TITLE 8 SOCIAL
SERVICES
CHAPTER 315 OTHER LONG TERM CARE SERVICES
PART 2 PROGRAM OF ALL-INCLUSIVE CARE
FOR THE ELDERLY (PACE)
8.315.2.1 ISSUING AGENCY: New Mexico
Human Services Department.
[8.315.2.1 NMAC - Rp, 8 NMAC
4.MAD.000.1, 12-1-06]
8.315.2.2 SCOPE: The rule
applies to the general public.
[8.315.2.2 NMAC - Rp, 8 NMAC
4.MAD.000.2, 12-1-06]
8.315.2.3 STATUTORY AUTHORITY: The New Mexico
medicaid program is administered pursuant to regulations promulgated by the federal
department of health and human services under Title XIX of the Social Security
Act, as amended and by the state human services department pursuant to state
statute. See Section 27-2-12 et seq.
NMSA 1978 (Repl. Pamp. 1991).
[8.315.2.3 NMAC - Rp, 8 NMAC
4.MAD.000.3, 12-1-06]
8.315.2.4 DURATION: Permanent
[8.315.2.4 NMAC - Rp, 8 NMAC
4.MAD.000.4, 12-1-06]
8.315.2.5 EFFECTIVE DATE: December 1,
2006, unless a later date is cited at the end of a section.
[8.315.2.5 NMAC - Rp, 8 NMAC
4.MAD.000.5, 12-1-06]
8.315.2.6 OBJECTIVE: The objective
of these regulations is to provide policies for the service portion of the New
Mexico medicaid program. These policies
describe eligible providers, covered services, noncovered services, utilization
review, and provider reimbursement.
[8.315.2.6 NMAC - Rp, 8 NMAC
4.MAD.000.6, 12-1-06]
8.315.2.7 DEFINITIONS: [RESERVED]
8.315.2.8 MISSION STATEMENT: The mission of
the New Mexico medical assistance division (MAD) is to maximize the health
status of medicaid-eligible individuals by furnishing payment for quality
health services at levels comparable to private health plans.
[8.315.2.8 NMAC - Rp, 8 NMAC
4.MAD.002, 12-1-06]
8.315.2.9 PACE PROGRAM SERVICES: The New Mexico
medicaid program (medicaid) pays for medically necessary health services
furnished to eligible recipients, including services furnished in nursing
facilities. To help New Mexico
recipients receive necessary services, the New Mexico medical assistance
division (MAD) pays for capitated and community-based services through the PACE
program. This project provides a
complete package of acute, long term care, personal care and social services to
a frail population that meets nursing facility clinical criteria. See Section 9412(b) of the federal Omnibus
Budget Reconciliation Act of 1986 and Section 1915(a) of the Social Security
Act. This part describes the following:
eligible providers, services for recipients who are nursing home eligible,
covered services, service limitations, and reimbursement methodology.
[8.315.2.9 NMAC - Rp, 8 NMAC
4.MAD.777, 12-1-06]
8.315.2.10 Eligible
Providers:
A. The eligible provider will have a
professional services agreement (PSA) with the human services department. The provider will also meet the following
conditions:
(1) be licensed and certified by the licensing
and certification bureau of the department of health (DOH) to meet conditions
as a diagnostic and treatment center;
(2) participate in the MAD utilization review
process and agree to operate in accordance with all policies and procedures of
that system; and
(3) meet and comply with the centers for
medicare and medicaid services (CMS) requirements for full provider status for
PACE organizations.
B. Once enrolled, the provider will
receive a packet of information, including medicaid program policies,
utilization review instructions, and other pertinent material from MAD. The provider is responsible for ensuring
receipt of these materials and for updating as new materials are received from
MAD.
[8.315.2.10 NMAC - Rp, 8 NMAC
4.MAD.777.1, 12-1-06]
8.315.2.11 Provider
Responsibilities:
A. The provider who furnishes services to
medicaid recipients will comply with all specified medicaid participation
requirements. See 8.302.1 NMAC, General Provider Policies. The provider will verify that individuals are
eligible for medicaid, medicare, or other health insurance at the time services
are furnished. The provider will verify
whether or not an individual is self-pay at the time services are
provided. The provider will maintain
records which are sufficient to fully disclose the extent and nature of the
services provided to recipients. See
8.302.1 NMAC, General Provider Policies. The provider will provide the coordination
which will enable the client to utilize PACE as the single source for primary
care. This will assist the enrollee in
the coordination of care by specialists.
