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A Guide to the Program of All-inclusive Care for Elderly MassHealth Members Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth March 2014 Contents MassHealth Program of All-inclusive Care for the Elderly............................................... 3 PACE Enrollment ............................................................................................................................ 3 Determination of MassHealth Eligibility ................................................................................... 3 Enrollment Requirements ........................................................................................................... 3 Enrollment Processing................................................................................................................. 4 Initial Enrollment ........................................................................................................................... 4 Enrollment Confirmations - HIPAA 834 Transactions .......................................................... 5 Submission of Enrollments and Disenrollments ................................................................. 5 Automatic Enrollment Adjustments........................................................................................... 6 MassHealth Enrollment Centers ................................................................................................ 6 Rate Cells .......................................................................................................................................... 6 Status Changes ............................................................................................................................... 7 Demographic Changes................................................................................................................ 7 Disenrollment ................................................................................................................................... 7 Involuntary Disenrollment ........................................................................................................... 8 Admissions and Discharges from Nursing Facilities ........................................................ 8 MassHealth Capitation Payments ............................................................................................. 8 Financial Reconciliation .............................................................................................................. 9 Payment Confirmations-HIPAA 820 Transaction .................................................................. 9 PACE Application Submissions ................................................................................................ 9 New PACE Members ................................................................................................................... 9 Reassessments........................................................................................................................... 10 Management Reports .................................................................................................................. 10 Other Provider Reports ............................................................................................................. 11 Key MassHealth PACE Contacts ............................................................................................. 11 2 MassHealth Program of All-inclusive Care for the Elderly PACE is the Program of All-inclusive Care for the Elderly. PACE is a fully capitated Medicare and Medicaid managed care program authorized under federal regulation and managed jointly by MassHealth and the Centers for Medicare & Medicaid Services (CMS). For a MassHealth member to be eligible to apply for enrollment in the PACE program, the member must be aged 55 or over, reside in a geographical area served by a PACE provider, and be enrolled in MassHealth Standard. PACE Enrollment PACE organizations are responsible for verifying potential PACE enrollees’ eligibility for MassHealth by checking the Eligibility Verification System. The EVS User Manual is accessible on the MassHealth Web site at www.mass.gov/masshealth/newmmis. Click on Read Updated Billing Guides, Companion Guides, and Other Publications. PACE organizations are also responsible for checking EVS monthly to ensure that MassHealth members enrolled in PACE have not lost their MassHealth eligibility. Potential PACE enrollees who are not MassHealth members should be referred to the MassHealth Enrollment Center serving their area for MassHealth eligibility determination. For more information on enrollment centers, refer to Appendix B of your MassHealth provider manual at the MassHealth Web site www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, and then on Provider Library. Now click on MassHealth Provider Manual Appendices. Determination of MassHealth Eligibility For a MassHealth member to be eligible to apply for enrollment in the PACE program, the MassHealth member must be
a Massachusetts resident with a community residence in an approved PACE service area;
55 years of age or older; and
enrolled in MassHealth Standard. Enrollment Requirements The MassHealth member must choose to enroll in PACE voluntarily and
live in the geographic area served by the PACE organization at the time of 3 enrollment;
agree to receive all services from the PACE organization, except in the case of an emergency or when traveling temporarily out of the service area; and
agree to assist his or her primary care physician or primary care team in developing an individualized plan of care. MassHealth members are not eligible to enroll in PACE if they are
residents of an intermediate care facility for the developmentally disabled;
inpatients in a chronic disease or rehabilitation hospital; or
