Florida § 430.84 - Program of All-Inclusive Care for the Elderly.

§ 430.84. Program of All-Inclusive Care for the Elderly.

(1) DEFINITIONS. — As used in this section, the term: (a) “Agency” means the Agency for Health Care Administration. (b) “Applicant” means an entity that has filed an application with the agency for consideration as a Program of All-Inclusive Care for the Elderly (PACE) organization. (c) “CMS” means the Centers for Medicare and Medicaid Services within the United States Department of Health and Human Services. (d) “Department” means the Department of Elderly Affairs. (e) “PACE organization” means an entity under contract with the agency to deliver PACE services. (f) “Participant” means an individual receiving services from a PACE organization who has been determined by the department to need the level of care required under the state Medicaid plan for coverage of nursing facility services. (2) PROGRAM CREATION. — The agency, in consultation with the department, may approve entities that have submitted applications required by the CMS to the agency for review and consideration which contain the data and information required in subsection (3) to provide benefits pursuant to the PACE program as established in 42 U.S.C. s. 1395eee and in accordance with the requirements set forth in this section. (3) PACE ORGANIZATION SELECTION. — The agency, in consultation with the department, shall, on a continuous basis, review and consider applications required by the CMS for PACE that have been submitted to the agency by entities seeking initial state approval to become PACE organizations. Notice of such applications shall be published in the Florida Administrative Register. (a) A prospective PACE organization shall submit application documents to the agency before requesting program funding. Application documents submitted to and reviewed by the agency, in consultation with the department, must include all of the following: 1. Evidence that the applicant has the ability to meet all of the applicable federal regulations and requirements, established by the CMS, for participation as a PACE organization by the proposed implementation date. 2. Market studies, including an estimate of the number of potential participants and the geographic service area in which the applicant proposes to serve. 3. A business plan of operation, including pro forma financial statements and projections, based on the proposed implementation date. (b) Each applicant must propose to serve a unique and defined geographic service area. In designating a service area under a contract with a PACE organization, the state administering agency may exclude from designation an area that is already covered under another PACE organization contract in order to avoid unnecessary duplication of services and avoid impairing the financial service viability of an existing PACE organization. However, if a new applicant submits a letter of intent to provide PACE services in an area where an existing PACE organization is under contract and has been operating for at least 10 years, the state shall determine whether there is an unmet need that could be provided by the new PACE organization and the applicant must satisfactorily demonstrate to the state administering agency that there is justification for the proposed PACE organization in such service area. All applicants must demonstrate in the application that the PACE services provided by the proposed PACE organization will be comprehensive and organized to meet all state and CMS requirements. (c) Upon agency approval, a PACE organization that is authorized to provide and has received funding for PACE slots in a given geographic area may use such slots and funding to serve the needs of participants in a contiguous geographic area if such PACE organization is authorized to provide PACE services in that area. (d) An existing PACE organization seeking authority to serve an additional geographic service area not previously authorized by the agency or Legislature shall meet the requirements set forth in paragraphs (a) and (b). (e) Any prospective PACE organization that is granted initial state approval by the agency, in consultation with the department, shall submit its complete federal PACE application, in accordance with the application process and guidelines established by the CMS, to the agency and the CMS within 12 months after the date of initial state approval, or such approval is void. (4) ACCOUNTABILITY. — All PACE organizations must meet specific quality and performance standards established by the CMS and the state administering agency for the PACE program. The agency shall oversee and monitor the PACE program and organizations based upon data and reports periodically submitted by PACE organizations to the agency and the CMS. A PACE organization is exempt from the requirements of chapter 641.