100-11 Programs of All-Inclusive Care for the Elderly (PACE)Manual: Chapter 6 - Services

Programs of All-Inclusive Care for the
Elderly (PACE)
Chapter 6 – Services
Table of Contents
(Rev. 2, Issued: 06-09-11)
Transmittals for Chapter 6
10 - Basic Rule
20 - No Co-payments/Deductibles/Fee-for-Service Limits on Medicare or Medicaid
Services
30 - Emergency Care
40 - Urgently Needed and Post Stabilization Care
50 - Service Delivery
50.1 - Primary Care
50.2 - Meal Requirements
50.3 - Sanitary Conditions
50.4 -Transportation Services
50.5 - Safety, Accessibility, and Equipment
50.6 - Maintenance of Vehicles
50.7 - Communication with PACE Center
50.8 - Training
60 - Required Services for Medicare Participant
70 - Excluded Services

10 - Basic Rule
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE benefit package is required to include for all participants, regardless of source
of payment, all Medicare covered services, all Medicaid covered services as specified in
the State’s approved Medicaid plan, and any other services determined necessary by the
IDT to meet the participant’s needs and which improve or maintain the participant’s
overall health status. IDT Assessment is the foundation for provision of participant–
specific, appropriate services. See Chapter 8 for composition and description of the scope
of IDT responsibilities.
The PACE organization must establish and implement a written plan to provide care that
meets the needs of its participants across all care settings on a 24-hour basis each day of
the year. The PACE organization must furnish comprehensive medical, health, and social
services that integrate acute and long-term care. These services must be furnished at least
in the PACE center, the participant’s home, and inpatient facilities such as acute and long
term care hospitals and nursing/rehabilitation facilities. The PACE organization must not
discriminate against any participant in the delivery of required PACE services based on
race, ethnicity, national origin, religion, sex, age, sexual orientation, mental or physical
disability, or source of payment.
[42 CFR §§ 460.92, 460.98(a) and (b)]
20 - No Co-payments/Deductibles/Fee-for-Service Limits on Medicare
or Medicaid Services
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
If a Medicare beneficiary or Medicaid recipient chooses to enroll in a PACE program,
Medicare and Medicaid benefit limitations and conditions relating to amount, duration,
scope of services, deductibles, copayments, coinsurance, or other cost-sharing do not
apply. The amount, duration and scope of services provided to PACE participants are
participant-specific and are specified by the IDT in the plan of care. The scope of benefits
under PACE includes any other item or service determined necessary by the IDT to
improve and maintain the participant’s overall health status.
Under Sections 1894(a) and 1934(a) of the Act, PACE participants must receive
Medicare and Medicaid benefits solely through the PACE organization. PACE
organizations are required to provide enrollees with all medically necessary services,
including drugs, without any limitation or condition as to the amount, duration, or scope.
The PACE benefit includes all outpatient prescription drugs, as well as over-the-counter
medications indicated by the participant’s care plan. PACE programs cannot charge
deductibles, copayments, coinsurance or other cost-sharing for medications.
The PACE organization may contract with other providers for specialty medical or other
services to meet participant needs. The PACE organization must maintain primary
responsibility and accountability for participant care in all settings and for all provided

services. Refer to Chapter 9 for a description of PACE organization oversight
requirements for all services.
[42 CFR § 460.90; 71 FR 71248 and 71280 (Dec. 8, 2006)]
30 - Emergency Care
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Emergency care is appropriate when services are needed immediately because of an
injury or sudden illness and the time required to reach the PACE organization, or one of
its contract providers, would cause risk of permanent damage to the participant’s health.
Emergency services include inpatient and outpatient services that meet the following
requirements:
• 	Are furnished by a qualified emergency services provider, other than the
PACE organization or one of its contract providers, either in or out of the
PACE organization’s service area;
• 	Are needed to evaluate or stabilize an emergency medical condition. An
emergency medical condition means a condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent
layperson, with an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in
serious jeopardy to health of the participant, serious impairment to bodily
functions, or serious dysfunction of any bodily organ or part.
The organization must ensure that the participant or caregiver, or both, understand when
and how to access emergency services and that no prior authorization is needed.
A PACE organization must establish and maintain a written plan to handle emergency
care. The plan must ensure that CMS, the State, and PACE participants are held harmless
if the PACE organization does not pay for emergency services. The written plan also
must provide for an on-call provider to be available 24-hours per day to address
participant questions about emergency services and respond to requests for authorization
of urgently needed out-of-network services and post stabilization care services following
emergency services.
[42 CFR §§ 460.100(a), (b), (c), (d), and (e)(1)]
40 - Urgently Needed and Post Stabilization Care
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Urgent care means the care provided to a PACE participant who is out of the PACE
service area, and who believes their illness or injury is too severe to postpone treatment
until they return to the service area, but their life or functioning is not in severe jeopardy.
Post-stabilization care means services provided subsequent to an emergency that a

