§ 42-4-121 — Program of all-inclusive care for the elderly

Wyoming § 42-4-121

• Jurisdiction: Wyoming
• Title 42: Welfare
• Ch. 4: MEDICAL ASSISTANCE AND SERVICES
• Art. 1: IN GENERAL

Text

(a) The department, as an optional services program of the
Medicaid program, may develop and implement a program of all-
inclusive care for the elderly (PACE) in accordance with section
4802 of the Balanced Budget Act of 1997, P.L. 105-33, as
amended, and 42 C.F.R. part 460.
(b) The department may contract with approved PACE
organizations to provide, in the manner and to the extent
authorized by federal law, comprehensive, community based acute
and long term care services for older Medicaid eligible
participants who are at least fifty-five (55) years old, living
in a PACE service area, certified by the department as eligible
for long term care facility placement and who elect to
participate in the PACE program. Services provided through a
PACE organization shall include all necessary medical and
related care required by the PACE participant, including but not
limited to physician and other health care provider visits,
regular check ups, prescription drugs, rehabilitation services,
home and personal care services, medically necessary
transportation, hospitalization and skilled nursing facility
services.
(c) The objective of the PACE program is to provide
prepaid, capitated, quality comprehensive health care services
that are designed to:
(i) Enhance the quality of life and autonomy for
frail, older adults;
(ii) Maximize dignity of, and respect for, older
adults;
(iii) Enable frail, older adults to live in the
community as long as medically and socially feasible;
(iv) Preserve and support the older adult's family
unit.
(d) The department shall adopt rules as necessary to
implement this section. In adopting rules, the department
shall:
(i) Provide application procedures for organizations
seeking to become a PACE program provider;
(ii) Establish the capitation rate for Medicaid
participants electing to participate in the PACE program instead
of receiving Medicaid services on a fee for service basis. The
capitation rate shall be no less than ninety percent (90%) of
the fee for service equivalent cost, including the department's
cost of administration, that the department estimates would be
payable for all services covered under the PACE organization
contract if all of those services were to be provided on a fee
for service basis;
(iii) Provide application procedures, including
acknowledgment of informed consent, for Medicaid participants
electing to participate in the PACE program in lieu of receiving
fee for service Medicaid benefits.
(e) PACE provider organizations shall be public or private
organizations providing or having the capacity to provide, as
determined by the department, comprehensive health care services
on a risk based capitated basis to PACE patients.
(f) To demonstrate capacity as required by subsection (e)
of this section, the department shall consider evidence such as
an organization's insurance, reinsurance, cash reserves, letters
of credit, guarantees of companies affiliated with the
organization or a combination of those arrangements.
(g) PACE organizations shall assume responsibility for all
costs generated by PACE program participants, and shall create
and maintain a risk reserve fund that will cover any cost
overages for any participant. A PACE organization is
responsible for the full financial risk that the cost of
services required by a program participant might exceed the
Medicaid capitated fee for that participant.
(h) The department shall develop and implement a
coordinated plan to promote the PACE program among prospective
Medicaid long term care patients in the service areas of
approved PACE organizations.
(j) As soon as practicable after July 1, 2010, the
department shall submit to the federal centers for Medicare and
Medicaid services an amendment to the state Medicaid plan
authorizing the state to implement the program of all-inclusive
care for the elderly pursuant to this section. The department
shall not enter into a contract with any PACE provider
organization until all necessary state plan amendments or
waivers are approved. An additional amendment to the state
Medicaid plan shall not be required each time the department
enters into a contract with a new PACE provider organization.
(k) Nothing in this section shall be construed to require
a PACE organization to hold a certificate of authority as an
insurer or a health maintenance organization under title 26 of
the Wyoming statutes.
(m) Repealed by Laws 2015, ch. 59, § 2.
(n) No PACE organization shall withhold any necessary
medical or nonmedical services to any PACE participant in order
to increase the organization's profit from the Medicaid
capitated payment.
(o) PACE participants may disenroll from the PACE program
at any time. A PACE organization shall promptly report the
identity of all disenrolled participants to the department.