32.1-330.3 - Operation of a pre-PACE plan or PACE plan; oversight by Department of Medical Assistance Services.
§ 32.1-330.3. Operation of a pre-PACE plan or PACE plan; oversight byDepartment of Medical Assistance Services.
A. Operation of a pre-PACE plan or PACE plan that participates in the medicalassistance services program must be in accordance with a prepaid health plancontract or other PACE contract consistent with Chapter 6 of Title IV of thefederal Balanced Budget Act of 1997 with the Department of Medical AssistanceServices.
1. As used in this section, "pre-PACE" means of or associated withlong-term care prepaid health plans (i) authorized by the United StatesHealth Care Financing Administration pursuant to § 1903 (m) (2) (B) of TitleXIX of the United States Social Security Act (42 U.S.C. § 1396b et seq.) andthe state plan for medical assistance services as established pursuant toChapter 10 (§ 32.1-323 et seq.) of this title and (ii) which have signedagreements with the Department of Medical Assistance Services as long-termcare prepaid health plans.
2. As used in this section, "PACE" means of or associated with long-termcare health plans (i) authorized as programs of all-inclusive care for theelderly by Subtitle I (§ 4801 et seq.) of Chapter 6 of Title IV of theBalanced Budget Act of 1997, Pub. L. No. 105-33, 111 Stat. 528 et seq., §§4801-4804, 1997, pursuant to Title XVIII and Title XIX of the United StatesSocial Security Act (42 U.S.C. § 1395eee et seq.), and the state plan formedical assistance services as established pursuant to Chapter 10 (§ 32.1-323et seq.) of this title and (ii) which have signed agreements with theDepartment of Medical Assistance Services as long-term care health plans.
B. All contracts and subcontracts shall contain an agreement to hold harmlessthe Department of Medical Assistance Services and pre-PACE and PACE enrolleesin the event that a pre-PACE or PACE provider cannot or will not pay forservices performed by the subcontractor pursuant to the contract orsubcontract.
C. During the pre-PACE or PACE period, the plan shall have a fiscally soundoperation as demonstrated by total assets being greater than totalunsubordinated liabilities, sufficient cash flow and adequate liquidity tomeet obligations as they become due, and a plan for handling insolvencyapproved by the Department of Medical Assistance Services.
D. The pre-PACE or PACE plan must demonstrate that it has arrangements inplace in the amount of, at least, the sum of the following to cover expensesin the event of insolvency:
1. One month's total capitation revenue to cover expenses the month prior toinsolvency; and
2. One month's average payment of operating expenses to cover potentialexpenses the month after the date of insolvency has been declared oroperations cease.
The required arrangements to cover expenses shall be in accordance with thePACE Protocol as published by On Lok, Inc. in cooperation with the UnitedStates Health Care Financing Administration, as of April 14, 1995, or anysuccessor protocol that may be agreed upon between the United States HealthCare Financing Administration and On Lok, Inc.
Appropriate arrangements to cover expenses shall include one or more of thefollowing: reasonable and sufficient net worth, insolvency insurance, lettersof credit or parental guarantees.
E. Enrollment in a pre-PACE or PACE plan shall be restricted to thoseindividuals who participate in programs authorized pursuant to Title XIX orTitle XVIII of the United States Social Security Act, respectively.
F. Full disclosure shall be made to all individuals in the process ofenrolling in the pre-PACE or PACE plan that services are not guaranteedbeyond a thirty-day period.
G. The Board of Medical Assistance Services shall establish a TransitionalAdvisory Group to determine license requirements, regulations and ongoingoversight. The Advisory Group shall include representatives from each of thefollowing organizations: Department of Medical Assistance Services,Department of Social Services, Department of Health, Bureau of Insurance,Board of Medicine, Board of Pharmacy, Department for the Aging, and apre-PACE or PACE provider.
(1997, cc. 414, 475; 1998, c. 318.)