treating physician views as medically necessary after an emergency medical condition
has been stabilized. They are not emergency services, which PACE organizations are
obligated to cover. Rather, they are non-emergency services that the PACE organization
should approve before they are provided outside of the service area.
The PACE organization must establish and maintain a written plan which provides for
coverage of urgently needed out-of-network and post-stabilization care services when
either of the following conditions is met:
• 	The services are preapproved by the PACE organization; or
• 	The services are not preapproved by the PACE organization because the
PACE organization did not respond to a request for approval within one hour
after being contacted or cannot be contacted for approval.
An on-call provider must be available 24-hours per day to address participant questions
about emergency services and respond to requests for authorization of urgently needed
out-of-network services and post stabilization care services following emergency
services.
Periodic education of participants is necessary to ensure they and their caretakers can
distinguish between urgent and emergent care needs, and to emphasize that PACE
authorization is never required before seeking emergency care. The PACE organization
needs to educate its participants in the difference between emergency care (where prior
authorization is not required), and urgent care (where prior authorization is appropriate).
Participants need to understand when to request prior authorization and when to request
urgent care.
[42 CFR §§ 460.100(e)(2) and (3); 71 FR 71284 and 71297 (Dec. 8, 2006)]
50 - Service Delivery
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE organization must operate at least one PACE center either in or contiguous to
its designated service area with sufficient capacity for routine attendance by its
participants.
The PACE organization must ensure accessible and adequate services to meet the needs
of all its participants. When necessary, the organization must increase the number of
centers, staff, and other PACE services.
If a PACE organization operates more than one center, each PACE center must offer the
full range of services and have sufficient staff to meet the needs of participants.
The frequency of a participant’s attendance at the center is determined by the IDT based
on the needs and preferences of each participant.

At a minimum the following services must be furnished by each PACE center:
• 	Primary care services including physician and nursing services;
• 	Social work services;
• 	Restorative therapies, including physical therapy, occupational therapy;
• 	Personal care and supportive services;
• 	Nutritional counseling;
• 	Recreational therapy;
• 	Meals.
These services and others are described in detail below, however, if there is a service a
participant needs, that service will be required. For a comprehensive list of possible
required services, refer to 42 CFR § 460.92, 66 FR 66286-66287.
[42 CFR §§ 460.98(c), (d), and (e)]
50.1 -Primary Care
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Primary medical care must be furnished to a participant by a PACE primary care
physician. Each primary care physician is responsible for managing a participant’s
medical situation and for overseeing a participant’s use of medical specialists and
inpatient care. Other primary care services provided by physicians and/or nurses include:
• 	Medical and medication history, assessment, diagnosis, treatment, education
and team care planning by a primary care physician;
• 	Management of a participant’s medical condition;
• 	Referral to and oversight of specialists;
• 	Oversight of inpatient care;
• 	Informing female participants about their right to select a qualified specialist
for women’s health services;
[42 CFR §§ 460.102(c), 460.104(b)]

50.2 - Meal Requirements
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Except when a participant has a problem and must receive substitute foods or nutritional
supplements or needs nutrition support (as discussed below) the PACE organization must
ensure, through the assessment and care planning process that each participant receives
nourishing, palatable, well-balanced meals that meet the participant’s daily
nutritional/medical and special dietary needs. Meals should be procured, prepared and
provided by appropriately trained/certified/experienced food service staff (i.e., qualified
by training/certification in food safety and sanitation). Each meal must meet the
following requirements:
• 	Be prepared by methods that conserve nutritive value, flavor, and appearance;
• 	Be prepared in a form designed to meet individual needs; and
• 	Be prepared and served at the proper temperature.
The PACE organization must provide substitute foods or nutrition supplements that meet
the daily nutritional and special dietary needs of any participant who has any of the
following problems:
• 	Refuses the food served;
• 	Cannot tolerate the food served;
• 	Does not consume adequate calories and nutrients appropriate in meeting the
individual’s estimated nutritional needs determined at the initial and interim
assessments.
The PACE organization must provide nutrition support to meet the daily nutritional needs
of a participant, if indicated by his or her medical condition or diagnosis. Nutrition
support consists of tube feedings, total parenteral nutrition, or peripheral parenteral
nutrition.
[42 CFR §§ 460.64(a)(1), 460.78(a)]
50.3 - Sanitary Conditions
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE organization must do the following:
• 	Procure foods (including nutritional supplements and nutrition support items)
from sources approved or considered satisfactory, by Federal, State, Tribal, or
local authorities with jurisdiction over the service area of the organization;

