1) public or nonprofit PACE providers in rural or underserved urban areas for planning, administrative, capital, and other expenses that are necessary for site development; and (2) states that do not have PACE providers for expenses deemed necessary for program establishment. The bill also allows the Center for Medicare and Medicaid Innovation to test a model for expanded PACE eligibility that targets high-need and high-cost populations.