Source: http://www.law.cornell.edu/uscode/text/42/1395eee
Timestamp: 2013-12-12 20:00:36
Document Index: 751479228

Matched Legal Cases: ['§ 1395', '§ 1395', '§ 1395', '§ 1894', '§ 4801', '§ 1', '§ 902', '§ 236', '§ 161', '§ 3201', '§ 1102', '§ 3201', '§ 1102', '§ 1', '§ 902', '§ 5302', '§ 205', '§ 1', '§ 903', '§ 1', '§ 901', '§ 4801', '§ 4801', '§ 4801']

42 USC § 1395eee - Payments to, and coverage of benefits under, programs of all-inclusive care for elderly (PACE) | Title 42 - The Public Health and Welfare | U.S. Code | LII / Legal Information Institute
USC › Title 42 › Chapter 7 › Subchapter XVIII › Part E › § 1395eee › prevnext
42 USC § 1395eee - Payments to, and coverage of benefits under, programs of all-inclusive care for elderly (PACE)
Receipt of benefits through enrollment in PACE program; definitions for PACE program related terms (1)
Benefits through enrollment in a PACE program In accordance with this section, in the case of an individual who is entitled to benefits under part A of this subchapter or enrolled under part B of this subchapter and who is a PACE program eligible individual (as defined in paragraph (5)) with respect to a PACE program offered by a PACE provider under a PACE program agreement—
the individual may enroll in the program under this section; and
so long as the individual is so enrolled and in accordance with regulations—
the individual shall receive benefits under this subchapter solely through such program; and
the PACE provider is entitled to payment under and in accordance with this section and such agreement for provision of such benefits.
subject to subparagraph (B), is (or is a distinct part of) a public entity or a private, nonprofit entity organized for charitable purposes under section 501(c)(3) of the Internal Revenue Code of 1986; and
“PACE program agreement” defined For purposes of this section, the term “PACE program agreement” means, with respect to a PACE provider, an agreement, consistent with this section, section 1396u–4 of this title (if applicable), and regulations promulgated to carry out such sections, between the PACE provider and the Secretary, or an agreement between the PACE provider and a State administering agency for the operation of a PACE program by the provider under such sections.
“State administering agency” defined For purposes of this section, the term “State administering agency” means, with respect to the operation of a PACE program in a State, the agency of that State (which may be the single agency responsible for administration of the State plan under subchapter XIX of this chapter in the State) responsible for administering PACE program agreements under this section and section 1396u–4 of this title in the State.
“Regulations” defined For purposes of this section, the term “regulations” refers to interim final or final regulations promulgated under subsection (f) of this section to carry out this section and section 1396u–4 of this title.
provide to PACE program eligible individuals enrolled with the provider, regardless of source of payment and directly or under contracts with other entities, at a minimum—
all items and services covered under this subchapter (for individuals enrolled under this section) and all items and services covered under subchapter XIX of this chapter, but without any limitation or condition as to amount, duration, or scope and without application of deductibles, copayments, coinsurance, or other cost-sharing that would otherwise apply under this subchapter or such subchapter, respectively; and
a written plan of quality assurance and improvement, and procedures implementing such plan, in accordance with regulations; and
written safeguards of the rights of enrolled participants (including a patient bill of rights and procedures for grievances and appeals) in accordance with regulations and with other requirements of this subchapter and Federal and State law that are designed for the protection of patients.
(k)(1) of this title (relating to limitations on balance billing against MA organizations for noncontract physicians and other entities with respect to services covered under this subchapter) shall apply to PACE providers, PACE program eligible individuals enrolled with such PACE providers, and physicians and other entities that do not have a contract or other agreement establishing payment amounts for services furnished to such an individual in the same manner as such section applies to MA organizations, individuals enrolled with such organizations, and physicians and other entities referred to in such section.
Reference to related provision for noncontract providers of services For the provision relating to limitations on balance billing against PACE providers for services covered under this subchapter furnished by noncontract providers of services, see section 1395cc
Reference to related provision for services covered under subchapter XIX but not under this subchapter For provisions relating to limitations on payments to providers participating under the State plan under subchapter XIX of this chapter that do not have a contract or other agreement with a PACE provider establishing payment amounts for services covered under such plan (but not under this subchapter) when such services are furnished to enrollees of that PACE provider, see section 1396a
(a)(66) of this title.