• 	Store, prepare, distribute, and serve foods (including nutritional supplements
and nutrition support items) under sanitary/safe conditions;
• 	Dispose of garbage and refuse properly.
Should Nutrition Services be contracted outside of the PACE organization, the contractor
must be able to show appropriate/current state and/or local certification demonstrating
adequate food preparation facilities, transportation and have staff with training and
experience able to provide safe, nourishing, palatable, well-balanced meals that meet
national standards for the population being served.
[42 CFR §§ 460.70, 460.78(b)]
50.4 - Transportation Services
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Transportation must be provided as indicated in a participant’s plan of care. As part of the
IDT process, PACE organization staff (employees and contractors) must communicate
relevant changes in a participant’s care plan to transportation personnel. The IDT must
have a process in place to get input from the transportation personnel regarding status and
changes noted in participant condition.
[42 CFR §§ 460.76(e), 460.92(i), 460.102(e)]
50.5 - Safety, Accessibility, and Equipment
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
A PACE organization’s transportation services must be safe, accessible, and equipped to
meet the needs of the participant population.
[42 CFR § 460.76(a)]
50.6 - Maintenance of Vehicles
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
If the PACE organization owns, rents, or leases transportation vehicles, it must maintain
these vehicles in accordance with the manufacturer’s recommendations.
If a contractor provides transportation services, the PACE organization must ensure that
the vehicles are maintained in accordance with the manufacturer’s recommendations.
[42 CFR § 460.76(b)]
50.7 - Communication with PACE Center
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)

The PACE organization must ensure that transportation vehicles are equipped to
communicate with the PACE center.
50.8 - Training
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE organization must train all transportation personnel (employees and
contractors) in the following:
• 	Managing the special needs of participants;
• 	How to, and types of issues to communicate to the PACE center staff about
participants;
• 	Handling emergency situations;
• 	Transportation workers are considered direct care workers. All health
requirements and background checks must be assured by human resources or
contractor oversight staff.
[42 CFR §§ 460.64, 460.71(b), 460.76(d), 460.102(e)]
60 - Required Services for Medicare Participants
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The PACE benefit package for Medicare participants must include, in addition to the
service required by 42 CFR § 460.92, the scope of hospital insurance benefits described
in 42 CFR Part 409 and the scope of supplemental medical insurance benefits described
in 42 CFR Part 410. In addition, some requirements of Title XVIII of the Act are waived
and do not apply to services under the PACE program, which include:
• 	The provisions of subpart F of Part 409 of 42 CFR that limit coverage of
institutional services;
• 	The provisions of subparts G and H of 42 CFR Part 409 and Parts 412 through
414 that relate to rules for payment for benefits;
• 	The provisions of subparts D and E of 42 CFR Part 409 that limit coverage of
extended care services or home health services;
• 	The provisions of subpart D of 42 CFR Part 409 that impose a 3-day prior
hospitalization requirement for coverage of extended care services; and
• 	The provisions of 42 CFR § 411.15(g) and (k) that may prevent payment for
PACE program services to individuals enrolled in the PACE program.

[42 CFR § 460.94]
70 - Excluded Services
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
The services that are excluded from coverage under the PACE program are as follows:
• 	Any service that is not authorized by the IDT, even if it is listed as a required
service, unless it is an emergency service;
• 	Services rendered in a non-emergency setting or for a non-emergency reason
without authorization;
• 	Prescription and over-the-counter drugs not prescribed by the PACE provider
physician;
• 	For services in inpatient facilities, private room and private duty nursing services,
(unless medically necessary) and non-medical items for personal convenience
such as telephone charges, radio or television rental, (unless specifically
authorized by the IDT as part of a participant’s plan of care);
• 	Cosmetic surgery, which does not include surgery required for improved
functioning of a malformed part of the body resulting from an accidental injury or
for reconstruction following mastectomy;
• 	Experimental medical, surgical or other health procedures.
PACE will not cover services rendered outside the United States, except as may be
permitted in accordance with 42 CFR § 424.122 regarding conditions for payment for
emergency inpatient hospital services and 42 CFR § 424.124 regarding conditions for
payment for physician services and ambulance services or as may be permitted under the
State’s approved Medicaid Plan. There are limited exceptions to this rule. For example, a
State that borders another country might include some Medicaid coverage across the
border, and Medicare covers some emergency hospital, ambulance, and physician
services outside the United States. (As defined in 42 CFR § 400.200, the United States
includes the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa,
and the Northern Mariana Islands).
[42 CFR § 460.96; 71 FR 71282 (Dec. 8, 2006)]

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date CR#
R2PACE 06/09/2011 	Initial Publication of Manual 	06/03/2011 NA
R1_SO 06/03/2011 	Initial Publication of Manual - Rescinded and
replaced by Transmittal 2
06/03/2011 NA
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