Program of All-Inclusive Care for the Elderly (PACE) Manual

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Program of All-Inclusive Care for the Elderly (PACE)

What is PACE?

Program of All-Inclusive Care for the Elderly (PACE) is operated by Health First Colorado (Colorado's Medicaid Program) and Medicare. The PACE program provides comprehensive medical and social services to certain frail individuals 55 years of age and older. The goal of PACE is to help individuals live and stay in their homes and communities through comprehensive care coordination.

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Who Qualifies?

  • Members must be 55 years of age or older;
  • Members must meet nursing facility level of care (this is determined by a Single Entry Point agency);
  • Members must live in the service area of the PACE organization; and
  • Members must be able to live in a community without risking their health or safety.

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Benefits and Services

  • Adult day care
  • Dental services
  • Emergency services
  • Durable Medical Equipment
  • Home care services
  • Hospital care
  • Laboratory/X-ray services
  • Meals
  • Medical specialty services
  • Nursing home care
  • Nutritional counseling
  • Occupational therapy
  • Optometry
  • Physical therapy
  • Prescription drugs
  • Preventative care
  • Primary care (including doctor and nursing services)
  • Recreational therapy
  • Respite
  • Social services
  • Social work counseling
  • Transportation
  • and more...

PACE includes services for all participants, including: all Medicare covered services, all Medicaid covered services as specified in the State Plan, or any other services determined medically necessary by a team of health care professionals to improve or maintain the member’s overall health.

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How does a member get these services?

The interdisciplinary team will develop a care plan with the member and anyone designated, to coordinate all the services needed to stay safely in the member’s community. The interdisciplinary team will arrange for the member to receive services within a PACE Center or through providers within the PACE network. Members may have to choose a new primary care provider within the PACE network. The primary care provider and interdisciplinary team will complete regular assessments of the member’s health needs to help the member stay safely in their community.

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What is the Interdisciplinary Team?

The interdisciplinary team is a group of health-care and social service professionals who work with the member to assess needs, develop a care plan, and deliver and coordinate services, including acute care services and if necessary, nursing home services. This team meets regularly to ensure needs are being met. A PACE Interdisciplinary Team is comprised of:

  • Primary care physician
  • Nurse
  • Social worker
  • Physical therapist
  • Occupational therapist
  • Recreational therapist or activity coordinator
  • Dietitian
  • PACE center supervisor
  • Home-care liaison
  • Personal care attendants
  • Transportation staff

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Who has a say in treatment?

The member and the member’s authorized representative have the primary say.

The PACE doctor and other care providers are the people who work with the member to make decisions about care. The member, the doctor and other care providers agree on what is best. If the member disagrees with the interdisciplinary team about a care plan, they have the right to appeal.

If a member’s request for service is denied or a service is reduced or suspended, that decision may be appealed through an impartial third party provided through the PACE provider, a Medicaid Administrative Law Judge, or the Medicare Independent Review Board, if Medicare eligible. To file an appeal, the member should contact their social worker, case manager or the PACE ombudsman.

If a member has a complaint about the quality of services received, a grievance may be filed with the PACE provider. To file a grievance, the member should contact their social worker or the PACE ombudsman.

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What Does It Cost?

PACE program benefits and services may be available at no cost, or a member may have to pay a monthly payment. Some participants may pay a monthly premium based on income. For some, the premium can be paid for by Health First Colorado and Medicare. There are no co-pay amounts or out-of-pocket expenses for PACE-covered services. A Personal Needs Allowance (PNA) may be used for medical expenses not covered by Health First Colorado or other insurance, like hearing aids, eyeglasses and health insurance premiums. The member should contact an eligibility site or PACE organization for questions about premiums or personal needs allowances.

Further details regarding PACE can be found on the Department's website.

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PACE Procedure Code Types

PACE organizations may submit the following procedure codes for PACE services:

  • Behavioral Health Services
  • Center Manager
  • Chaplin Services
  • Clinic CNA
  • Dental Services
  • Durable Medical Equipment
  • Home Health Services
  • Integrated Care Model
  • Medication Services
  • Nursing Services
  • Primary Care Physician Services
  • Recreation Therapy
  • Occupational and Physical Therapy Rehab Services
  • Transportation Services
  • and more…

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Electronic Encounter Submission Format

 

PACE Encounters must follow the CMS 837 claims transaction format.There are three different formats for the 837, divided into three groups:

  • 837D – for dental practices
  • 837P – for professionals
  • 837I – for institutions

For PACE organizations, the 837P (Professional) is the standard format to transmit health care claims electronically.  For instructions relating to the 837P submission and related technical information, please see the CMS 837P Companion Guide available on the EDI Support web page.

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Coding

Correct coding is necessary for the submission of valid claims.  There are two types of coding that PACE organizations will use: diagnosis coding and procedure coding.  Diagnosis coding will use the International Classification of Diseases, Procedure Coding System (ICD-10 PCS); procedure coding with use the Healthcare Common Procedure Coding System (HCPCS). Please ensure that diagnosis and procedure codes are current and correct.

HCPCS Level I and II codes are updated annually, which are presented in October and are implemented in January.  Level II codes, however, may be issued quarterly.

If a PACE organization has a claim that cannot be identified with a current coding terminology, the PACE organization must submit to HCPF a document showing services that were provided to members that would like to be coded for future consideration.

For more information on ICD-10, please refer to this CMS link: https://www.cms.gov/Medicare/Coding/ICD10/index.

For more information on HCPCS, please refer to this CMS link: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo

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Coding Information

To see a comprehensive list of codes used within PACE centers, please see the PACE Billing Manual Codes List.

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PACE Program Revisions Log

Revision Date Addition/Changes Made by
9/18/18 Creation of PACE Manual HCPF
3/2/2020 Conversion to web page HCPF
7/31/2020 Additions to the Billing Manual were made. Major additions include specifics of Encounter Data submission, which include:  PACE Procedure Code Types, Electronic Encounter Submission Format, Coding, and Encounters. HCPF