B. Outreach and marketing: The provider will have a written plan which
accomplishes the following outreach and marketing objectives.
(1) Strategies of how prospective participants
are provided adequate program descriptions.
(a) The program descriptions shall be written
in a culturally competent format at a language level understandable by the
participant (sixth grade). The format
should be sensitive to the culture and language common to the service area.
(b) Program descriptions should include the
services available through the program.
The services include, but are not limited to, the following: enrollment
and disenrollment, procedures to access services, after hours call-in system,
provisions for emergency treatment, restrictions against using medical
providers and/or services not authorized by the interdisciplinary team, and any
other information necessary for prospective participants to make informed
decisions about enrollment. Prior to
enrollment, each participant will be informed of what individualized initial
assessment and treatment plan has been developed by the interdisciplinary team.
(2) Development of outreach and enrollment
materials (including marketing brochures, enrollment agreements, website and
disenrollment forms). These materials
should be submitted in draft form to MAD for approval prior to publication. Distribution prior to approval is prohibited.
(3) Submit an active and ongoing marketing
plan, with measurable enrollment objectives and a system for tracking its
effectiveness. The plan shall also
include, but not be limited to, the sequence and timing of promotional and
enrollment activities and the resources needed for implementation.
(4) Ensure that prohibited marketing
activities are not conducted by its employees or its agents. Prohibited practices are:
(a) discrimination of any kind while
maintaining the PACE program requirements;
(b) statements or activities that could
mislead or confuse potential participants, or misrepresent the contractor, CMS,
or the state medicaid agency;
(c)
inducing enrollment through gifts or payments; the Procurement Code,
Sections 13-1-28 through 13-1-199 NMSA 1978, imposes civil and misdemeanor
criminal penalties for its violation; in addition, the New Mexico criminal
statutes impose felony penalties for bribes, gratuities and kickbacks; and
(d) subcontracting outreach efforts to
individuals or organizations whose sole responsibility involves direct contact
with elderly to solicit enrollment.
[8.315.2.11 NMAC - Rp, 8 NMAC
4.MAD.777.2, 12-1-06]
8.315.2.12 Eligible
Recipients: Medicaid recipients who meet the eligibility
requirements as stated in the medical assistance division eligibility manual
may be eligible to participate in the PACE program.
[8.315.2.12 NMAC - Rp, 8 NMAC
4.MAD.777.3, 12-1-06]
8.315.2.13 Covered
Services: The PACE program is a partially capitated,
community-based service program. The
PACE program will ensure access to a comprehensive benefit package of services
to a frail population that meets nursing facility clinical criteria. The provider will provide all medicaid
services that are included in a capitated rate.
Medicare covered services will be reimbursed through a medicare
capitated rate. The provider will
provide medicare-eligible PACE participants with all medicare services that are
included in the medicare capitated rate.
Effective Janaury 1, 2006, upon the implementation of medicare part D
prescription drug coverage, pharmacy costs for PACE medicare beneficiaries are
covered by the medicare capitated rate.
Pharmacy costs for medicaid only recipients would be covered by the
medicaid only capitated rate.
A. Adult day health center: The focal point for coordination and
provision of the majority of the PACE program services is the adult day health
center. The adult day health center will
include a primary care clinic and areas for therapeutic recreation, restorative
therapies, socialization, personal care and dining. The center shall include the following areas:
(1)
examination room(s);
(2) treatment room(s);
(3) therapy room(s);
(4) dining room(s);
(5) activity room(s);
(6) kitchen;
(7) bathroom(s);
(8) personal care room(s);
(9) administrative office(s);
(10) counseling office(s);
(11) pharmacy/medication room; and
(12) laboratory;
B. Interdisciplinary team: The interdisciplinary team is a critical
element of the PACE program. The ongoing
process of service delivery in this model requires the team to identify
participant problems, determine appropriate treatment objectives, select
interventions and evaluate efficiencies of care on an individual participant
basis. The interdisciplinary team is
composed of, but not limited to, the following members: Primary care physician, nurse, dietician, social
worker, physical therapist, occupational therapist, speech therapist,
recreational therapist or coordinator, day health center supervisor, home care
liaison, health workers/aides, and drivers.
