PACE Program Development Chris van Reenen, NPA MN PACE Summit July 2004

Session Objectives Identify milestones in PACE development Review PACE provider application process, State plan amendment process and 3-way program agreement Consider CMS and State roles in PACE development and implementation

Milestones in PACE Development Understanding the PACE Model Organizational Assessment and Decision-Making Planning and Development Program Operations

Step 1: Understanding the PACE Model Gain understanding of PACE model and service requirements Understand scope and extent of current PACE experience Understand stages of development for initiating new PACE organization Assess availability and cost of resources to assist in decision-making and start-up Milestone: Organization’s governing body commits to in-depth self-assessment

Step 2: Organizational Assessment and Decision-Making Assess federal and state regulatory requirements and implications for PACE Describe critical factors for moving forward and assess need for outside support Complete a business plan including recommendation to organization’s governing body

Step 2: Organizational Assessment and Decision-Making, cont. Key topics to be included in decision-making plan: Environmental assessment/demand analysis Organizational structure and management Service area and site location Service arrangements/provider network Marketing and enrollment plan Start-up and operations plan Goals, risk assessment and exit strategy Financial analysis Milestone: Organization commits resources to timeline and workplan for start-up

Step 3: Planning and Development / PACE Provider Application Secure financing and risk insurance Obtain approval of PACE provider application Establish effective marketing strategies Establish an operational PACE Center Milestone: PACE organization is operational and initiates enrollment

PACE Provider Application Content State assurances General Information & Organization Service area Organizational structure Governing body Consumer Advisory Committee PACE Administration Training program and competency assessment Contract services Physical environment, including PACE Center, emergency readiness, infection control, transportation, dietary services

PACE Provider Application Content, cont. Financial Financial statements Financial projections Insolvency plan Insurance arrangements Marketing Copies of all marketing materials Marketing plan PACE Services Service delivery plan PACE Centers Interdisciplinary team Participant assessment/reassessment Care planning

PACE Provider Application Content, cont. Participants Rights Bill of rights Restraints Grievance and appeals processes Quality Assessment & Performance Improvement QAPI plan External quality assessment and reporting requirements Participant Enrollment & Disenrollment Eligibility determination process Enrollment process and agreement Disenrollment processes

PACE Provider Application Content, cont. Payment Medicare secondary payor Information to set up systems for payment Data Collection, Record Maintenance & Reporting Medical records Confidentiality Data reporting

PACE Provider Application Process Provider applicant drafts application and submits to State for review and comment State submits final application to CMS with assurances If application is complete, CMS activates 1st 90-day clock CMS responds to State with approval, disapproval or request for add’l info (RAI)

PACE Provider Application Process, cont. Provider applicant drafts response to RAI and submits to State for review and comment State submits response to RAI to CMS State conducts on-site State Readiness Review and forwards results to CMS 2nd 90-day clock begins – no later than Day 90, CMS must approve (or deny) provider application

State Plan Amendment for PACE State must amend its State Medicaid Plan to elect PACE as a voluntary state option SPA and provider application processes can occur simultaneously State must receive CMS approval of SPA before 3-way Program Agreement can be signed

PACE Program Agreement 3-way agreement signed by PACE organization, CMS and State following approval of PACE provider application Consists largely of elements of provider application, e.g., participant bill of rights, grievance and appeals procedures, eligibility and enrollment policies, QAPI program PACE organization can now initiate operations

State and CMS Roles in PACE Development State Role Site selection Licensing and certification requirements UPL(s) and Medicaid capitation rate(s)-setting Program eligibility requirements and determination processes Medicaid enrollment and disenrollment systems Medicaid state plan amendment Reviews/submits PACE provider application and participate in provider application process Participates in 3-way Program Agreement Medicaid contract, if necessary Ongoing oversight and monitoring

State and CMS Roles in PACE Development, cont. Responsible for development/implementation of federal PACE regulatory requirements Implements Medicare payment methodology Reviews/approves PACE provider applications and SPAs Medicare enrollment and disenrollment systems Participates in 3-way program agreement Ongoing oversight and monitoring

For more information… CMS Website (www.cms.gov/pace): PACE regulation (11/24/99 AND 10/1/02) PACE Provider Application PACE Program Agreement PACE State Plan Amendment information PACE State Readiness Review Tool HPMS Data Elements Solicitation for For-Profit Demonstration NPA Website (www.npaonline.org)

Evolving Innovations PACE in rural areas PACE programs working in collaboration with housing

Regulatory flexibility for rural PACE organizations The likelihood that PACE organizations serving rural areas will need flexibility in adapting the PACE model is recognized in both statute and regulation §460.26 and §460.28 define the process by which existing and prospective PACE organizations can request waivers of specific regulatory requirements Waiver requests can accompany a PACE provider application or be submitted independently

Requirements that CANNOT be waived without changing current law Focus on frail elderly who require nursing home level of care Delivery of comprehensive, integrated acute and long-term care services Interdisciplinary team approach to care management and service delivery Capitated, integrated financing Assumption of full financial risk

Additional provisions not subject to waiver Nonprofit or public status of PACE organization Elements of provider application process and PACE program agreement Availability of health care services at PACE Center Interdisciplinary team approach to care management Comprehensive assessment & reassessment of health care needs Participant rights

Types of flexibility that may be important in rural areas Use of non-staff, community-based primary care physicians Composition of PACE IDT Recognition that PACE Centers in rural areas may not look like those in urban areas and be utilized differently Use of alternative delivery settings Personnel requirements

Opportunities for flexibility in rural areas Engage State and CMS partners in development of PACE in rural areas Utilize “new” contracting opportunities Utilize waiver process for regulatory flexibility Pursue statutory changes as necessary and appropriate

CORE Act of 2004 Community Options for Rural Elders Act of 2004 Intended to “jumpstart” development of PACE in rural areas Provides for start-up and development funding for rural PACE providers Waive requirements of full-financial risk for initial 3-year period Establishes formal technical assistance program for rural PACE providers

PACE and Senior Housing As PACE programs mature and their enrollees age, access to supportive housing environments becomes increasingly important Most PACE organizations have informal or formal links to senior housing

Federal Housing Programs Section 202 (loan/grants) 350,000+ units Section 236 80,000 units Section 8 (rent subsidy) Project based 260,000 units Tenant based (vouchers) 240,000 units Public housing 600,000+ units Other 200,000+ units

Senior Housing Residents Residents’ average age is about 80 years (Section 202/PHA) 90% of residents are older women living alone with less than $10,000 in annual income Estimate 20-30% need supportive services to remain at home (3+ ADLs)

PACE and Senior Housing: Benefits in Collaboration Residents: aging in place, quality care, future needs addressed Housing: addressing needs of elderly residents, does not require direct involvement in provision of care PACE: increased enrollment, continued community residence for enrollees, community visibility HUD-HHS: opportunity for collaboration

PACE and Senior Housing: Relationships Enrollment of frail residents in PACE Assist PACE enrollees to access suitable and affordable housing Lease/own community space and/or units Collaborate with development Ownership and/or management Joint funding (housing/common space) Co-location

PACE and Senior Housing: Co-location model

Example in Pittsburgh, PA -- Homestead