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House Engrossed |
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State of Arizona House of Representatives Forty-seventh Legislature Second Regular Session 2006
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HOUSE BILL 2383 |
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AN ACT
Amending title 36, chapter 29, Arizona Revised Statutes, by adding article 5; relating to the Arizona health care cost containment system.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 36, chapter 29, Arizona Revised Statutes, is amended by adding article 5, to read:
ARTICLE 5. PACE PROGRAM
36-2999.01. Definitions
In this article, unless the context otherwise requires:
1. "Administration" means the Arizona health care cost containment system administration.
2. "Centers for medicare and medicaid services" means the federal agency under the United States department of health and human services that is responsible for approving the pace program application and joining the state in signing an agreement with the pace organization once it has been approved as a provider under 42 Code of Federal Regulations part 460.
3. "cONTRACT" MEANS A WRITTEN AGREEMENT BETWEEN A PERSON, AN ORGANIZATION, OR OTHER ENTITY AND THE ADMINISTRATION TO PROVIDE HEALTH CARE SERVICES TO A MEMBER UNDER TITLE 36, CHAPTER 29.
4. "Director" means the director of the Arizona health care cost containment system administration.
5. "Eligible participant" means a person who:
(a) Is a resident of this state and a United States citizen or a person who meets the requirements for qualified alien status as determined pursuant to section 36-2903.03, who entered the United States on or before August 21, 1996 or who entered the United States on or after August 22, 1996 and who is a member of an exception group under Public Law 104-193, section 412.
(b) Meets the eligibility criteria pursuant to section 36-2934.
(c) Needs institutional services as determined pursuant to section 36‑2936.
(d) Is defined as eligible pursuant to section 1902(a)(10)(A)(ii)(XV) and (XVI) of title XIX of the social security act and who meets the income requirements of section 36-2950 or is willing to pay private fees.
(e) Is at least fifty-five years of age.
(f) Resides in the PACE organization’s service area on enrollment.
(g) Is willing to abide by the requirement that enrollees receive all health and long-term care services exclusively from the PACE organization and its contracted or referred providers.
(h) Is able to be maintained in a community based setting at the time of enrollment without jeopardizing the person's health or safety.
6. "Interdisciplinary team" means PACE staff and PACE subcontractors who have current and appropriate licensure, certification or accreditation and who are responsible for assessment and development of the PACE participant’s care plan and may conduct assessments of PACE participants and provide services to PACE participants within their scope of practice.
7. "Nonparticipating provider" means a provider who does not have a contractual relationship with the PACE organization.
8. "PACE" means the program OF all-inclusive care for the elderly as defined in section 4801 of the balanced budget act of 1997 and authorized under sections 1894 and 1934 of the social security act.
9. "PACE center" means a facility operated by a PACE organization where primary care and other services are furnished to PACE participants.
10. "Pace organization" means an organization that:
(a) Is defined under section 1894(a)(2) of the social security act.
(b) Has an agreement to operate a PACE program in accordance with 42 code of federal regulations part 460.
(c) Is a permanent provider type under medicare that allows states the option to pay for PACE services under medicaid.
(d) Is capitated by both medicare and medicaid or medicare and private pay to provide all medical and long-term care services.
11. "PACE program agreement" means an agreement between a PACE organization, centers for medicare and medicaid services and the administration.
12. "Participant" means an individual who is enrolled in a PACE program.
13. "Section 1115 waiver" means the research and demonstration waiver granted by the United States department of health and human services.
14. "Service area" means the geographic area in which the PACE organization has agreed to provide services under the PACE program agreement.
15. "State administering agency" means the Arizona health care cost containment system administration, the state agency responsible for administering the pace program agreement.
36-2999.02. PACE program; powers and duties of the director; interdisciplinary teams
A. The PACE program is established to provide managed care benefits for the frail elderly through a comprehensive medical and social service delivery system that uses interdisciplinary teams in an adult day health center in accordance with 42 code of federal regulations part 460 and sections 1894, 1905(a) and 1934 of the social security act. The administration shall offer the PACE program as a voluntary option for individuals who are at least fifty-five years of age, live in the PACE service area, are certified as eligible for nursing home level of care and meet the requirements for an eligible participant. The program shall provide services to pace participants pursuant to this article and federal medicare and medicaid requirements that govern PACE organizations.
