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May 29, 2019 at 02:36 PM
Federal regulators have agreed to let trained agents and brokers market Programs of All-Inclusive Care for the Elderly, or PACE programs.
The Centers for Medicare and Medicaid Services (CMS) has included that provision in a new set of final PACE program regulations. The regulations are set to appear in the Federal Register, an official government publication, June 3.
Traditionally, Medicaid has paid for nursing home care for poor people, and for some other people who meet state Medicaid nursing home benefits eligibility rules. Federal rules have prohibited Medicare plans from covering long-term care (LTC) services.
A PACE program can provide comprehensive, community-based care for people ages 55 and older, including Medicare enrollees, who can live safely in the community but who already have disabilities, or enough frailty, to make them eligible for Medicaid nursing home care benefits.
(Related: Feds Update Application Process for PACE Health-LTC Programs)
A PACE program is supposed to provide primary medical care, specialty care, nursing care, unavoidable hospital care, home care, social support services, transportation services, and any other services needed to keep enrollees as healthy as possibility.
Medicare and Medicaid pay all of the bills for some enrollees, but some enrollees pay at least part of the premiums themselves.
PACE plan enrollees give up ordinary Medicare and Medicaid coverage when they enroll in the plans, but they can get that coverage back if they cancel their PACE coverage.
Some consumers like the convenience of having one PACE organization agree to take responsibility for providing, and coordinating, all of their care. Some dislike the idea of having to depend on one organization to decide what type of care is necessary, and how to provide it.
CMS published the original PACE program regulations in 2006. Today, there about 100 PACE organizations in 31 states. Those organizations have only about 45,000 enrollees. In theory, CMS could use PACE organizations as a model for creating a large-scale public LTC benefits program for Americans who are not eligible for Medicaid nursing home benefits.
Here are seven things for financial professionals to know about the new final PACE program regulations.
1. Basics
The regulations are set to take effect 60 days after the official June 3 Federal Register publication date.
A preliminary version of the final regulation packet lists Brandy Alston as the CMS contact person for the regulations.
CMS posted the draft version of the regulations in September 2016 and received about 110 public comments.
2. Agents and Brokers
Some PACE organizations have been working with outside agents, brokers and marketing organizations to reach out to potential enrollees.
Originally, CMS was going to prohibit PACE organizations from working with non-employee agents and marketing organizations, because of concerns that outside marketers might not give potential enrollees, and their caregivers, enough information about the consequences of having to get all care from the providers in the PACE plan’s provider network.
Two commenters agreed with the idea of banning use of outside marketers. “One such commenter expressed concern with fraud, confusion, and abuse with marketing by non-employees,” according to CMS officials’ introduction to the final regulations.
But several commenters said CMS should let PACE organizers use outside marketers.
CMS officials say in the introduction to the final regulations that they have decided to let PACE organizations use outside individuals and entities to help with marketing, if the non-employee marketers receive appropriate training, such as training on PACE program participant rights, enrollment rules and disenrollment rules.
PACE organizations must take responsibility for the activities of the non-employee marketers, and they must develop a method to document training for non-employee marketers, officials say.
