Section 441.88.27. Program administrative requirements.

A PACE organization shall comply with the federal administrative requirements stated in 42 CFR Sections 460.60 through 460.82 as amended to December 8, 2006, including requirements relating to organizational structure, governing body, qualifications for staff who have direct contact with enrollees, training, program integrity, contracted services, oversight of direct care services, physical environment, infection control, transportation services, dietary services, fiscal soundness, and marketing.

         88.27(1) Enrollee rights. A PACE organization shall comply with the federal participant rights requirements stated in 42 CFR Sections 460.110 through 460.124 as amended to December 8, 2006. Upon exhaustion of the PACE organization’s appeal process, a Medicaid enrollee has the right to appeal to the department any adverse coverage or payment decision regarding any service, including any denial, reduction, or termination of any service, pursuant to 441—Chapter 7.

         88.27(2) Data collection, record maintenance, and reporting.  A PACE organization shall comply with federal data collection, records maintenance, and reporting requirements stated in 42 CFR Sections 460.200 through 460.210 as amended to December 8, 2006.

         88.27(3) Quality assessment and performance improvement. A PACE organization shall comply with the federal quality assessment and performance improvement requirements stated in 42 CFR Sections 460.130 through 460.140 as amended to November 24, 1999.

         88.27(4) Federal and state monitoring.

            a.               The PACE program shall cooperate with federal and state monitoring pursuant to 42 CFR Sections 460.190 through 460.196 as amended to Nov. 24, 1999, including:

             (1)             Corrective action required pursuant to 42 CFR Section 460.194; and

             (2)             Disclosure of review results pursuant to 42 CFR Section 460.196(c) and (d).

            b.              The PACE program is subject to sanctions or termination pursuant to subrules 88.23(3) and 88.23(4).

            c.               During the trial period, CMS, in cooperation with the department, shall conduct comprehensive annual reviews of the operations of a PACE organization to ensure compliance with PACE federal regulations and 441—Chapter 88, Division II.

            d.               After the trial period, the department, in cooperation with CMS, shall conduct on-site reviews of a PACE organization at least every two years.

            e.               After a review, CMS and the department shall report the results of the review to the PACE organization, along with any recommendations for changes to the organization’s program.

            f.                Within 30 days of issuance of the report, the PACE organization shall develop and implement a corrective action plan to address any deficiencies identified through the review.

            g.               CMS or the department shall monitor the effectiveness of the corrective actions implemented.

[ARC 2358C, IAB 1/6/16, effective 1/1/16]