Home and Community Based Services Manual
4.35.3 HCBS and PACE Coordination
Introduction
The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing or other care facility.
Purpose
PACE provides comprehensive health care services to eligible individuals. PACE covers all Medicaid covered services as well as additional services necessary to improve and maintain health, which includes:
- Adult Day Care (including physician, nursing, and therapy services)
- Home care
- Meals
- Medical specialty services
- Physician and nursing services
- Prescription drugs
- Transportation to the PACE center and medical appointments
Eligibility
The eligibility for PACE includes the following:
- Must be 55 years of age or older,
- Live in a designated PACE service area,
- Require nursing facility level of care, and
- Be able to live safely in the community with PACE supports.
Enrollment determination for PACE can be made by contacting the PACE organization.
Note: A participant enrolled in the PACE program is not eligible for any service authorized through the Home and Community Based Services (HCBS) program.
PACE Enrollment Process
As part of the PACE enrollment process the MO HealthNet Division (MHD) will:
- Verify if there is an active authorization for HCBS.
- Notify the PACE organization of an authorization for HCBS.
The PACE organization will inform the participant that all HCBS authorizations will close upon enrollment into the PACE program. If the participant chooses to continue with enrollment, the PACE organization will assist the participant in submitting a letter to the Division of Senior and Disability Services (DSDS) requesting HCBS closure due to enrolling in the PACE program and include the effective date. The Person Centered Care Plan (PCCP) team will process the request the day before the effective date of PACE enrollment.
PACE Disenrollment/HCBS Referral Process
The process for a PACE participant to voluntarily disenroll from the PACE program to access HCBS is as follows:
- The PACE organization will submit an HCBS referral, utilizing a referral form specific for PACE.
- The referral shall be submitted at least 30 business days before the tentative PACE disenrollment date.
- DSDS will process PACE coordinated referrals outside of the electronic case record.
- DSDS will complete the initial assessment, develop a proposed PCCP worksheet ( In-Home Service Worksheet and/or CDS Worksheet), and coordinate with the selected HCBS provider.
Note: The tentative effective date for HCBS services must be the first day of the following month, as PACE services can only end on the last day of the month.
DSDS will send notification to MHD.PACE@dss.mo.gov and obtain confirmation on the date the PACE participant will be disenrolled from the program. DSDS will not be able to enter actions or authorizations into the electronic case record until the PACE lock-in has ended. PACE coordinated referrals will be handled as standard priority, as PACE services can be accessed up to the date HCBS is authorized.
PACE Complaint Process
The Division of Senior and Disability Services (DSDS) shall direct any grievances or complaints about PACE services to the PACE organization to file a complaint. An official PACE grievance policy specific to each PACE organization must be followed. Participants will be informed of the official grievance policy in their participant enrollment agreement. MHD must allow the PACE organization an opportunity to address all grievances before MHD can take action. Additional grievance guidance is located in the Code of Federal Regulations for PACE.
If the participant refuses to contact the PACE organization to file a complaint, DSDS shall send a detailed summary of the reported concerns to MHD.PACE@dss.mo.gov.