In general The determination of whether an individual is a PACE program eligible individual—
shall be made under and in accordance with the PACE program agreement; and
who is entitled to medical assistance under subchapter XIX of this chapter, shall be made (or who is not so entitled, may be made) by the State administering agency.
Condition An individual is not a PACE program eligible individual (with respect to payment under this section) unless the individual’s health status has been determined by the Secretary or the State administering agency, in accordance with regulations, to be comparable to the health status of individuals who have participated in the PACE demonstration waiver programs. Such determination shall be based upon information on health status and related indicators (such as medical diagnoses and measures of activities of daily living, instrumental activities of daily living, and cognitive impairment) that are part of a uniform minimum data set collected by PACE providers on potential PACE program eligible individuals.
Exception The requirement of annual reevaluation under subparagraph (A) may be waived during a period in accordance with regulations in those cases where the State administering agency determines that there is no reasonable expectation of improvement or significant change in an individual’s condition during the period because of the severity of chronic condition, or degree of impairment of functional capacity of the individual involved.
Regulations promulgated by the Secretary under this section and section 1396u–4 of this title, and the PACE program agreement, shall provide that the PACE program may not disenroll a PACE program eligible individual except—
Payments to PACE providers on capitated basis (1)
In general In the case of a PACE provider with a PACE program agreement under this section, except as provided in this subsection or by regulations, the Secretary shall make prospective monthly payments of a capitation amount for each PACE program eligible individual enrolled under the agreement under this section in the same manner and from the same sources as payments are made to a Medicare Choice organization under section 1395w–23 of this title (or, for periods beginning before January 1, 1999, to an eligible organization under a risk-sharing contract under section 1395mm of this title). Such payments shall be subject to adjustment in the manner described in section 1395w–23
(a)(2) of this title or section 1395mm
(a)(1)(E) of this title, as the case may be.
Capitation amount The capitation amount to be applied under this subsection for a provider for a contract year shall be an amount specified in the PACE program agreement for the year. Such amount shall be based upon payment rates established for purposes of payment under section 1395w–23 of this title (or, for periods before January 1, 1999, for purposes of risk-sharing contracts under section 1395mm of this title) and shall be adjusted to take into account the comparative frailty of PACE enrollees and such other factors as the Secretary determines to be appropriate. Such amount under such an agreement shall be computed in a manner so that the total payment level for all PACE program eligible individuals enrolled under a program is less than the projected payment under this subchapter for a comparable population not enrolled under a PACE program.
Capitation rates determined without regard to the phase-out of the indirect costs of medical education from the annual Medicare Advantage capitation rate Capitation amounts under this subsection shall be determined without regard to the application of section 1395w–23
(k)(4) of this title.
In general The Secretary, in close cooperation with the State administering agency, shall establish procedures for entering into, extending, and terminating PACE program agreements for the operation of PACE programs by entities that meet the requirements for a PACE provider under this section, section 1396u–4 of this title, and regulations.
40 as of August 5, 1997; or
is operating under a demonstration project waiver under subsection (h) of this section; or
shall be effective for a contract year, but may be extended for additional contract years in the absence of a notice by a party to terminate and is subject to termination by the Secretary and the State administering agency at any time for cause (as provided under the agreement);
make available to the Secretary and the State administering agency reports that the Secretary finds (in consultation with State administering agencies) necessary to monitor the operation, cost, and effectiveness of the PACE program under this section and section 1396u–4 of this title.
an on-site visit to the program site;
any other elements the Secretary or State administering agency considers necessary or appropriate.
the Secretary or a State administering agency may terminate a PACE program agreement for cause; and
a PACE provider may terminate an agreement after appropriate notice to the Secretary, the State agency, and enrollees.
the provider has failed to comply substantially with conditions for a program or provider under this section or section 1396u–4 of this title; and
Withhold some or all further payments under the PACE program agreement under this section or section 1396u–4 of this title with respect to PACE program services furnished by such provider until the deficiencies have been corrected.
