CMS Releases Final Rule Updating PACE Program

King & Spalding

CMS published a final rule today in the Federal Register updating the Program of All-Inclusive Care for the Elderly (PACE). The updated rule makes several changes intended to expand the flexibilities of the interdisciplinary team (IDT) that comprehensively assesses and provides for the individual needs of each PACE participant. Key provisions in the final rule include permitting one individual to fill two separate roles on the IDT if the individual has the appropriate licenses and qualifications for both roles and allowing nurse practitioners, physician assistants, and community-based physicians, in addition to physicians, to be the required primary care provider for each IDT. The final rule also removes the requirement that IDT members serve primarily PACE participants.

Non-physician medical providers are still required to practice within the scope of their state licensure and clinical practice guidelines but now have more flexibility in the roles they can play within the IDT. For example, a registered nurse cannot fill the role of a master’s-level social worker unless the registered nurse also has a master’s degree in social work. This final rule marks the first major update since 2007.

The rule acknowledges that changes in the practice of medicine and state laws have expanded the practice of non-physician practitioners, such that these practitioners, in many cases, are able to fulfill the role served by the primary care physician. Thus, allowing such non-physician providers to serve in the primary provider role in certain circumstances may prove to be more operationally feasible and cost-effective, particularly in rural areas or areas where labor costs are high.

The PACE program provides comprehensive medical and social services to certain elderly individuals who qualify for nursing home care but can still live safely in the community at the time of enrollment. Many PACE participants are “dually-eligible beneficiaries,” meaning they are eligible for both Medicare and Medicaid. The PACE model of care includes, as core services, the provision of adult day health care and IDT care management, through which access to and allocation of all health services is managed. Physician, therapeutic, ancillary, and social support services are furnished in the participant’s residence or on-site at a PACE center. Hospital, nursing home, home health, and other specialized services are generally furnished under contract.

The final rule published in the Federal Register can be found here.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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