Some of the interdisciplinary team members may be project staff and some
may be contracted positions. All members
must meet applicable state licensing and certification requirements and provide
direct care and services appropriate to participant need.
C. Benefit package: The benefit package includes the following:
(1) a service delivery system that ensures
prompt access to all covered services, including referral protocols, approved
by the interdisciplinary team;
(2) access to medical care and other services,
as applicable, twenty four (24) hours per day, seven (7) days a week, three
hundred sixty five (365) days per year; all care and services shall be
available and shall be provided at such times and places, including the
participants home or elsewhere, as are necessary and practical;
(3) access to an acute and comprehensive
benefit package of services, including, but not limited to:
(a) interdisciplinary assessment and treatment
planning;
(b) social work services;
(c) nutritional counseling; see MAD-758, Nutrition Services [8.324.9 NMAC];
(d) recreational therapy;
(e) meals;
(f) restorative therapies, including physical
therapy, occupational therapy and speech therapy, see MAD-767, Rehabilitation Service Providers
[8.325.8 NMAC];
(g) home care (personal care, nursing care and
disposable medical supplies), see MAD-768, Home
Health Services [8.325.9 NMAC];
(h) transportation, see MAD-756, Transportation [8.324.7 NMAC];
(i) drugs and biologicals; effective January
1, 2006, pharmacy costs are reimbursed by medicare for medicare beneficiaries;
pharmacy costs for medicaid-only recipients are reimbursed by medicaid through
the medicaid-only capitated rate; see 8.324.4 NMAC, Pharmacy Services, and Subsection D of 8.310.2.12 NMAC, Medical Services Providers;
(j) prosthetics, medical supplies and durable
medical equipment, corrective vision devices such as eyeglasses and lenses,
hearing aids, dentures and repairs and maintenance for these items; see 8.324.8
NMAC, Prosthetics and Orthotics;
8.310.6 NMAC, Vision Care Services;
8.324.6 NMAC, Hearing Aids and Related
Evaluations; 8.310.7 NMAC, Dental
Services; 8.324.5 NMAC, Durable
Medical Equipment and Medical Supplies; MAD-768, Home Health Services;
(k) behavioral health services, 8.310.8 NMAC, Mental Health Professional Services and
8.315.3 NMAC, Psychosocial Rehabilitation
Services;
(l) nursing facility services which include,
but are not limited to, the following:
semi-private room and board, physician and skilled nursing services,
custodial care, personal care and assistance, biologicals and drugs, physical, speech,
occupational and recreational therapies, if necessary, social services, and
medical supplies and appliances, see MAD-731, Nursing Facilities [8.312.2 NMAC]; MAD-722, Outpatient Psychiatric Services and Partial Hospitalization
[8.311.4 NMAC]; MAD-767, Rehabilitation
Service Providers [8.325.8 NMAC]; 8.324.4 NMAC, Pharmacy Services; Subsection D of 8.310.2.12 NMAC, Medical Services Providers; 8.324.5
NMAC, Durable Medical Equipment and
Medical Supplies; and
(m) urgent care services.
