Sec. 2. Improving access to and affordability of PACE programs for Medicare beneficiaries who are not dual eligible beneficiaries through flexibility in rate setting for services not covered by Medicare
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/bill/117/s/3626/is/section-2A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 1894 of the Social Security Act ( 42 U.S.C. 1395eee ) is amended by adding at the end the following new subsection: Subject to the succeeding provisions of this subsection, a PACE program operated by a PACE provider under a PACE program agreement in any State may charge a Medicare-only PACE program eligible individual (as defined in paragraph (4)(A)) who is enrolled in such PACE program a monthly capitation payment amount for the provision of non-Medicare services (as defined in paragraph (4)(B)) under the PACE program.
Notwithstanding section 460.186 of title 42, Code of Federal Regulations (or any successor regulation), the monthly capitation payment amount that may be charged under paragraph
(1)shall be determined by the PACE provider operating the PACE program. Such monthly capitation payment amount shall be based on assessments conducted on the Medicare-only PACE program eligible individual who is enrolled in such PACE program by the PACE program interdisciplinary team and shall take into account the health status of such individual. In determining the monthly capitation amount for a Medicare-only PACE program eligible individual under this paragraph, a PACE provider may take into account the services determined necessary for the individual by the PACE program interdisciplinary team based upon their assessment of the individual. A determination described in the preceding sentence shall not be construed as limiting the responsibility of the PACE provider to meet any unforeseen needs or provide for any required services for such individual. Subject to clause
(ii)and paragraph (3), the monthly capitation payment amount that may be charged under paragraph
(1)to a Medicare-only PACE program eligible individual enrolled in a PACE program for non-Medicare services may increase or decrease based on assessments conducted on such individual. Any change in the monthly capitation payment amount charged to such an individual shall take effect beginning with the first day of the first month that begins after the month during which the plan of care is developed for such individual based on such an assessment. The monthly capitation payment amount that may be charged under paragraph
(1)to such an individual may not increase more frequently than once per calendar quarter. A PACE provider shall disclose to Medicare-only PACE program eligible individuals the capitation payment amounts that may be charged under this section to such individuals for non-Medicare services under the PACE program operated by such PACE provider under this section— prior to enrollment of such individual in such PACE program, and periodically, and upon request of such individual, after enrollment. The Secretary shall develop an assessment instrument for use by PACE programs with respect to Medicare-only PACE program eligible individuals under this subsection. The monthly capitation payment amount charged under paragraph
(1)to a Medicare-only PACE program eligible individual for non-Medicare services shall be based on an assessment of such individual conducted by the PACE provider (using the assessment instrument developed by the Secretary under clause (i)), accounting for health status and corresponding needs. The assessment instrument used by the interdisciplinary team of the PACE program to evaluate the health and social status of PACE participants shall be disclosed to the individual prior to the assessment. The Secretary shall establish a process for a Medicare-only PACE program eligible individual to seek review of any assessment conducted on the individual under this subsection. Nothing in this subsection shall be construed to preclude the testing under section 1115A of a model to permit a PACE provider operating a PACE program to establish and charge monthly capitation payment amounts for the provision of non-Medicare services under the PACE program to Medicare-only PACE program eligible individuals under a rate structure established by such PACE provider for such purpose, including the use of an assessment instrument developed by the PACE program to assign such individuals to an appropriate rate category under such rate structure. In this subsection— the term Medicare-only PACE program eligible individual means an individual who is described in subsection (a)(1) and who is not entitled to medical assistance under title XIX, and includes the designated representative of the individual as appropriate; and the term non-Medicare services means items and services covered under title XIX that are not covered under this title and items and services described in subsection (b)(1)(A)(ii). . The amendment made by subsection
(a)shall take effect on the date of the enactment of this Act, and apply with respect to capitation amounts that may be charged for months beginning on or after January 1, 2023. Nothing in this section, or the amendments made by this section, shall be construed to modify or otherwise impact the following Medicare capitation rates that may be charged by PACE plans for PACE participants who are Medicare beneficiaries who are not both entitled to (or enrolled for) benefits under part A of title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) and enrolled for benefits under part B of such title: In the case of a Medicare beneficiary who is a PACE participant who is entitled to (or enrolled for) benefits under part A of such title XVIII but who is not enrolled for benefits under part B of such title, the Medicare Part B capitation rate under paragraph
(b)of section 460.186 of title 42, Code of Federal Regulations (or any successor regulations). In the case of a Medicare beneficiary who is a PACE participant who is enrolled for benefits under part B of such title XVIII but who is not entitled to (or enrolled for) benefits under part A of such title, the Medicare Part A capitation rate under paragraph
(c)of such section 460.186 (or any successor regulations).
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Sec. 2
Improving access to and affordability of PACE programs for Medicare beneficiaries who are not dual eligible beneficiaries through flexibility in rate setting for services not covered by Medicare
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