(g)(1) (or section 1395mm
(i)(6)(A) of this title for such periods) or 1396b(m)(5)(A) of this title, respectively (in relation to agreements, enrollees, and requirements under this section or section 1396u–4 of this title, respectively).
(i)(9) of this title) shall apply to termination and sanctions respecting a PACE program agreement and PACE provider under this subsection in the same manner as they apply to a termination and sanctions with respect to a contract and a Medicare Choice organization under part C of this subchapter (or for such periods an eligible organization under section 1395mm of this title).
In general The Secretary shall issue interim final or final regulations to carry out this section and section 1396u–4 of this title.
Flexibility In order to provide for reasonable flexibility in adapting the PACE service delivery model to the needs of particular organizations (such as those in rural areas or those that may determine it appropriate to use nonstaff physicians according to State licensing law requirements) under this section and section 1396u–4 of this title, the Secretary (in close consultation with State administering agencies) may modify or waive provisions of the PACE protocol so long as any such modification or waiver is not inconsistent with and would not impair the essential elements, objectives, and requirements of this section, but may not modify or waive any of the following provisions:
Continuation of modifications or waivers of operational requirements under demonstration status If a PACE program operating under demonstration authority has contractual or other operating arrangements which are not otherwise recognized in regulation and which were in effect on July 1, 2000, the Secretary (in close consultation with, and with the concurrence of, the State administering agency) shall permit any such program to continue such arrangements so long as such arrangements are found by the Secretary and the State to be reasonably consistent with the objectives of the PACE program.
In general In issuing such regulations and subject to subparagraph (B), the Secretary may apply with respect to PACE programs, providers, and agreements such requirements of part C of this subchapter (or, for periods before January 1, 1999, section 1395mm of this title) and sections 1396b
(m) and 1396u–2 of this title relating to protection of beneficiaries and program integrity as would apply to Medicare Choice organizations under part C of this subchapter (or for such periods eligible organizations under risk-sharing contracts under section 1395mm of this title) and to medicaid managed care organizations under prepaid capitation agreements under section 1396b
take into account the differences between populations served and benefits provided under this section and under part C of this subchapter (or, for periods before January 1, 1999, section 1395mm of this title) and section 1396b
not include any requirement restricting the proportion of enrollees who are eligible for benefits under this subchapter or subchapter XIX of this chapter.
Waivers of requirements With respect to carrying out a PACE program under this section, the following requirements of this subchapter (and regulations relating to such requirements) are waived and shall not apply:
Section 1395d of this title, insofar as it limits coverage of institutional services.
Sections 1395e, 1395f, 1395l, and 1395ww of this title, insofar as such sections relate to rules for payment for benefits.
Sections 1395f
(a)(2)(B), 1395f
(a)(2)(C), and 1395n
(a)(2)(A) of this title, insofar as they limit coverage of extended care services or home health services.
Section 1395x
(i) of this title, insofar as it imposes a 3-day prior hospitalization requirement for coverage of extended care services.
Paragraphs (1) and (9) of section 1395y
(a) of this title, insofar as they may prevent payment for PACE program services to individuals enrolled under PACE programs.
Miscellaneous provisions Nothing in this section or section 1396u–4 of this title shall be construed as preventing a PACE provider from entering into contracts with other governmental or nongovernmental payers for the care of PACE program eligible individuals who are not eligible for benefits under part A of this subchapter, or enrolled under part B of this subchapter, or eligible for medical assistance under subchapter XIX of this title.
(Aug. 14, 1935, ch. 531, title XVIII, § 1894, as added Pub. L. 105–33, title IV, § 4801,Aug. 5, 1997, 111 Stat. 528; amended Pub. L. 106–554, § 1(a)(6) [title IX, § 902(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–582; Pub. L. 108–173, title II, § 236(a)(2),Dec. 8, 2003, 117 Stat. 2210; Pub. L. 110–275, title I, § 161(c),July 15, 2008, 122 Stat. 2569; Pub. L. 111–148, title III, § 3201(i)(1),Mar. 23, 2010, 124 Stat. 453; Pub. L. 111–152, title I, § 1102(a),Mar. 30, 2010, 124 Stat. 1040.)