permanent residents of a nursing facility. Note: A potential PACE enrollee may be receiving services from the Department of Developmental Services (DDS). Before enrolling the member, the PACE organization must contact the member’s DDS service coordinator to determine whether PACE enrollment is appropriate. Call 617-624-7779 for information about DDS services and PASARR regulations. Enrollment Processing The Provider Online Service Center is accessible via the EOHHS Virtual Gateway. This portal allows the electronic enrollment and disenrollment of members without the necessity of submitting enrollment forms. However, the MassHealth PACE enrollment form must be completed by the member or his or her eligibility representative and retained by the PACE organization. The PACE organization must keep the original MassHealth PACE enrollment form or an electronic image on file while the member is an active participant, and for six years following the member’s disenrollment from PACE. All enrollment forms are subject to review by MassHealth and CMS at any time. You must continue to complete the standard HIPAA signature forms and keep them in the member record so that the PACE organization knows who has the authority to receive information and to participate in health-care decisions on the member’s behalf. The PACE enrollment form contains a statement explaining under what circumstances a family caregiver or other responsible person can act as the applicant’s eligibility representative making decisions related to voluntary enrollment in PACE on behalf of the member. Initial Enrollment The PACE organization must check the Eligibility Verification System (EVS) to determine the prospective enrollee’s MassHealth eligibility status, which must be MassHealth Standard. EVS provides important information about deductibles, 4 spend downs, and patient-paid amount (PPA). After confirming the prospective enrollee’s eligibility for MassHealth, the PACE organization submits the MDS-HC to the MassHealth RN for initial clinical screening eligibility. The MassHealth RN approves the MDS-HC for PACE eligibility and MassHealth Operations enrolls the approved applicant into MMIS. New enrollments must be submitted by 2PM on the last business day of the month. Upon receiving confirmation of enrollment into MMIS from the MassHealth RN the PACE organization may enroll the applicant into PACE. Note: Prospective PACE members who are nursing-home certifiable in the community may have access to a 300% income consideration for MassHealth eligibility. For prospective members already in MassHealth Standard the PACE organization needs to submit the PACE waiver and PACE contact information to the Tewksbury MassHealth Enrollment Center (MEC). Enrollment Confirmations - HIPAA 834 Transactions Enrollment confirmations are posted daily and are available for download from the Provider Online Service Center. In addition to the daily enrollment confirmations, a monthly 834 file is available for download. The monthly 834 file contains details of all members for which a monthly capitation payment is being made. For more information on the HIPAA 834 transaction, refer to the 834 Companion Guide available on the MassHealth Web site at www.mass.gov/masshealth. Submission of Enrollments and Disenrollments The PACE organization may process new member enrollments and disenrollments through the last business day of the month. The PACE organization must check with the PACE Operations Unit monthly to determine the cut-off time for processing. The cut-off may vary month to month and is determined by the MassHealth production schedule. All effective enrollment dates are the first of the month following enrollment. All disenrollment dates are the last day of the month in which the disenrollment is requested. Retroactive effective enrollment and disenrollment dates are not generally permitted. However, individual consideration will be given on a case-by-case basis. All member enrollment information is considered protected health information (PHI) under HIPAA. If any member information is faxed, the fax cover sheet must 5 indicate PHI is included. The PACE organization must call the PACE Operations Unit in advance whenever PHI is being faxed. Automatic Enrollment Adjustments Other state agencies or MassHealth units may change MassHealth member eligibility or demographic data. As these changes may affect a member’s rate cell, automatic enrollment adjustments are batch processed through NewMMIS. NewMMIS verifies and edits enrollment information on a daily and monthly basis. PACE status and rate cells will be affected on the following conditions:
Addition or termination of Medicare Part A, or Part B, or both; and
Loss of MassHealth eligibility These changes to PACE enrollment are reported to the PACE organization via the HIPAA 834 enrollment confirmation transaction. MassHealth Enrollment Centers The MassHealth Enrollment Center locations are listed below. For more information, refer to Appendix B of your MassHealth provider manual at the MassHealth Web site www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, and then on Provider Library. Now click on MassHealth Provider Manual Appendices. 45-47 Spruce Street Chelsea, MA 02150 Phone: 1-888-665-9993 333 Bridge Street Springfield, MA 01103 Phone: 1-800-332-5545 21 Spring Street Suite 4 Taunton, MA 02780 Phone: 1-800-242-1340 367 East Street Tewksbury, MA 01876 Phone: 1-800-408-1253 Rate Cells PACE members are assigned rate cells according to whether they are dually eligible for Medicare Part A and MassHealth, or MassHealth only. If PACE members have only Medicare Part B, they are considered MassHealth only. 6 Status Changes Demographic Changes The PACE organization is responsible for reporting any change of address of the participant to the MassHealth Enrollment Center. If members are receiving MassHealth through SSI, they must report the change in address to the local Social Security Administration office. MassHealth cannot change SSI member records. Note: The most common reason MassHealth members lose their eligibility is unreported address changes, because financial redetermination forms do not reach the members who have moved and are not completed as required. Disenrollment Include a disenrollment reason with all PACE disenrollment requests. On the disenrollment panel, enter a disenrollment reason from the list below. If the reason for disenrollment is death of the member, enter the date of death. • Moved out of service area
