HF 4839

as introduced - 93rd Legislature (2023 - 2024) Posted on 04/04/2024 09:38pm

A bill for an act
relating to human services; implementing the PACE program; proposing coding
for new law in Minnesota Statutes, chapter 256B.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

new text begin [256B.6902] PACE SERVICE DELIVERY SYSTEM.
new text end

new text begin Subdivision 1. new text end

new text begin Establishment. new text end

new text begin The Program of All-Inclusive Care for the Elderly (PACE)
is created with the powers and duties established by law. PACE is a program authorized
under section 9412(b)(2) of the federal Omnibus Reconciliation Act of 1986, Public Law
99-509, and section 256B.69, subdivision 23. PACE requires the secretary of the federal
Department of Health and Human Services to grant Medicare and Medicaid waivers to
permit community-based organizations to provide comprehensive health care services on
a capitated basis to eligible individuals who are at risk of institutionalization.
new text end

new text begin Subd. 2. new text end

new text begin Definitions. new text end

new text begin (a) For the purposes of this section, the following terms have the
meanings given.
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new text begin (b) "Department" means the Department of Human Services.
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new text begin (c) "PACE organization" means an entity as defined in Code of Federal Regulations,
title 42, section 460.6.
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new text begin (d) "Eligible population" means persons 55 years of age and older who have been screened
by the county and found eligible for services under the elderly waiver or community access
for disability inclusion or who are already eligible for Medicaid and meet the level of care
criteria for receipt of waiver services who may choose to enroll in the PACE program.
new text end

new text begin Subd. 3. new text end

new text begin Services for eligible persons. new text end

new text begin (a) Within the context of the PACE program
under this section, the commissioner of human services may include any or all the services
in medical assistance long-term services and supports.
new text end

new text begin (b) An eligible person may elect to receive services from the PACE program. If the
PACE election is made, the eligible person shall not remain eligible for payment through
the regular Medicare or Medicaid program. All services and programs provided through
the PACE program must be provided in accordance with this section. An eligible person
may elect to disenroll from the PACE program at any time.
new text end

new text begin (c) For purposes of this subdivision, "eligible person" means an individual 55 years of
age or older who voluntarily enrolls in the PACE program, whose income and resources do
not exceed limits established by the commissioner of human services, and for whom a
licensed physician certifies the PACE program provides an appropriate alternative to
institutionalized care.
new text end

new text begin Subd. 4. new text end

new text begin Requirements. new text end

new text begin By coordinating an extensive array of medical and nonmedical
services, the needs of the program participants shall be met primarily in an outpatient
environment in an adult day health center, the participant's home, or an institutional setting.
The PACE service delivery system enhances the quality of life for the participant and offers
the potential to reduce and cap the costs of the medical needs of the participants, including
hospital and nursing home admissions. The PACE service delivery system shall:
new text end

new text begin (1) maintain eligible persons at home as an alternative to long-term institutionalization;
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new text begin (2) provide optimum accessibility to various important social and health resources that
are available to assist eligible persons in maintaining independent living;
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new text begin (3) provide that eligible persons who are frail elderly but who have the capacity to remain
in an independent living situation have access to the appropriate social and health services
without which independent living would not be possible;
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new text begin (4) coordinate, integrate, and link social and health services by removing obstacles that
impede or limit improvements in delivery of these services;
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new text begin (5) provide the most efficient and effective use of capitated funds for the delivery of the
social and health services; and
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new text begin (6) ensure that capitation payments amount to no more than 100 percent of the amount
paid under the Medicaid fee-for-service or the relevant managed care programs for an
actuarially similar population.
new text end

new text begin Subd. 5. new text end

new text begin Implementation. new text end

new text begin (a) By October 1, 2024, the commissioner of human services
shall prepare and submit a PACE state plan amendment to the federal Centers for Medicare
and Medicaid Services (CMS) to establish the Program of All-Inclusive Care for the Elderly
(PACE) to provide community-based, risk-based, and capitated long-term care services as
optional services under the Minnesota Title XIX State Plan and under contracts entered into
between the federal Centers for Medicare and Medicaid Services, the commissioner of
human services, and the PACE organization meeting the requirements of the Balanced
Budget Act of 1997, Public Law 105-33, and any other applicable law or regulation.
new text end

new text begin (b) By December 31, 2024, or upon federal approval, whichever is later, the commissioner
of human services shall establish the PACE organization application process for receiving
bids for competitive capitated rates.
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new text begin (c) By June 30, 2025, for services to be delivered beginning January 1, 2026, PACE
organizations awarded contracts by the commissioner must establish service operations.
new text end

new text begin (d) Using a risk-based financing model, the organizations contracted to implement the
PACE program must assume responsibility for all costs generated by the PACE program
participants and must create and maintain solvency according to CMS regulations that will
cover any cost overages for any participant. The PACE program is responsible for the entire
range of services in the consolidated service model, including hospital and nursing home
care according to participant need as determined by an interdisciplinary team. The contracted
organizations are responsible for the full financial risk. Specific arrangements of the
risk-based financing model shall be adopted and negotiated by the federal Centers for
Medicare and Medicaid Services, the organizations contracted to implement the PACE
program, and the commissioner of human services.
new text end