Section 4804(b) of the Balanced Budget Act of 1997, referred to in subsec. (a)(3)(B)(ii), is section 4804(b) ofPub. L. 105–33, which is set out as a note below.
For the effective date of this section, referred to in subsec. (a)(9)(B), see section 4803 ofPub. L. 105–33, set out below.
2010—Subsecs. (h) to (j). Pub. L. 111–148, § 3201(i)(1), which directed addition of subsec. (h) and the redesignation of former subsecs. (h) and (i) as (i) and (j), respectively, was repealed by Pub. L. 111–152, § 1102(a). Prior to repeal, text of subsec. (h) read as follows:
“With respect to a PACE program under this section, the following provisions (and regulations relating to such provisions) shall not apply:
“(1) Section 1395w–23
(j)(1)(A)(i) of this title, relating to MA area-specific non-drug monthly benchmark amount being based on competitive bids.
“(2) Section 1395w–23
(d)(5) of this title, relating to the establishment of MA local plan service areas.
“(3) Section 1395w–23
(n) of this title, relating to the payment of performance bonuses.
“(4) Section 1395w–23
(o) of this title, relating to grandfathering supplemental benefits for current enrollees after implementation of competitive bidding.
“(5) Section 1395w–23
(p) of this title, relating to transitional extra benefits.”
2008—Subsec. (d)(3). Pub. L. 110–275added par. (3).
Repeal of section 3201 ofPub. L. 111–148and the amendments made by such section, effective as if included in the enactment of Pub. L. 111–148, see section 1102(a) ofPub. L. 111–152, set out as a note under section 1395w–21 of this title.
Pub. L. 106–554, § 1(a)(6) [title IX, § 902(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–583, provided that: “The amendments made by this section [amending this section and section 1396u–4 of this title] shall be effective as [if] included in the enactment of BBA [Pub. L. 105–33].”
Rural PACE Provider Grant Program
Pub. L. 109–171, title V, § 5302,Feb. 8, 2006, 120 Stat. 51, as amended by Pub. L. 109–432, div. B, title II, § 205(a),Dec. 20, 2006, 120 Stat. 2989, provided that:
“(1) CMS.—The term ‘CMS’ means the Centers for Medicare & Medicaid Services.
“(2) PACE program.—The term ‘PACE program’ has the meaning given that term in sections 1894(a)(2) and 1934(a)(2) of the Social Security Act (42 U.S.C. 1395eee
(a)(2); 1396u–4(a)(2)).
“(3) PACE provider.—The term ‘PACE provider’ has the meaning given that term in section 1894(a)(3) or 1934(a)(3) of the Social Security Act (42 U.S.C. 1395eee
(a)(3); 1396u–4(a)(3)).
“(4) Rural area.—The term ‘rural area’ has the meaning given that term in section 1886(d)(2)(D) of the Social Security Act (42 U.S.C. 1395ww
(d)(2)(D)).
“(5) Rural pace pilot site.—The term ‘rural PACE pilot site’ means a PACE provider that has been approved to provide services in a geographic service area that is, in whole or in part, a rural area, and that has received a site development grant under this section.
“(b) Site Development Grants and Technical Assistance Program.—
“(1) Site development grants.—
“(A) In general.—The Secretary shall establish a process and criteria to award site development grants to qualified PACE providers that have been approved to serve a rural area.
“(B) Amount per award.—A site development grant awarded under subparagraph (A) to any individual rural PACE pilot site shall not exceed $750,000.
“(C) Number of awards.—Not more than 15 rural PACE pilot sites shall be awarded a site development grant under subparagraph (A).
“(D) Use of funds.—Funds made available under a site development 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:
“(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 expense reporting required for calculation of outlier payments or reconciliation processes.
“(vii) Development of any special quality of care or patient satisfaction data collection efforts.
“(viii) Establishment of a working capital fund to sustain fixed administrative, facility, or other fixed costs until the provider reaches sufficient enrollment size.
“(ix) Startup and development costs incurred prior to the approval of the rural PACE pilot site’s PACE provider application by CMS.
“(x) Any other efforts determined by the rural PACE pilot site to be critical to its successful startup, as approved by the Secretary.
