programs of all-inclusive care for the elderly: how does it work? lcdr amy hesselgesser, otr account...
TRANSCRIPT
Programs of All-InclusiveCare for the Elderly: How Does it Work?
LCDR Amy Hesselgesser, OTRAccount Manager, Centers for Medicare & Medicaid Services
1
Stay in the home you love, visit us for the care you need.
2
National PACE Association , 2011
I was alone a lot of the time. Now I have a place to go where I have friends, I can keep my mind challenged
and always have someone to talk to.
3National PACE Association, 2011
Agenda
History of PACE PACE Services & EligibilityKey Program AreasCMS/State MonitoringQuestions
4
PACE
What are Programs of All-inclusive Care for the Elderly (PACE)?PACE is a Medicare and Medicaid program for older adults and people over age 55 living with disabilities. The program provides community-based care and services to people who otherwise need nursing home level of care.
5
PACE Regulations
PACE is governed by regulations at CFR 42, Part 460, and is a three way agreement:
6
History
On Lok, first PACE Organization (PO), developed in 1979 in San Francisco, CA
1986 federal government expansion allowed up to ten POs nation wide
1997 Balanced Budget Act recognized PACE as a permanent CMS provider type
7
Enrollment
Currently over 75 PACE organizations
Serves over 23,000 beneficiaries Located in rural and urban areas
in 29 states Twelve pilot sites offer veterans
care in collaboration with the VA
8
Growth of PACE Programs
9
Source: National PACE Association
GOAL
The PACE model provides: comprehensive medical and social
services to frail, low-income seniors.
PACE is intended to help seniors stay in their homes as long as possible.
10
PACE Eligibility
Individuals who wish to participate must voluntarily enroll and:
Be at least 55 years of age. Live in the PACE service area. Be in need of nursing facility care as
defined by the State At the time of enrollment, be able to
safely live in a community setting.
11
Eligibility
Once enrolled, participants must: get their medical care only
through PACE providers. out of network care must be
authorized by the PACE interdisciplinary team (IDT).
12
How it works….
PACE organizations receive a fixed monthly payment per enrollee from Medicare and Medicaid.
In return, they are responsible for providing 100% of the health services their participants require.
13
What it Looks Like……
PACE offers & manages all the medical, social and rehabilitative services their enrollees need to preserve or restore their independence, to remain in their homes and communities, and to maintain their quality of life.
14
Focus on Preventive Care:
The PACE interdisciplinary team (IDT) provides:
treatment and preventive health care to keep seniors healthy and to avoid hospitalizations or nursing home visits.
15
The Interdisciplinary Team
The Interdisciplinary Team (IDT) manages the care of the participant.
The IDT, by regulation, must consist of:Primary care physicians and nursesPhysical, occupational, and recreational therapistsSocial workers and Home Care CoordinatorsPersonal care attendantsDietitiansDriversPACE Center Manager
16
Plan of Care
The IDT must perform participant assessments:
at enrollment every 6 months when a participant’s condition
changes upon participant request
17
Plan of Care
Once the IDT assesses, they must develop a plan of care designed to meet the medical, physical, social and emotional needs of the participant.
The plan of care must reflect the
participants preferences for care.
18
PACE Services
PACE regulations require PACE organizations to provide participants with all medically necessary services including prescription drugs, without any limitation or condition as to:
amount, duration, or scope and without application of deductibles, co-
payments, or coinsurance that would otherwise apply under Medicare or Medicaid.
19
PACE Services
Minimum services provided in the PACE center:
primary care services social services restorative therapies (physical AND
occupational therapy) personal care and supportive services, nutritional counseling, recreational therapy, meals.
20
Participant Costs
Participant Prescriptions Health Coverage
Medicare/Medicaid No cost No cost
Medicare-Only Premium only, no deductible or co-pay
Premium equivalent to State Capitation
21
The Day Center
Services are provided in an adult day health center setting, but may also include in-home and other referral services that enrollees may need.
22
Outside the Day Center
Transportation Home care Other services deemed necessary
by the Interdisciplinary Team
23
Other Services
Other services include but are not limited to:
medical specialists laboratory other diagnostic services hospital nursing home care
24
Excluded Services
Any service not authorized by the IDT EXCEPT emergency careExperimental procedures, cosmetic surgeryNon medical items for personal convenience
25
Key Program Areas
The PACE Organization must:
have a governing board that includes community representation be able to provide the complete service package regardless of frequency or duration of services have a physical site to provide adult day services have a defined service area
26
Key Program Areas
The PACE Organization must:
have safeguards against conflict of interest; have demonstrated fiscal soundness; have a formal Participant Bill of Rights, andmust demonstrate Interdisciplinary Team driven participant care.
27
Quality Assessment/Performance Improvement (QAPI)
PACE organizations must have written QAPI performance improvement plans which identify:
Areas to improve the delivery of services/patient care
Plans to improve or maintain quality of care
28
Examples of PACE QAPI initiatives
Utilization of services
Caregiver/participant satisfaction
Outcome measures derived from clinical data and non-clinical data
29
CMS/State Monitoring
Technical Advisory Visits Trial Period Audits Routine Audits Focused Audits
30
CMS/State Monitoring
PACE Organizations are required to report 9 quality indicators to CMS:
ImmunizationsGrievancesAppealsEnrollments/DisenrollmentsProspective EnrolleesReadmissionsEmergency CareParticipant DeathsUnusual Incidents
31
Level II Reporting
PACE organizations are required to:
report serious events having adverse health outcomes to CMS and the State agency.
conduct an internal investigation and report the results to CMS via teleconference.
32
Cost Effectiveness
Statistics vary by state. Some
report significant savings. No comprehensive evaluation of
PACE cost-effectiveness currently exists.
33
Expansion
Barriers include:High start up costsMarketing challengesFinancial risksLack of standardized outcome measures
National PACE Association, 12/2010
34
Do you want to know more about PACE?
35
What’s New at CMS: PCIP
Pre-Existing Condition Insurance Plan (PCIP)
Program
37
38
Statutory Authority for PCIP
Section 1101 of the Affordable Care Act (ACA) requires that HHS establish a “temporary high risk health insurance pool program” Provides coverage for individuals with pre-existing conditions until the Health Insurance Exchanges are available in 2014
Law required establishment within 90 days of enactment
PCIP Offers Comprehensive Benefits…
Care in medical offices for treatment of illness or injuryEmergency servicesInpatient and outpatient hospital servicesInpatient and outpatient mental health and substance abuse servicesPrescription drugsHome health care and hospice servicesOutpatient laboratory and diagnostic servicesIn- and out-of-network benefits
…and Important Features for Consumers
First-dollar coverage for preventive careNo lifetime maximum on the amount the plan pays for enrollee’s careBenefits are available immediately when coverage begins, even for pre-existing conditionsThe ability to receive benefits at any qualified provider
41
Eligibility for PCIP
A person applying for PCIP must:Reside within the service area of the PCIP;Be a U.S. citizen or reside in the U.S. legally;Have been without health coverage for a minimum of 6 months before applying; and Have a pre-existing condition, as defined by the PCIP and approved by HHS.*Rate must equal at least 200% of corresponding PCIP rate. Permitted for select applicants.
Applying for PCIP Coverage
In federally-run PCIP, apply for coverage by:
Mailing a paper application;Calling the call center to complete an application over the phone; or Filing out an online application at www.pcip.gov
State-run PCIP enrollment mechanisms vary
42
43
For more information on the Pre-existing Condition Insurance Plan, please visit
http://www.pcip.gov