new text begin (e) The requirements of the PACE model under the federal Social Security Act, section
1894, United States Code, title 42, section 1395eee; and section 1934, United States Code,
title 42, section 1396u-4, shall not be waived or modified. The requirements that are not
waived or modified include the following:
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new text begin (1) the focus on qualifying individuals who require the level of care provided in a nursing
facility;
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new text begin (2) the delivery of comprehensive, integrated acute and long-term care services;
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new text begin (3) the interdisciplinary team approach to care management and service delivery;
new text end

new text begin (4) capitated, integrated financing that allows the provider to pool payments received
from public and private programs and individuals;
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new text begin (5) the assumption by the provider of full financial risk; and
new text end

new text begin (6) the provision of a PACE benefit package for all participants, regardless of source of
payment that includes all of the following:
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new text begin (i) all Medicare-covered items and services;
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new text begin (ii) all Medicaid-covered items and services as listed in the Minnesota Title XIX State
Plan; and
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new text begin (iii) any other services determined necessary by the interdisciplinary team to improve
and maintain the participant's overall health status.
new text end

new text begin (f) The provisions under sections 256B.056 and 256B.69 shall apply when determining
eligibility for medical assistance of a person receiving PACE services from an organization
providing services under this section.
new text end

new text begin (g) Provisions for governing the treatment of income and resources of a married couple,
for the purposes of determining the eligibility of a nursing facility certifiable or
institutionalized spouse, shall be established to qualify for federal financial participation.
new text end

new text begin (h) Notwithstanding paragraph (e), and to the extent federal financial participation is
available, the commissioner of human services, in consultation with PACE organizations,
may seek increased federal regulatory flexibility from the federal Centers for Medicare and
Medicaid Services to modernize the PACE program, including but not limited to addressing
the following:
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new text begin (1) composition of PACE interdisciplinary teams;
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new text begin (2) use of community-based physicians;
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new text begin (3) marketing practices; and
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new text begin (4) development of a streamlined PACE waiver process.
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new text begin (i) This subdivision is effective upon federal approval of a capitation rate methodology
in section 256B.69.
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new text begin (j) Each PACE organization must provide the department with the reporting documents
required by Code of Federal Regulations, Title 42, sections 460.190 to 460.196.
new text end

new text begin Subd. 6. new text end

new text begin Rates of payment. new text end

new text begin (a) Beginning July 1, 2025, for services delivered on or
after January 1, 2026, the commissioner shall use medical assistance appropriations to fund
services under this section. The commissioner shall develop and pay capitation rates to
organizations contracted to implement the PACE program under this section using actuarial
methods. The commissioner may develop capitation rates using a standardized rate
methodology across managed care plan models for comparable populations. The specific
rate methodology applied to PACE organizations shall address features of PACE that
distinguishes it from other managed care plan models. The rate methodology must be
consistent with actuarial rate development principles and must provide for all reasonable,
appropriate, and attainable costs for each PACE organization within a region.
new text end

new text begin (b) The commissioner may develop statewide rates and apply geographic adjustments
using available data sources deemed appropriate. Consistent with actuarial methods, the
primary source of data used to develop rates for each PACE organization shall be the
organization's cost and utilization data for the medical assistance program or other data
sources as deemed necessary by the commissioner. Rates developed under this subdivision
must reflect the level of care associated with the specific populations served under the
contract.
new text end

new text begin (c) The rate methodology developed in accordance with this subdivision must contain
a mechanism to account for the costs of high-cost drugs and treatments. The rates developed
must be actuarially certified prior to implementation.
new text end

new text begin (d) Consistent with the requirements of federal law, the commissioner shall calculate
an upper payment limit for payments to PACE organizations. In calculating the upper
payment limit, the commissioner shall collect the applicable community-based and skilled
nursing facility data and costs as necessary and shall consider the risk of nursing home
placement for the comparable population when estimating the level of care and risk of PACE
participants.
new text end

new text begin (e) The commissioner shall pay organizations contracted to implement the PACE program
at a rate within the certified actuarially sound rate range developed with respect to that entity
as necessary to mitigate the impact to the entity of the methodology developed in accordance
with this subdivision.
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new text begin Subd. 7. new text end

new text begin Commissioner's duties. new text end

new text begin (a) The commissioner shall:
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new text begin (1) provide a reimbursement system for services under the PACE program;
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new text begin (2) develop and implement contracts with organizations and set contractual obligations
for the PACE program, including but not limited to reporting and monitoring of utilization
of costs of the PACE program as required; and
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new text begin (3) acknowledge that the department is participating in the national PACE project as
initiated by federal law.
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new text begin (b) The department is responsible for certifying the eligibility for services of all PACE
program participants.
new text end