“(i) In general.—Out of funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary to carry out this subsection for fiscal year 2006, $7,500,000.
“(ii) Availability.—Funds appropriated under clause (i) shall remain available for expenditure through fiscal year 2008.
“(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 PACE programs in rural areas; and
“(B) technical assistance necessary to support rural PACE pilot sites.
“(c) Cost Outlier Protection for Rural PACE Pilot Sites.—
“(1) Establishment of fund for reimbursement of outlier costs.—Notwithstanding any other provision of law, the Secretary shall establish an outlier fund to reimburse rural PACE pilot sites for recognized outlier costs (as defined in paragraph (3)) incurred for eligible outlier participants (as defined in paragraph (2)) in an amount, subject to paragraph (4), equal to 80 percent of the amount by which the recognized outlier costs exceeds $50,000.
“(2) Eligible outlier participant.—For purposes of this subsection, the term ‘eligible outlier participant’ means a PACE program eligible individual (as defined in sections 1894(a)(5) and 1934(a)(5) of the Social Security Act (42 U.S.C. 1395eee
(a)(5); 1396u–4(a)(5))) who resides in a rural area and with respect to whom the rural PACE pilot site incurs more than $50,000 in recognized costs in a 12-month period.
“(3) Recognized outlier costs defined.—
“(A) In general.—For purposes of this subsection, the term ‘recognized outlier costs’ means, with respect to services furnished to an eligible outlier participant by a rural PACE pilot site, the least of the following (as documented by the site to the satisfaction of the Secretary) for the provision of inpatient and related physician and ancillary services for the eligible outlier participant in a given 12-month period:
“(i) If the services are provided under a contract between the pilot site and the provider, the payment rate specified under the contract.
“(ii) The payment rate established under the original Medicare fee-for-service program for such service.
“(iii) The amount actually paid for the services by the pilot site.
“(B) Inclusion in only one period.—Recognized outlier costs may not be included in more than one 12-month period.
“(3)[two pars. (3) have been enacted] Outlier expense payment.—
“(A)[no subpar. (B) has been enacted] Payment for outlier costs.—Subject to subparagraph (B), in the case of a rural PACE pilot site that has incurred outlier costs for an eligible outlier participant, the rural PACE pilot site shall receive an outlier expense payment equal to 80 percent of such costs that exceed $50,000.
“(4) Limitations.—
“(A) Costs incurred per eligible outlier participant.—The total amount of outlier expense payments made under this subsection to a rural PACE pilot site with respect to an eligible outlier participant for any 12-month period shall not exceed $100,000 for the 12-month period used to calculate the payment.
“(B) Costs incurred per provider.—No rural PACE pilot site may receive more than $500,000 in total outlier expense payments in a 12-month period.
“(C) Limitation of outlier cost reimbursement period.—A rural PACE pilot site shall only receive outlier expense payments under this subsection with respect to costs incurred during the first 3 years of the site’s operation.
“(5) Requirement to access risk reserves prior to payment.—A rural PACE pilot site shall access and exhaust any risk reserves held or arranged for the provider (other than revenue or reserves maintained to satisfy the requirements of section 460.80(c) of title 42, Code of Federal Regulations) and any working capital established through a site development grant awarded under subsection (b)(1), prior to receiving any payment from the outlier fund.
“(6) Application.—In order to receive an outlier expense payment under this subsection with respect to an eligible outlier participant, a rural PACE pilot site shall submit an application containing—
“(A) documentation of the costs incurred with respect to the participant;
“(B) a certification that the site has complied with the requirements under paragraph (4); and
“(C) such additional information as the Secretary may require.
“(7) Appropriation.—
“(A) In general.—Out of funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary $10,000,000 to carry out this subsection for the period of fiscal years 2006 through 2010.
“(B) Availability.—Funds appropriated under subparagraph (A) shall remain available for obligation through fiscal year 2010.
“(d) Evaluation of PACE Providers Serving Rural Service Areas.—Not later than 60 months after the date of enactment of this Act [Feb. 8, 2006], the Secretary shall submit a report to Congress containing an evaluation of the experience of rural PACE pilot sites.
“(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; 1396u–4).”
