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PA Bulletin, Doc. No. 20-1115



Rate Methodology for Living Independence for the Elderly Sites Operating Under Medicare and Medicaid Capitation Program of All-Inclusive Care for the Elderly

[50 Pa.B. 4198]
[Saturday, August 15, 2020]

 This announcement provides advance notice that the Department of Human Services (Department) intends to revise its current rate methodology for the Living Independence for the Elderly (LIFE) sites operating under Medicare and Medicaid capitation Program of All-Inclusive Care for the Elderly (PACE) to be effective beginning Fiscal Year (FY) 2021-2022.

Proposed Methodology

 The Department will determine on an annual basis the rates paid to the PACE plans as a percentage of the amount that would have otherwise been paid (AWOP) (Formerly Upper Payment Limit). The AWOP is based on the current Medicaid delivery system costs derived from a comparable population (55 or older) of nursing facility and Home and Community-Based Services (HCBS) eligibles. To develop the AWOP, the data from sub-populations (Dually Eligible and Non-Dually Eligible) of nursing facility and HCBS clients are blended into the final AWOP.

 Paid Medicaid claims are the source data for the AWOP calculation. Detailed claims data is obtained from the State's Provider Reimbursement and Operations Management System. The AWOP percentage is determined annually after negotiation with the LIFE providers and consideration of differences between the Medicaid population from which the PACE AWOP is developed and the actual enrollment in the PACE plans, including relative acuity.

The following two groups are used to determine payment for PACE:

 Dually Eligible Individuals (Medicaid and Medicare)

 Non-Dually Eligible Individuals (Medicaid Only)

 The State assures Centers for Medicare & Medicaid Services (CMS) that the capitated rates are less than comparable Medicaid costs as defined by the PACE AWOP.

 The Department will submit a State Plan Amendment (SPA) to the CMS to request approval of the revised rate methodology. If CMS approves the SPA, the total funds will consist of both State and Federal funding.

Fiscal Impact

 There is no fiscal impact associated with this change in FY 2021-2022.

Public Comment

 Interested persons are invited to submit written comments regarding this change in methodology to the Department of Human Services, Office of Long-Term Living, Division of Integrated Care Programs, Attention: Jonathan Bowman, P.O. Box 8025, Harrisburg, PA 17105-8025 or at Comments received within 30 days will be reviewed and considered for any subsequent revision of the notice.

 Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).


Fiscal Note: 14-NOT-1401. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 20-1115. Filed for public inspection August 14, 2020, 9:00 a.m.]

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