(4) coordinating access for the following
services:
(a) primary care services including physician
and nursing services;
(b) medical specialty services, including but
not limited to: anesthesiology, audiology, cardiology, dentistry, dermatology,
gastroenterology, gynecology, internal medicine, nephrology, neurosurgery,
oncology, ophthalmology, oral surgery, orthopedic surgery,
otorhino-laryngology, plastic surgery, pharmacy consulting services, podiatry,
psychiatry, pulmonary disease, radiology, rheumatology, surgery, thoracic and
vascular surgery, urology; see 8.301.2 NMAC, General Benefit Description; 8.310.2 NMAC, Medical Services Providers; MAD-721 Hospital Services [8.311.2 NMAC]; 8.310.5 NMAC, Anesthesia Services; 8.324.6 NMAC, Hearing Aids and Related Evaluations;
8.310.7 NMAC, Dental Services; and
8.310.6 NMAC, Vision Care Services;
(c) laboratory and x-rays and other diagnostic
procedures; see MAD-751, Laboratory
Services [8.324.2 NMAC];
(d) acute inpatient services, including but
not limited to, the following: ambulance, emergency room care and treatment
room services, semi-private room and board, general medical and nursing
services, medical surgical/intensive care/coronary care unit as necessary,
laboratory tests, x-rays and other diagnostic procedures, drugs and
biologicals, blood and blood derivatives, surgical care, including the use of
anesthesia, use of oxygen, physical, speech, occupational, and respiratory
therapies, and social services; see
8.301.2 NMAC, General Benefit
Description; MAD-721, Hospital
Services; 8.324.8 NMAC, Prosthetics
and Orthotics; 8.324.10 NMAC, Ambulatory
Surgical Center Services; and 8.310.5 NMAC, Anesthesia Services; MAD-751, Laboratory
Services [8.324.2 NMAC]; 8.324.4 NMAC, Pharmacy
Services; Subsection D of 8.310.2.12 NMAC, Medical Services Providers; MAD-767, Rehabilitation Service Providers [8.325.8 NMAC]; and
(e)
hospital emergency room services.
(5) in-area emergency care; all medicaid
reimbursable emergency services included in the capitated rate will be
reimbursed by the PACE program to a non-affiliated provider when these services
are rendered within the PACE program geographic service area; these emergency
services will be reimbursed by the PACE program only until such time as the
participant’s condition permits travel to the nearest PACE program-affiliated
facility;
(6) out-of-area emergency care that is
provided in, or en route to, a hospital or hospital emergency room, in a
clinic, or physicians office, or any other site outside of the PACE program
service area; covered services included in the capitation rate will be paid by
the PACE program when rendered in and out-of-area medical emergency, but only
until such time as the participants condition permits travel to the nearest
PACE program-affiliated facility.
[8.315.2.13 NMAC - Rp, 8 NMAC
4.MAD.777.4, 12-1-06]
8.315.2.14 Noncovered
Services:
A. The following services are not the
responsibility of the provider or medicaid:
(1) any medicaid capitated or fee-for-service
benefit which has not been authorized by the multidisciplinary team;
(2) in inpatient facilities, private room and
private duty nursing, unless medically necessary, and non-medical items for
personal convenience, such as telephone charges, radio, or television rental;
(3)
cosmetic surgery unless required for improved functioning of a malformed
part of the body resulting from an accidental injury or for reconstruction
following mastectomy;
(4) experimental medical, surgical or other health
procedures or procedures not generally available;
(5) care in a government hospital (veterans
administration, federal/state hospital) unless authorized;
(6) service in any hospital for the treatment
of chronic, medically uncomplicated drug dependency or alcoholism; and
(7) any services rendered outside of the
United States.
B. The participant will be financially
responsible for any of the above-mentioned services.
[8.315.2.14 NMAC - Rp, 8 NMAC
4.MAD.777.5, 12-1-06]
8.315.2.15 Treatment
Plans:
A. Prior to enrollment, an initial
assessment and treatment plan for each participant is developed by the
interdisciplinary team.
B. Each participant will be reassessed
by the interdisciplinary team on a semi-annual basis and informed about a new
treatment plan.
C. The enrollee, enrollees family, or
representative shall be included in the initial assessment, treatment plan and
semi-annual reassessment of the treatment plan.
[8.315.2.15 NMAC - Rp, 8 NMAC
4.MAD.777.6, 12-1-06]
8.315.2.16 Enrollment
of Participants:
A. The effective date for the
recipients enrollment in the program is the first day of the calendar month
following the signing of the enrollment agreement, if an approved level of care
(LOC) and all financial and non-financial eligibility criteria have been
approved by the income support division (ISD).
