Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-330 - PACE definitions

Current through Register Vol. 40, No. 24, July 15, 2024
For purposes of this part and all contracts establishing
					 the Program of All-Inclusive Care for the Elderly (PACE) programs as defined in
					 42 CFR Part 460, the following definitions shall apply:
"Adult day health care center" or "ADHC" means a
					 DMAS-enrolled provider that offers a community-based day program providing a
					 variety of health, therapeutic, and social services designed to meet the
					 specialized needs of those elderly and disabled individuals at risk of
					 placement in a nursing facility.
"Applicant" means an individual seeking enrollment in a
					 PACE plan.
"Capitation rate" means the negotiated Medicaid monthly per
					 capita amount paid to a PACE provider for all services provided to
					 enrollees.
"Catchment area" means the designated service area for a
					 PACE plan.
"Centers for Medicare and Medicaid Services" or "CMS" means
					 the unit of the U.S. Department of Health and Human Services that administers
					 the Medicare and Medicaid programs.
"CFR" means the Code of Federal Regulations.
"Direct marketing" means either (i) conducting directly or
					 indirectly door-to-door, telephonic or other "cold call" marketing of services
					 at residences and provider sites; (ii) mailing directly; (iii) paying "finders'
					 fees;" (iv) offering financial incentives, rewards, gifts or special
					 opportunities to eligible individuals or family/caregivers as inducements to
					 use the providers' services; (v) continuous, periodic marketing activities to
					 the same prospective individual or family/caregiver for example, monthly,
					 quarterly, or annual giveaways as inducements to use the providers' services;
					 or (vi) engaging in marketing activities that offer potential customers rebates
					 or discounts in conjunction with the use of the providers' services or other
					 benefits as a means of influencing the individual's or family/caregiver's use
					 of the providers' services.
"DMAS" means the Department of Medical Assistance
					 Services.
"DSS" means the Department of Social Services.
"Enrollee" means a Medicaid-eligible individual meeting
					 PACE enrollment criteria and receiving services from a PACE plan.
"Full disclosure" means fully informing all PACE enrollees
					 at the time of enrollment that, pursuant to §
										32.1-330.3
					 of the Code of Virginia, PACE plan enrollment can only be guaranteed for a
					 30-day period.
"Imminent risk of nursing facility placement" means that an
					 individual will require nursing facility care within 30 days if a
					 community-based alternative care program, such as a PACE plan, is not
					 available.
"Long-term services and supports (LTSS) screening" or
					 "screening" means the face to face process to (i) evaluate the functional,
					 medical or nursing, and social support needs and at-risk status of individuals
					 referred for certain long-term services requiring nursing facility level of
					 care eligibility; (ii) assist individuals in determining what specific services
					 the individual needs; (iii) evaluate whether a service or a combination of
					 existing community services are available to meet the individual's needs; and
					 (iv) provide a list to individuals of appropriate providers for Medicaid-funded
					 nursing facility, PACE plan services, or the Commonwealth Coordinated Care Plus
					 waiver for those individuals who meet nursing facility level of care.
"Long-term services and supports (LTSS) screening team"
					 means the hospital screening team, community-based team (CBT), nursing facility
					 team, or DMAS designee contracted to perform screenings pursuant to §
										32.1-330
					 of the Code of Virginia.
"PACE" means a Program of All-Inclusive Care for the
					 Elderly. PACE services are designed to enhance the quality of life and autonomy
					 for frail, older adults; maximize dignity of, and respect for, older adults;
					 enable frail, older adults to live in the community as long as medically and
					 socially feasible; and preserve and support the older adult's family
					 unit.
"PACE plan" means a comprehensive acute and long-term care
					 prepaid health plan, pursuant to §
										32.1-330.3
					 of the Code of Virginia and as defined in
					 42
					 CFR 460.6, operating on a capitated payment
					 basis through which the PACE provider assumes full financial risk. PACE plans
					 operate under both Medicare and Medicaid capitation.
"PACE plan contract" means a contract, pursuant to §
										32.1-330.3
					 of the Code of Virginia, under which an entity assumes full financial risk for
					 operation of a comprehensive acute and long-term care prepaid health plan with
					 capitated payments for services provided to Medicaid enrollees being made by
					 DMAS. The parties to a PACE plan contract are the entities operating the PACE
					 plan, DMAS and CMS.
"PACE plan feasibility study" means a study performed by a
					 research entity approved by DMAS to determine a potential PACE plan provider's
					 ability and resources, or lack thereof, to effectively operate a PACE plan. All
					 study costs are the responsibility of the potential PACE provider.
"PACE protocol" means the protocol for the Program of
					 All-Inclusive Care for the Elderly, as published by On Lok, Inc., as of April
					 14, 1995, or any successor protocol that may be agreed upon by the federal
					 Secretary of Health and Human Services and On Lok, Inc.
"PACE provider" means the entity contracting with the
					 Department of Medical Assistance Services to operate a PACE plan.
"PACE site" means the location, which includes a primary
					 care center, where the PACE provider both operates the PACE plan's adult day
					 health care center and coordinates the provision of core PACE services,
					 including the provision of primary care.
"Plan of care" means the written plan developed by the
					 provider related solely to the specific services required by the individual to
					 ensure optimal health and safety while receiving services from the
					 provider.
"Primary care provider" or "PCP" means the individual
					 responsible for the coordination of medical care provided to an enrollee under
					 a PACE plan.
"Provider" means the individual or other entity registered,
					 licensed, or certified, as appropriate, and enrolled by DMAS to render services
					 to Medicaid recipients eligible for services.
"State Plan for Medical Assistance" or "the Plan" means the
					 Commonwealth's legal document approved by CMS identifying the covered groups,
					 covered services and their limitations, and provider reimbursement
					 methodologies as provided for under Title XIX of the Social Security
					 Act.
"Virginia Uniform Assessment Instrument" or "UAI" means the
					 standardized, multidimensional assessment instrument that is completed by the
					 LTSS screening team that assesses an individual's physical health, mental
					 health, and psycho/social and functional abilities to determine if the
					 individual meets the nursing facility level of care.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396.