Transcription
NEIGHBORHOOD PACEProgram of All Inclusive Care for the ElderlyServing the Communities of East Boston,Revere, Chelsea, Winthrop and Everett,Stoneham, Malden, Medford, Melrose andBoston’s North EndParticipant Enrollment GuideThis program is supported through a cooperative agreement with the US Department ofHealth and Human Services, Centers for Medicare & Medicaid Services and theCommonwealth of Massachusetts Office of MassHealth. The agreement is subject torenewal on a periodic basis and, if the agreement is not renewed, the program will beterminated.
CONTENTSSECTION 1: Welcome to the Neighborhood PACE . 4SECTION 2: Special Features of Neighborhood PACE . 51. Interdisciplinary Team (IDT) and Your Care Plan . 52. Coordination and Authorization of Comprehensive Care . 53. Neighborhood PACE Centers . 64. Services Provided/Authorized Exclusively through Neighborhood PACE . 6SECTION 3: Benefits and Coverage . 71. PACE Health Center Services . 72. Outpatient Health Services . 73. Inpatient Hospital Care . 84. Emergency Care and Services (See Section 4 of this Agreement) . 85. Skilled Nursing Facility and Nursing Facility Care . 86. Home Health Care and Related Services . 87. Dental Care . 98. Hearing Instruments . 99. Vision Services and Eyewear . 910. Palliative Care and End-of-Life Services . 1011. Other Health-Related Services . 10SECTION 4: Access to After-Hours Care, Emergency Care, and Urgent Care . 101. After-Hours Non-Emergency Care . 102. Emergency Care . 10Post-Emergency Stabilization Services . 113. Urgent Care . 11Out of Service Area Coverage Provisions . 12SECTION 5: Eligibility, Enrollment, and Disenrollment . 121.2.3.4.Eligibility . 12Enrollment . 12Continuation of Enrollment. 13Disenrollment . 13Voluntary Disenrollment . 14Involuntary Disenrollment. 145. Re-Enrollment . 15SECTION 6: Assessments and Care Plans . 151. Assessments. 15Your interdisciplinary team will conduct a comprehensive assessment within 30 days ofenrollment and at least annually. . 152. Care Plan. 153. Obtaining the Care and Services Included in Your Care Plan. 166. Appeals of Care Plan Change. 162 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
7. Request for Service Change . 16SECTION 7: Appeals Processes . 17Appeals Process . 17Standard Appeal . 17Expedited or “FAST” Appeal Process for Service Requests . 19External Appeals . 19SECTION 8: Participant Grievance/Concern Process. 21Grievance/Concern Process. 21SECTION 9: Monthly Payments . 21Your Monthly Bill: How Much Will You Have to Pay? . 21Prescription Drug Coverage Late Enrollment Penalty. 23Instructions for Making Payments to Neighborhood PACE . 23Your Share of Costs for Nursing Facility Care . 23For MassHealth Members. 24For All Other Neighborhood PACE Participants . 24SECTION 10: Service Exclusions and Limitations . 24SECTION 11: General Provisions . 25SECTION 12: Definition of Terms . 28SECTION 13: Participant Bill of Rights and Responsibilities . 30Participant Rights . 30Respect and Non-Discrimination . 30Information . 31Confidentiality . 31Emergency Care . 31Treatment Decisions . 32Exercising Your Rights . 32Shared Responsibilities . 333 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
SECTION 1: Welcome to the Neighborhood PACEWe are pleased to introduce you to the Neighborhood PACE. We welcome you as aparticipant in the plan and urge you to review this booklet carefully. Feel free to askquestions about any of the information addressed. We will be happy to answer anyquestions or concerns. Please keep this booklet as this is your Enrollment Guide.You are eligible to enroll in Neighborhood PACE if you: Are at least 55 years of age; Are capable of safely residing in the community setting without jeopardizing yourhealth and safety; Meet the level of care required for coverage of nursing facility services ascertified by MassHealth; and Live in the service area: Chelsea, East Boston, Everett, Malden, Medford,Melrose, Revere, Stoneham, Winthrop and Boston’s North End.The purpose of Neighborhood PACE is to help you remain as independent as possible.The program coordinates a complete range of health and health-related services, alldesigned to keep you living in the community and in your own home for as long as it issafe and feasible. We are dedicated to providing a personalized approach to your careso that you, your family, and our health care staff can know each other well and workeffectively together on your behalf.Neighborhood PACE provides access to services 24 hours a day, 7 days a week, and365 days a year. To treat the multiple chronic health problems of our participants, ournetwork of health care professionals monitor changes in your health status, provideappropriate care, and encourage self-help. Medical, nursing, and nutrition services,physical therapy, occupational therapy, and in-home support are provided, along withsuch medical specialty services as audiology, dentistry, optometry, podiatry, psychiatry,and speech therapy. All non-emergency services must be provided through theNeighborhood PACE contracted network unless authorized in advance by yourInterdisciplinary Team. Neighborhood PACE coordinates hospital and nursing facilitycare in its contracted facilities. With your permission, Neighborhood PACE will work inpartnership with your family, friends, and neighbors to maintain your independence andsafety in the community. Neighborhood PACE may also help you purchase equipmentto modify your home environment to increase safety and convenience.Some of the terms used in this document may not be familiar to you.Please refer to Section 11: Definition of Terms for explanations of terms used.4 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