B. The potential participant signs an
enrollment agreement which includes, but is not limited to, the following
information:
(1) enrollment and disenrollment data that
will be collected and submitted to the department, including, but not limited
to, the following:
(a) social security number;
(b) health insurance claim number (HIC);
(c) last name, first name, middle initial;
(d) date of birth;
(e) address of current residence;
(f) assigned ISD office address;
(g) medicare number (part A and/or part B) for
medicare beneficiaries;
(h) medicaid number; and
(i) effective date of enrollment in the PACE
program;
(2) benefits available, including all medicare
and medicaid covered services, and how services are allocated or can be
obtained from the PACE program provider, including, but not limited to:
(a) appropriate use of the referral system;
(b) after hours call-in system;
(c) provisions for emergency treatment;
(d) hospitals to be used; and
(e) the restriction that enrollees may not
seek services or items from medicaid and medicare providers without
authorization from the interdisciplinary team;
(3) participant premiums and procedures for
payment, if any; this includes the medical care credit if the participant
enters a nursing home;
(4) participant rights, grievance procedures,
conditions for enrollment and disenrollment and medicare and medicaid appeal
processes;
(5) participants obligation to notify the PACE
program provider of a move or absence from the providers service area;
(6) procedures to assure that applicants
understand that all medicaid services must be received through the PACE program
provider (the “lock-in” provision);
(7) procedures for obtaining emergency
services and urgent care;
(8) statements that the PACE program provider
has a program agreement with CMS and the state medicaid agency that may be
subject to periodic renewal, and that termination of that agreement may result
in termination of enrollment in the PACE program; statement that the PACE
program provider and the state medicaid agency enter into a contract, which
must be periodically renewed, and that failure to renew the contract may result
in termination of enrollment in the PACE program;
(9) participants authorization for the
disclosure and exchange of information between CMS, its agent, the state
medicaid agency and the PACE program provider; and
(10) participant’s signature and date.
C. Once the participant signs the
enrollment agreement, the participant receives the following:
(1) a copy of the enrollment agreement;
(2) participant/provider contract and/or
evidence of coverage, if this is different from the enrollment agreement;
(3) a PACE program membership card; and
(4) an emergency sticker to be posted in the
participants home in case of emergency.
D. The provider will inform the
participant and the ISD office when enrollment is completed.
E. Enrollment and services continue
unless eligibility of recipient changes or until the participant either
voluntarily disenrolls or involuntary disenrollment occurs as described below.
[8.315.2.16 NMAC - Rp, 8 NMAC
4.MAD.777.7, 12-1-06]
8.315.2.17 Disenrollment
of Participants: All voluntary and involuntary disenrollments
will be documented and available for review by the state medicaid agency. The provider will inform the ISD office when
a participant is being disenrolled either voluntarily or involuntarily. Disenrollment is effective by the first day
of the second calendar month following the date in which enrollment has
changed.
A. Voluntary disenrollment: A participant may begin the process of
voluntary disenrollment at any time during the month. The provider shall use the most expedient
process allowed by medicaid and medicare procedures while ensuring a
coordinated disenrollment date. Until
enrollment is terminated, the participants are required to continue using the
PACE program services and remain liable for any premiums. The provider shall continue to provide all
needed services until the date of termination.
B. Involuntary disenrollment: A participant may be involuntarily
disenrolled if the participant:
(1) moves out of the PACE program service
area;
(2) is a person with decision-making capacity
who consistently does not comply with the individual plan of care and poses a
significant risk to self or others;
(3) experiences a breakdown in the physician
or team participant relationship such that the PACE program provider’s ability
to furnish services to either the participant or other participant(s) is
seriously impaired;
(4) refuses services and/or is unwilling to
meet conditions of participation as they appear in the enrollment agreement;
(5) refuses to provide accurate financial
information, provides false information or illegally transfers assets;
(6)
is out of the PACE program provider service area for more than thirty
(30) days (unless arrangements have been made with the PACE program provider);
(7) is enrolled in a PACE program that loses
its contracts and/or licenses which enable it to offer health care services;
(8) ceases to meet the financial or
non-financial criteria; and
(9) ceases to meet the level of care (LOC) at
any time.
[8.315.2.17 NMAC - Rp, 8 NMAC
4.MAD.777.8, 12-1-06]
8.315.2.18 Appropriate
Referral for other Services:
A. The provider will assist a
participant who either voluntarily or involuntarily disenrolls from the PACE
program to apply for other possible services, including medicare or private-pay
services; and,
B. The provider will work with the
state medicaid agency to ascertain the individuals potential eligibility for
other medicaid categories.