Flexibility in Exercising Waiver Authority
Pub. L. 106–554, § 1(a)(6) [title IX, § 903], Dec. 21, 2000, 114 Stat. 2763, 2763A–583, provided that: “In applying sections 1894(f)(2)(B) and 1934(f)(2)(B) of the Social Security Act (42 U.S.C. 1395eee
(f)(2)(B), 1396u–4
(f)(2)(B)), the Secretary of Health and Human Services—
“(1) shall approve or deny a request for a modification or a waiver of provisions of the PACE protocol not later than 90 days after the date the Secretary receives the request; and
“(2) may exercise authority to modify or waive such provisions in a manner that responds promptly to the needs of PACE programs relating to areas of employment and the use of community-based primary care physicians.”
Transition; Regulations
Section 4803 of title IV of Pub. L. 105–33, as amended by Pub. L. 106–554, § 1(a)(6) [title IX, § 901], Dec. 21, 2000, 114 Stat. 2763, 2763A–582, provided that:
“(a) Timely Issuance of Regulations; Effective Date.—The Secretary of Health and Human Services shall promulgate regulations to carry out this subtitle [subtitle I (§§ 4801–4804) of title IV of Pub. L. 105–33, enacting this section and section 1396u–4 of this title, amending sections 1396b, 1396d, 1396r–5, and 1396v of this title, and enacting provisions set out as notes under this section and section 1395b–6 of this title] in a timely manner. Such regulations shall be designed so that entities may establish and operate PACE programs under sections 1894 and 1934 of the Social Security Act [this section and section 1396u–4 of this title] (as added by sections 4801 and 4802 of this subtitle) for periods beginning not later than 1 year after the date of the enactment of this Act [Aug. 5, 1997].
“(b) Expansion and Transition for PACE Demonstration Project Waivers.—
“(1) Expansion in current number and extension of demonstration projects.—Section 9412(b) of the Omnibus Budget Reconciliation Act of 1986 [see subsec. (d) below], as amended by section 4118(g) of the Omnibus Budget Reconciliation Act of 1987, is amended—
“(A) in paragraph (1), by inserting before the period at the end the following: ‘, except that the Secretary shall grant waivers of such requirements to up to the applicable numerical limitation specified in sections 1894(e)(1)(B) and 1934(e)(1)(B) of the Social Security Act’ [subsec. (e)(1)(B) of this section and section 1396u–4
(e)(1)(B) of this title]; and
“(B) in paragraph (2)—
“(i) in subparagraph (A), by striking ‘, including permitting the organization to assume progressively (over the initial 3-year period of the waiver) the full financial risk’; and
“(ii) in subparagraph (C), by adding at the end the following: ‘In granting further extensions, an organization shall not be required to provide for reporting of information which is only required because of the demonstration nature of the project.’
“(2) Elimination of replication requirement.—Section 9412(b)(2)(B) of such Act, as so amended, shall not apply to waivers granted under such section after the date of the enactment of this Act [Aug. 5, 1997].
“(3) Timely consideration of applications.—In considering an application for waivers under such section before the effective date of the repeals under subsection (d), subject to the numerical limitation under the amendment made by paragraph (1), the application shall be deemed approved unless the Secretary of Health and Human Services, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the applicant in writing with respect to any additional information which 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 90 days of such date, denies such request.
“(c) Priority and Special Consideration in Application.—During the 3-year period beginning on the date of the enactment of this Act [Aug. 5, 1997]:
“(1) Provider status.—The Secretary of Health and Human Services shall give priority in processing applications of entities to qualify as PACE programs under section 1894 or 1934 of the Social Security Act [this section and section 1396u–4 of this title]—
“(A) first, to entities that are operating a PACE demonstration waiver program (as defined in sections 1894(a)(7) and 1934(a)(7) of such Act [subsec. (a)(7) of this section and section 1396u–4
(a)(7) of this title]); and
“(B) then to entities that have applied to operate such a program as of May 1, 1997.
“(2) New waivers.—The Secretary shall give priority, in the awarding of additional waivers under section 9412(b) of the Omnibus Budget Reconciliation Act of 1986 [see subsec. (d) below]—
“(A) to any entities that have applied for such waivers under such section as of May 1, 1997; and
“(B) to any entity that, as of May 1, 1997, has formally contracted with a State to provide services for which payment is made on a capitated basis with an understanding that the entity was seeking to become a PACE provider.