SECTION 2: Special Features of Neighborhood PACEPACE stands for Program of All-Inclusive Care for the Elderly. PACE Plans, includingNeighborhood PACE have many special features including:1. Interdisciplinary Team (IDT) and Your Care PlanYour IDT includes a physician, nurse practitioner, registered nurse, social worker,nutritionist, rehabilitation and recreation therapists, health aides, drivers and others whowill assist you. Each team member uses his or her special expertise to assess yourhealth care needs and to call upon additional specialists, if necessary. Together withyou and your family, we create and implement a plan of care designed just for you.2. Coordination and Authorization of Comprehensive CareWe have flexibility in providing care according to your needs. The IDT will work closelywith you to identify and arrange for the services you need to meet your care plan goals.You may receive the majority of your health care services at one of our PACE Centers.The PACE Center combines your doctor’s office with rehabilitation and activities whereyou can socialize while getting the care you need.In addition to our own clinical staff, we have contracts with other providers and facilitiesin our service area, including physician specialists (such as cardiologists, urologists,and orthopedists), hospitals, nursing facilities, pharmacies, and medical equipmentsuppliers.The IDT may authorize services to be provided in your home, a hospital, or a nursingfacility.5 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
3. Neighborhood PACE CentersWe will work with you and your family to determine how the services and activities atPACE Centers and alternative settings can meet your needs. Attendance is based onyour individual needs and preferences. We will provide transportation to our locationsand other medical appointments, unless you prefer another arrangement.Neighborhood PACE Center Locations:Lewis Mall PACE Center225 Sumner StreetEast Boston, MA 02128617-568-4426Winthrop PACE Center26 Sturgis StreetWinthrop, MA 02152617-568-6300Barnes PACE Center127 Marion StreetEast Boston, MA 02128617-568-6333Alternative Care Setting/Wellness Center155 Addison StreetEast Boston, MA 02128Neighborhood PACE utilizes the Massachusetts Relay Service for Deaf or Hard ofHearing participants who use a TTY or other device for telephone communication. TTYand ASCII users can call the relay service at 800-720-3480 for connection toNeighborhood PACE locations.The general mailing address and administration phone number to Neighborhood PACEis:East Boston Neighborhood Health CenterAttn: Neighborhood PACE Administration10 Gove StreetEast Boston, MA 02128617-568-63774. Services Provided/Authorized Exclusively through Neighborhood PACEThe services offered by Neighborhood PACE are available to you because of a contractamong the East Boston Neighborhood Health Center, the Commonwealth ofMassachusetts Office of MassHealth, and the federal Department of Health and HumanServices, Centers for Medicare & Medicaid Services (CMS).Once you have enrolled in Neighborhood PACE, you agree to receive servicesexclusively from Neighborhood PACE and/or its network of providers, with the exceptionof emergency services or out-of-network services that have been authorized in advanceby your IDT.6 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
SECTION 3: Benefits and CoverageNeighborhood PACE covers items and services, as medically necessary that aretraditionally covered under Medicare and MassHealth. We also cover services that maynot be available under original Medicare and MassHealth when the IDT determinessuch services are necessary to improve and/or maintain your health status. Allauthorized benefits are covered 100% by Neighborhood PACE leaving no balancebilling to Participants.1. PACE Health Center Services Primary care physician services, including routine care, preventive healthcare, physical examinations, and treatment of illness.Physical therapy, speech therapy, and occupational therapyPersonal careSupportive services, including social services and transportationNutrition counseling and educationMealsRecreational therapy2. Outpatient Health Services Physician specialists services, including, but not limited to, services such asgastroenterology, oncology, urology, rheumatology, and dermatologyNursing careHome health careLaboratory tests, x-rays, and other diagnostic servicesPhysical therapy, speech therapy, and occupational therapyProsthetics and OrthoticsPersonal care attendant servicesPrescription drugs (only if obtained from a pharmacy designated byNeighborhood PACE, except when provided for emergency services orauthorized post-emergency or urgent care services)Durable medical equipmentPodiatryVision care, including examinations, treatment, and corrective devices suchas eyeglassesPsychiatry, including evaluation, consultation, diagnostic, and treatmentserviceAudiology evaluation, hearing aids, repairs, and maintenanceNon-emergency ambulance transportation, if medically necessary7 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