[8.315.2.18 NMAC - Rp, 8 NMAC
4.MAD.777.9, 12-1-06]
8.315.2.19 Provisions
for Reinstatement of Participants to the PACE PROGRAM: There are no
restrictions placed on a former participant’s reinstatement into the PACE
program, if the former participant continues to meet financial, non-financial
and medical eligibility criteria.
[8.315.2.19 NMAC - Rp, 8 NMAC
4.MAD.777.10, 12-1-06]
8.315.2.20 Redetermination: The ISD office
will conduct a redetermination at least annually of all financial and
non-financial criteria, per the standards of the medicaid eligibility
requirements. See Subsection A of
8.280.600.12 NMAC, Ongoing Benefits,
Regular Reviews. LOC is determined
by the department’s utilization review contractor.
[8.315.2.20 NMAC - Rp, 8 NMAC
4.MAD.777.11, 12-1-06]
8.315.2.21 Participant Rights: The provider
will have written policies and procedures for ensuring the rights of
participants as well as educating the participants to the PACE program. These policies and procedures should be
presented in a culturally competent format at a language level understandable by
the participant or their families (sixth grade level) covering, at a minimum,
the following:
A. the enrollment/disenrollment
process;
B. services available through the
program;
C. procedures to access services;
D. after hours call-in system;
E. provisions for emergency treatment;
and
F. restrictions against using medical
providers and/or services not authorized by the interdisciplinary team.
[8.315.2.21 NMAC - Rp, 8 NMAC
4.MAD.777.12, 12-1-06]
8.315.2.22 Grievance Procedures: The provider
will have participant grievance procedures which provide the participants and
their family members with a process for expressing dissatisfaction with the
program services, whether medical or nonmedical in nature. The procedures will explain and permit an
orderly resolution of informal and formal grievances. These procedures should be presented in a
culturally competent format at a language level understandable by the
participant or their families (sixth grade level). The procedures will:
A. ensure that all provider grievance
procedures and any subsequent changes are prior-approved by MAD in writing and
included in the enrollment agreement;
B. ensure that a staff member is
designated as having primary responsibility for the maintenance of the
grievance procedures, review of their operation, and revision of related
policies and procedures whenever necessary;
C. ensure that the grievance procedures
clearly explain to participants which staff members are assigned to receive
formal and informal complaints, the expected procedure, and the time frames for
doing so;
D. ensure that a copy of the
participant grievance procedures and complaint forms are available to
participants;
E. ensure that procedures are in place
for tracking, investigating, recording, resolving and appealing decisions
concerning grievances made by participants or others; and
F. ensure there is no discrimination
against a participant solely on the grounds the participant filed a grievance.
[8.315.2.22 NMAC - Rp, 8 NMAC
4.MAD.777.13, 12-1-06]
8.315.2.23 Quality Assurance System:
A. The provider will have a written
plan of quality assurance and improvement which provides for a system of
ongoing assessment, implementation, evaluation, and revision of activities
related to overall program administration and services. The plan will:
(1) ensure that standards are incorporated
into the provider policy and procedure manual; the provider standards will be
based on the PACE protocol, applicable PACE standards and applicable licensing
and certification criteria;
(2)
ensure that goals and objectives provide a framework for quality
improvement activities, evaluation and corrective action;
(3) ensure that quality indicators are
objective and measurable variables related to the entire range of services
provided by the PACE program provider; the methodology should assure that all
demographic groups, all care settings, e.g., inpatient, the PACE program center
and in-home, will be included in the scope of the quality assurance review;
(4) ensure that quality indicators are
selected for review on the basis of high volume, high risk diagnosis or
procedure, adverse outcomes, or some other problem-focused method consistent
with the state of the art;
(5)
ensure that the evaluation process and/or procedures review the
effectiveness of the interdisciplinary team in its ability to assess
participants care needs, identify the participant’s treatment goals, assess
effectiveness of interventions, evaluate adequacy and appropriateness of
service utilization and reorganize treatment plan as necessary;
(6) establish the composition and
responsibilities of a quality assurance committee and an ethics committee;
(7) ensure participant involvement in the
quality assurance plan and evaluation of satisfaction with services; and
(8) designate an individual to coordinate and
oversee implementation of quality assurance activities.