“(3) Special consideration.—The Secretary shall give special consideration, in the processing of applications described in paragraph (1) and the awarding of waivers described in paragraph (2), to an entity which as of May 1, 1997, through formal activities (such as entering into contracts for feasibility studies) has indicated a specific intent to become a PACE provider.
“(d) Repeal of Current PACE Demonstration Project Waiver Authority.—
“(1) In general.—Subject to paragraph (2), the following provisions of law are repealed:
“(A) Section 603(c) of the Social Security Amendments of 1983 (Public Law 98–21) [97 Stat. 168].
“(B) Section 9220 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (Public Law 99–272) [100 Stat. 183].
“(C) Section 9412(b) of the Omnibus Budget Reconciliation Act of 1986 (Public Law 99–509) [100 Stat. 2062].
“(2) Delay in application to current waivers.—
“(A) In general.—Subject to subparagraph (B), in the case of waivers granted with respect to a PACE program before July 1, 2000, the repeals made by paragraph (1) shall not apply until the end of a transition period (of up to 36 months) that begins on the initial effective date of such regulations, and that allows sufficient time for an orderly transition from demonstration project authority to general authority provided under the amendments made by this subtitle [subtitle I (§§ 4801–4804) of title IV of Pub. L. 105–33, enacting this section and section 1396u–4 of this title and amending sections 1396b, 1396d, 1396r–5, and 1396v of this title].
“(B) State option to seek extension of current period.—A State may elect to maintain the PACE programs which (as of the date of the enactment of this Act [Aug. 5, 1997]) were operating in the State under the authority described in paragraph (1) until a date (specified by the State) that is not later than 4 years after the initial effective date of regulations described in subsection (a). If a State makes such an election, the repeals made by paragraph (1) shall not apply to the programs until the date so specified, but only so long as such programs continue to operate under the same terms and conditions as apply to such programs as of the date of the enactment of this Act, and subparagraph (A) shall not apply to such programs.”
PACE Programs; Study and Reports
Section 4804(a), (b) of title IV of Pub. L. 105–33provided that:
“(1) In general.—The Secretary of Health and Human Services (in close consultation with State administering agencies, as defined in sections 1894(a)(8) and 1934(a)(8) of the Social Security Act [subsec. (a)(8) of this section and section 1396u–4
(a)(8) of this title]) shall conduct a study of the quality and cost of providing PACE program services under the medicare and medicaid programs under the amendments made by this subtitle [subtitle I (§§ 4801–4804) of title IV of Pub. L. 105–33, enacting this section and section 1396u–4 of this title and amending sections 1396b, 1396d, 1396r–5, and 1396v of this title].
“(2) Study of private, for-profit providers.—Such study shall specifically compare the costs, quality, and access to services by entities that are private, for-profit entities operating under demonstration projects waivers granted under sections 1894(h) and 1934(h) of the Social Security Act [subsec. (h) of this section and section 1396u–4
(h) of this title] with the costs, quality, and access to services of other PACE providers.
“(1) In general.—Not later than 4 years after the date of the enactment of this Act [Aug. 5, 1997], the Secretary shall provide for a report to Congress on the impact of such amendments on quality and cost of services. The Secretary shall include in such report such recommendations for changes in the operation of such amendments as the Secretary deems appropriate.
“(2) Treatment of private, for-profit providers.—The report shall include specific findings on whether any of the following findings is true:
“(A) The number of covered lives enrolled with entities operating under demonstration project waivers under sections 1894(h) and 1934(h) of the Social Security Act is fewer than 800 (or such lesser number as the Secretary may find statistically sufficient to make determinations respecting findings described in the succeeding subparagraphs).
“(B) The population enrolled with such entities is less frail than the population enrolled with other PACE providers.
“(C) Access to or quality of care for individuals enrolled with such entities is lower than such access or quality for individuals enrolled with other PACE providers.
“(D) The application of such section has resulted in an increase in expenditures under the medicare or medicaid programs above the expenditures that would have been made if such section did not apply.”