3. Inpatient Hospital Care Semi-private room (or private room if medically necessary)Meals, including special dietsGeneral medical and nursing servicesMedical, surgical, and special care such as intensive care and coronary careunitLaboratory tests, x-rays, and other radiology servicesOther diagnostic proceduresUse of appliances such as wheelchairsDrugs and biologicalsRehabilitative careBlood and blood derivativesSurgical care, including anesthesiaUse of oxygenPhysical, speech, occupational, and respiratory therapiesSocial services4. Emergency Care and Services (See Section 4 of this Agreement) AmbulanceEmergency room care and treatment including hospitalization, if necessary.5. Skilled Nursing Facility and Nursing Facility Care Semi-private room and boardPhysician and nursing servicesMeals, including special dietsCustodial or residential carePersonal care and assistanceDrugs and biologicalsPhysical, speech, and occupational therapiesSocial servicesMedical supplies and appliancesOther services determined necessary by the Interdisciplinary Team6. Home Health Care and Related Services Skilled nursing servicesPhysician visitsPhysical, speech, and occupational therapies8 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
Social servicesHome health aide servicesHomemaker/chore servicesMedical supplies and equipmentHome-delivered meals7. Dental CareNeighborhood PACE will assess the dental status of all participants and will offer dentalservices that conform to accepted standards with the goal of optimizing oral health andnutritional status. Dental services are based on individual needs. Participants areeligible for: Routine Dental Exams and Cleanings Full mouth X-rays Restorative fillings Single Crowns Dentures, one complete pair or separate upper/lowers every 4 years unlessan exception is approved by the IDT.Dental Care is provided by Neighborhood PACE contracted dentists and all treatmentplans are subject to prior approval by Neighborhood PACE8. Hearing InstrumentsHearing instruments are provided to participants with medical clearance from the IDTfor those who do not have other medical conditions that would contraindicate the use ofa hearing instrument. Participants are eligible for: One pair of hearing aids, including fittings, consultations and ongoingmaintenance as authorized by the IDT, once every 5 years unless an exceptionis made by the IDT.9. Vision Services and EyewearESP participants are covered for one routine eye exam per year and as neededmedically necessary treatments at an in-network provider or other approved provider. ESP participants are covered for one (1) routine eye exam per year. Relatedmedical necessary tests and treatments are covered with an authorized referral. One pair of eyeglasses is covered every two (2) years unless an exception ismade by the IDT. Two (2) pairs of glasses may be covered if approved by the IDT if multifocal lensdesigns are contraindicated due to fall risk.9 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
10. Palliative Care and End-of-Life ServicesPalliative Care and end-of-life services are generally provided by the PACEinterdisciplinary team. Such services may include in-home personal care, skillednursing, physician/nurse practitioner, and social work visits, pain management, andspiritual support for you and your family.11. Other Health-Related ServicesOther health-related services may be approved by the interdisciplinary team throughyour Care Plan or the Service Request process. If denied by the interdisciplinary team,service requests are subject to appeal.SECTION 4: Access to After-Hours Care, Emergency Care, and Urgent Care1. After-Hours Non-Emergency Care(Weekdays 4:00 p.m. to 8:00 a.m., weekends, and holidays)There may be times when you need to speak with a nurse, nurse practitioner, orphysician to receive advice or treatment for an injury or onset of an illness that simplycannot wait until regular Neighborhood PACE business hours. When you need nonemergency care after hours, there is always a provider available 24 hours a day, 7 daysa week, and 365 days a year. When you call your PACE center phone number afterhours, your call will be answered by Neighborhood PACE’s answering service. Theanswering service will contact the on call provider to assist you.For after-hours non-emergency care, call your PACE Center:Barnes: 617-568-6333; Lewis Mall: 617-568-4426; Winthrop: 617-568-63002. Emergency CareNeighborhood PACE covers emergency care for an emergency medical condition. Inan emergency, please call 911. An emergency medical condition is one that manifestsitself by acute symptoms of sufficient severity (including severe pain) such that aprudent layperson who possesses an average knowledge of health and medicine couldreasonably expect the absence of immediate medical attention to result in: (1) placingthe health of the individual in serious jeopardy; (2) serious impairment to bodilyfunction; or (3) serious dysfunction of any bodily organ or part.Prior authorization is not needed for emergency care.If you are not sure if you’re having an emergency, please call your Neighborhood PACECenter for medical advice.10 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