B. The quality assurance committee will
hold quarterly meetings with the provider staff, including, but not limited to,
the: 1) medical director; 2) interdisciplinary team; and, 3) administrative
director. The provider will prepare
quarterly written status reports for review at the quality assurance committee
meetings. Written status reports will
include, at a minimum, a discussion of project progress, problems encountered
and recommended solutions, identification of policy or management questions,
and requested project plan adjustments.
[8.315.2.23 NMAC - Rp, 8 NMAC
4.MAD.777.14, 12-1-06]
8.315.2.24 Data Gathering/Reporting System:
A. Standardized data: The provider will ensure the quality of the
data according to MAD medium and frequency of reporting.
B. Software: The provider shall make no use of computer
software developed pursuant to the contract, except as provided in the contract
or as specifically granted in writing by the department.
[8.315.2.24 NMAC - Rp, 8 NMAC
4.MAD.777.15, 12-1-06]
8.315.2.25 Financial Reporting: The provider
is required to submit certain financial reports as follows.
A. A budgeted versus actual financial
report for the current and year-to-date periods on a monthly basis forty five
(45) days after the end of each month.
During the first year of operation, the financial report will be
submitted on a monthly basis, 45 days after the end of each month. Thereafter, this report will be submitted on
a quarterly basis, 45 days after the end of each quarter. The state medicaid agency reserves the right
to extend the submission of this report on a monthly basis should provider
performance indicate a need for more frequent monitoring.
B. Fiscal data based on cost center
accounting structure provided by the state medicaid agency. At the twelfth month, the year-to-date
summary will provide the necessary annual data.
C. Submit a cumulative report to the
state medicaid agency in the form and detail described by On Lok senior health
services/national PACE association. The
interim cost report is due 45 days after the end of each providers fiscal
quarter and covers the period from the beginning of the fiscal year through the
respective quarter.
D. Submit to the state medicaid agency
a cost report in the form and detail prescribed by the state medicaid program
no later than 180 days after the end of the providers fiscal year.
E. Submit to the state medicaid agency
a quarterly balance sheet for those PACE program providers that are separate
corporate entities.
[8.315.2.25 NMAC - Rp, 8 NMAC
4.MAD.777.16, 12-1-06]
8.315.2.26 Utilization Review: All medicaid
services, including services covered under the PACE program, are subject to
utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished,
after services are furnished and before payment is made, or after payment is
made. See 8.302.5 NMAC, Prior Authorization and Utilization Review. Once enrolled, providers receive instructions
and documentation forms necessary for prior authorization and claims
processing.
A. Prior authorization: To be eligible for the PACE program, a
medicaid recipient must require a nursing facility level of care (LOC). Level of care determinations are made by MAD
or its designee. The plan of care (POC)
developed by the recipients interdisciplinary team must specify the type,
amount and duration of service. Some
services specified in the POC may require prior authorization from MAD or its
designee. Services for which prior
authorization was obtained remain subject to utilization review at any point in
the payment process.
B. Eligibility determination: Prior authorization of service does not
guarantee that individuals are eligible for medicaid. Providers must verify that individuals are
financially and medically eligible for medicaid at the time services are
furnished and determine if medicaid recipients have other health insurance.
C. Reconsideration: Providers who disagree with prior
authorization request denials or other review decisions may request a re-review
and a reconsideration. See MAD-953, Reconsideration of Utilization Review
Decisions [8.350.2 NMAC].
[8.315.2.26 NMAC - Rp, 8 NMAC
4.MAD.777.17, 12-1-06]
8.315.2.27 Reimbursement: PACE program
providers must submit claims for reimbursement on the UB 92 claim form or its
successor. See 8.302.2 NMAC, Billing for Medicaid Services. Once enrolled, providers receive instructions
on documentation, billing and claims processing.
[8.315.2.27 NMAC - Rp, 8 NMAC
4.MAD.777.18, 12-1-06]
HISTORY OF 8.315.2 NMAC:
History of Repealed
Material:
8 NMAC 4.MAD.777, Pre-PACE
Pilot Project Services , filed 1-20-98 - Repealed effective 12-1-06.