B. The administration shall serve as the state administering agency under 42 Code of Federal Regulations part 460, which includes additional obligations of coordination with centers for medicare and medicaid services in the administration of the PACE program. The director in the performance of all duties shall consider the use of existing programs, rules and procedures in the counties and department if appropriate in meeting federal requirements. In administering the pace program, the director has the same powers and duties prescribed in section 36-2932.
C. A pace organization must establish an interdisciplinary team at each pace center to comprehensively assess and meet the individual needs of each pace participant. The pace organization must assign each pace participant to an interdisciplinary team functioning at the pace center that the participant attends. The interdisciplinary team shall be composed of at least the members specified in 42 code of federal regulations part 460.102(b).
36-2999.03. Eligibility determination; applications; enrollment
A. In addition to the eligibility criteria prescribed in section 36‑2934 and the preadmission screening conducted pursuant to section 36-2936, to be eligible to enroll with a pace organization, a person must:
1. Be at least fifty-five years of age.
2. Reside in a PACE organization's service area on enrollment.
3. Be certified by the administration as eligible for nursing home level of care.
4. Agree to receive covered services through the PACE organization.
5. Be able at the time of enrollment to live in a community setting without jeopardizing the person’s health or safety.
6. A pace program shall not discriminate during the enrollment of members on the basis of the health of an individual and shall confirm its enrollment procedures to comply with 42 Code of federal regulations section 460.150.
B. The administration shall forward intake information of a potential enrollee to the PACE organization staff who shall assess the applicant’s appropriateness for enrollment in the PACE program in accordance with the requirements of 42 Code of Federal Regulations section 460.152.
C. All letters to applicants regarding denial of enrollment by the PACE ORGANIZATION must include the reason for the denial and the applicant's appeal rights. This letter, along with documentation or pertinent information related to the decision, must be forwarded to the administration for review. the denial letter must direct the applicant back to the administration for review.
D. Sections 36-2934.01, 36-2934.02 and 36-2935 also apply to the PACE organization and its participants.
36-2999.04. Case management; definition
A. In addition to services prescribed in section 36-2939, the PACE organization shall provide case management to coordinate services and promote access to all necessary medical, social and other services in coordination with rules adopted by the director. Case management services include the following:
1. An in-depth assessment to determine the level of case management needed and services to be accessed.
2. An individual case management service plan outlining needed services and access plans.
3. Service plan implementation to include counseling to encourage the PACE participant’s cooperation, service authorization, referral for services and case coordination.
4. A review of the service plan to be conducted on an as-needed basis, at a minimum of at least once each six month period of coverage.
B. A PACE organization shall provide payment or reimbursement only for services provided pursuant to this article under referral from its interdisciplinary team that conducts case management UNLESS IT IS AN EMERGENCY SERVICE.
C. For the purposes of this section, "case management" means a service that will direct participants to the most appropriate amount, duration and type of services and continually monitor and reassess a participant's need for services provided pursuant to this article.
36-2999.05. Establishment of capitation rate
A. Under a PACE program agreement and 42 Code of Federal Regulations section 460.182, the administration shall make a prospective monthly payment to the PACE organization of a capitation rate for each Medicaid participant.
B. The PACE organization must accept the capitation payment as payment in full for Medicaid participants and may not bill, charge, collect or receive any other form of payment from the administration or from or on behalf of the PACE participant, except as follows:
1. Payment with respect to the share of cost and any amounts due under the posteligibility treatment of income.
2. Medicare payment received from the centers for medicare and medicaid services or from other payors.
3. Adjustments related to enrollment and disenrollment of PACE participants in the PACE organization.
4. A fee-for-service payment by the administration or medicare prior to the PACE participant being capitated.
C. Medicaid capitated rates for pace organizations shall be established which are less than the amount that would otherwise have been paid under the state plan if the individuals were not enrolled with pace and shall be adjusted to take into account the comparative frailty of pace enrollees.
D. At least thirty days before finalizing the capitation rates, the administration shall send written notice of the proposed capitation rates to the PACE organization.
36-2999.06. PACE program notification; application; state assurance
A. A PACE organization’s application must be accompanied by an assurance from the state administering agency indicating that the state considers the organization to be qualified to be a pace organization and is willing to enter into a pace program agreement with the organization. The administration may collect from the pace organization applicant the direct cost associated with the evaluation of the pace application pursuant to this section.