If you call 911 and receive emergency treatment, please have someone notifyNeighborhood PACE to let us know what has happened. Your primary care providerwill be called immediately to coordinate your care.If you receive emergency care when you are temporarily outside of the servicearea, please ask the Provider to send bills to Neighborhood PACE:East Boston Neighborhood Health CenterAttn: Neighborhood PACE10 Gove StreetEast Boston, MA 02128617-568-7214If you have paid for emergency medical services you received outside of the servicearea, request a receipt from the facility, pharmacy or physician involved. This receiptmust show the provider’s name, date and type of treatment, date of discharge ifhospitalized, and the amount you were required to pay. Please bring a copy of thereceipt to your PACE Center or mail to the address above for reimbursement.Post-Emergency Stabilization ServicesPost-emergency stabilization services are services provided after you have receivedemergency medical treatment. The physician(s) who treated you for the emergencymay consider certain services necessary after your condition has been stabilized.Post-emergency stabilization services are not emergency services and must bepre-approved by the IDT before being provided outside the Neighborhood PACEProvider Network. Neighborhood PACE will cover post-emergency stabilizationservices that have not been pre-approved by the IDT if you or someone acting on yourbehalf tried, but did not receive a call back from Neighborhood PACE within one hour ofcalling for approval.For approval of services call you’re PACE Center.3. Urgent CareUrgent care is defined as care you receive when you are temporarily out of theNeighborhood PACE service area for an illness or injury that a prudent layperson whopossesses an average knowledge of health and medicine would believe requiresimmediate attention, but is not emergent as defined above. In an urgent situation, yourlife or functioning is not in severe jeopardy.Urgent care is appropriately provided in a clinic, physician’s office, or in a hospitalemergency department if a clinic or physician's office is inaccessible. Urgent care does11 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
not include services provided to treat an emergency condition, nor does it includeprimary care services.To be covered, urgent care services should be pre-approved by NeighborhoodPACE.Your doctor or another provider will assess your medical condition to determine ifimmediate care is required, and will coordinate care with out-of-network medicalproviders if needed.Neighborhood PACE will cover out-of-network urgent care services that have notbeen pre-approved if we do not respond to a request for approval within one hour ofbeing contacted.Out of Service Area Coverage ProvisionsBefore you leave the service area, you should notify the IDT. They will makearrangements to ensure that you receive the care and medications you need andexplain what to do if you become ill or injured while away. If you are hospitalized, you ora family member should notify us within 48 hours, or as soon as it is reasonablypossible to do so.Medical care received outside of the United States will not be covered by NeighborhoodPACE.SECTION 5: Eligibility, Enrollment, and Disenrollment1. EligibilityYou are eligible to enroll in Neighborhood PACE if you: Are at least 55 years of age Are capable of safely residing in the community setting without jeopardizing yourhealth and safety; Meet the level of care required for coverage of nursing facility services ascertified by MassHealth; and Live in the service area of Neighborhood PACE: Chelsea, East Boston, Everett,Revere, Winthrop, Stoneham, Melrose, Medford, Malden, or Boston’s North End2. EnrollmentCoverage in Neighborhood PACE always begins on the first of the month following thesigning of the Enrollment Agreement. Enrollment in PACE results in disenrollmentfrom any other Medicare or Medicaid prepayment plan or optional benefit.12 P a g eH2223 201704Neighborhood PACE Enrollment GuideVersion 1, 05/10/2017
You will receive a photo identification card with a lanyard to identify yourself at thePACE Center. You will also receive an insurance card that will replace your Medicareand/or MassHealth cards and can be brought with you on Medical Appointments.You may receive notifications from Medicare, Medicare Advantage Plans or Part DPlans. To protect your enrollment in Neighborhood PACE, please contact the BusinessOffice with any questions or concerns regarding Medicare, Medicare Part D orMassHealth. You may contact the Business Office by calling 617-568-7214.3. Continuation of EnrollmentQualifying for Nursing Home Level of CareIf the State determines that you no longer meet the criteria for nursing facility level ofcare, you will not be eligible to continue your enrollment with Neighborhood PACE.Neighborhood PACE will notify you in writing that we must disenroll you from the Plan.We will assist you in the transition back to traditional Medicare/MassHealth asapplicable. You have the right to appeal to the Executive Office of Health and HumanServices (See Section 7: Participant Grievance/Concerns and Appeals Processes.)Continuation of MassHealth or Other Payment AgreementsIf you are receiving benefits under the MassHealth program, you are required to reapply for these benefits on a schedule determined by MassHealth. Our insurancespecialists will assist you in completing the MassHealth application and documentationrequirements. Should you decline to complete the MassHealth re-determinationprocess, or be found ineligible for coverage under MassHealth, you will be required topay a monthly premium to Neighborhood PACE in order to remain enrolled.Neighborhood PACE will notify you in writing of y
The general mailing address and administration phone number to Neighborhood PACE is: East Boston Neighborhood Health Center Attn: Neighborhood PACE Administration 10 Gove Street East Boston, MA 02128 617-568-6377 4. Services Provided/Authorized Exclusively through Neighborhood PACE