Provider network unacceptable
Dissatisfied with health care
Dissatisfied with appeal decision
Death (date of death is required)
Transportation problem
Difficulty contacting doctor
Problem receiving emergency treatment
Language barrier
Poor access for disabled members
Takes too long to get appointment
Dissatisfaction with specialty care
Health care needs changed 7 
Did not meet clinical needs requirements
Request by PACE
Improperly enrolled
Fair hearing appeal decision Involuntary Disenrollment Involuntary disenrollment requests must be preapproved. You must present a detailed explanation with all applicable documentation to the MassHealth PACE Program Manager before entering the disenrollment transaction. The participant has appeal rights to the Board of Hearing and that information needs to be a part of the documentation that is sent to participant. Admissions and Discharges from Nursing Facilities Whenever a PACE community member is admitted to or discharged from a nursing facility, the contracted nursing facility must submit the SC-1 form (Status Change for a Member in a Nursing Facility, Chronic Disease and Rehabilitation Inpatient Hospital, or Rest Home) to the appropriate MassHealth Enrollment Center with “PACE Member” clearly indicated on the form. If the SC-1 form is not clearly indicated as “PACE Member,” the MassHealth Enrollment Center cannot process the status change. When the institutional member is discharged from the nursing facility, send the SC-1 form to the Tewksbury MassHealth Enrollment Center, 367 East Street, Tewksbury, MA 01876, 1-800-408-1253. MassHealth Capitation Payments Monthly capitation payments are prospective. Monthly Payment Cycle Payments are sent to PACE organizations on the second Thursday of each month. Payments are issued for all PACE members active on the first day of the payment month. Member deductibles (spend downs) or patient-paid amounts (PPA) are deducted from capitation payments. Note: The PACE provider is responsible for collecting the deductibles. The nursing home is responsible for collecting the PPA. 8 Financial Reconciliation Capitation payments are reconciled monthly. Retroactive enrollment changes up to a year from the payment month will be adjusted automatically and included with the monthly capitation payment. Payment Confirmations-HIPAA 820 Transaction Payment confirmations are posted monthly and are available for download from the Provider Online Service Center in the HIPAA 820 record format. For more information about the HIPAA 820 transaction, refer to the 820 Companion Guide available at www.mass.gov/masshealth. PACE Application Submissions Minimum Data Set – Home Care (MDS-HC) is the comprehensive assessment and screening tool used for data submission to MassHealth for most services and programs for elders residing in community settings across the state. A registered nurse must complete the MDS-HC for PACE. A good resource link for the specialized MDS-HC manual, updates and information is www.interRAI.org. Complete all submissions using MDS-HC via the Web-based electronic version. Complete the Request for Services (RFS) form with all submissions. Also include accurate enrollment, discharge, and assessment dates with all submissions to coincide with other required documentation. All medical data submitted via MDS is considered current if gathered within 30 days of submission. Determinations are effective for 12 months. The PACE organization must request a redetermination whenever a significant status change occurs within 30 days of application. New PACE Members A registered nurse from the PACE provider is responsible for the completion of the initial MDS-HC for a prospective PACE member. A licensed Social Worker (LSW, LCSW, and LICSW) may complete sections: AA, BB, CC, B, C, E, F, G, and O. No other licensed or other professional may complete sections of the MDS-HC. A physician must sign off in Section R. Submit the initial MDS-HC, with the RFS, to the MassHealth RN. A formal approval and authorization notice will be issued by the MassHealth nurse. Keep 9 this notice in the member’s record. It must be made available to MassHealth or CMS upon request. When the initial MDS-HC has been evaluated by the MassHealth RN, the approval will be entered into MMIS by the MassHealth RN. PACE approval must be recorded in NewMMIS before a new member enrollment can be submitted. Reassessments Annually, one month before the anniversary date of the member’s initial enrollment, submit an MDS-HC reassessment for the member using the electronic application located on the MassHealth Web site at www.mass.gov/masshealth. Management Reports Use of the HIPAA 834 and 820 transactions is optional. NewMMIS generates management reports that are available for download from the NewMMIS Provider Online Service Center. These reports include enrollment and payment information that can be used in lieu of the 834 and 820 transactions. The reports are produced monthly at the time the capitation payments are calculated. The following is a list of NewMMIS reports. Monthly New Enrollments Monthly Disenrollments Monthly Capitation Payments Monthly Member Lost Eligibility Monthly Other Insurance (members with Medicare Hospice or Medicare Advantage) Daily 834 batch Enrollment Errors (if inbound 834s were submitted) Monthly Capitation Errors Quarterly Capitation Payments Annual Capitation Payments Capitation Demographics e-Learning Reports 10 Other Provider Reports Monthly Grievance Logs Monthly Appeal Logs Key MassHealth PACE Contacts The Coordinated Care Systems Unit, MassHealth Office of Long Term Supports and Services, manages the PACE program. The office is located at One Ashburton Place, 5th Floor, Boston, MA 02108. PACE Director of Coordinated Care - 617-222-7466 PACE Program Manager - 617-222-7485 PACE Operations Coordinator - 617-222-7518 PACE Clinical Coordinator - 617-222-7425 Toll-free telephone and TTY lines are available for members. Toll-free telephone number: 1-888-885-0484 TTY number (for people with partial or total hearing loss): 1-888-821-5225 11