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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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 (

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

20. 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
§ and § 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

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

28. 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)

29. 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

30. 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

31. PACE and Senior Housing: Co-location model

32. Example in Pittsburgh, PA -- Homestead