B. In accordance with sections 1894, 1905(a) and 1934 of the social security act, PACE is established as a state option under medicaid. The director shall submit an amendment to the state’s medicaid plan, authorizing the implementation of PACE as soon as practicable but not later than September 1, 2006.
C. The administration shall begin accepting notices of intent to file a PACE program application no later than thirty days after approval of the state’s medicaid plan amendment.
D. An organization shall file a notice of intent to establish a PACE program with the administration. At a minimum, the notice shall describe the service area for the pace organization in accordance with the federal application process prescribed in 42 code of federal regulations section 460.12.
E. On receipt of a notice of intent to establish a PACE organization pursuant to this section, the administration shall provide adequate public notice of the intent and invite alternative proposals. The organization shall reimburse the administration for all publication costs. The administration shall prescribe a deadline after which it shall not accept new PACE applications for the defined service area. The deadline shall be no more than sixty days after the initial filing of intent to establish a PACE organization.
F. Within ninety days after application submission, the administration shall do one of the following:
1. Provide state assurance.
2. Deny state assurance based on noncompliance with federal and state statutes.
3. Request additional information needed to make a final determination.
G. The administration shall offer state assurance pursuant to this article. If multiple proposals are submitted for the same service area, the administration shall provide state assurance to the proposal that is the most responsive and cost-effective and that conforms to all of the applicable requirements of this article. The administration may develop additional criteria to evaluate competing proposals that are consistent with the federal application process prescribed in 42 code of federal regulations section 460.12.
36-2999.07. PACE organization qualifications; annual report; financial solvency
A. A PACE organization must be one of the following or be a distinct part of one of the following:
1. An entity of a city, county, state or tribal government.
2. A private nonprofit entity organized for charitable purposes under section 501(c)(3) of the internal revenue code of 1986.
B. The PACE organization's service area must be approved by the centers for medicare and medicaid services and the administration.
C. The PACE ORGANIZATION must:
1. Have a governing board that includes community representation.
2. Be able to provide the complete service package regardless of frequency or duration of services.
3. Have a physical site to provide services.
4. Have a defined service area.
5. Have safeguards against conflict of interest.
6. Have a demonstrated fiscal soundness.
7. Have a formal participants' bill of rights.
D. PACE ORGANIZATIONS assume the risk for providing services under contract with the administration and centers for medicare and medicaid services and must maintain sound financial management procedures, maintain protections against insolvency and generate periodic financial reports for submission to the administration.
E. Each PACE ORGANIZATION pursuant to this section must submit an annual audited financial and programmatic report for the preceding fiscal year as required by the administration. The report must include:
1. Beginning and ending balances, revenues and expenditures including specific identification of administrative costs.
2. The number of PACE participants served by the PACE organization and the cost incurred for various types of services provided to members in a format prescribed by the director.
F. The director shall require contract terms necessary to ensure adequate performance by the PACE ORGANIZATION of the provisions of each contract executed pursuant to this section. Contract provisions required by the director must include the maintenance of deposits, performance bonds, financial reserves or other financial security.
36-2999.08. PACE organizations; additional responsibilities; exemption from title 20
A. PACE organizations shall comply with all responsibilities and requirements prescribed in sections 36-2946, 36-2947, 36-2948 and 36-2952 through 36-2959.
B. To the extent that services are provided pursuant to this article, a PACE ORGANIZATION is not subject to the provisions of title 20.
Sec. 2. Auditor general PACE program review
Not later than three years after enrollment begins in the first PACE program as prescribed by this act, the auditor general shall conduct a performance audit as defined in section 41-1278, Arizona Revised Statutes, of the PACE program. The audit shall include an examination of the cost‑effectiveness of all PACE organizations and shall assess the impact of the PACE program on the program contractors. The auditor general shall submit copies of the audits to the governor, the president of the senate, the speaker of the house of representatives and the chairpersons of the senate health committee and the house of representatives health committee or their successor committees.
Sec. 3. Initial PACE programs; limitation
Notwithstanding title 36, chapter 29, article 5, Arizona Revised Statutes, as added by this act, the Arizona health care cost containment system administration shall not authorize more than four qualified PACE programs before October 1, 2009.