CMS Pub. 100-11, ch. 6, § 20

or Medicaid Services

(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)

If a Medicare beneficiary or Medicaid recipient chooses to enroll in a PACE program,

Medicare and Medicaid benefit limitations and conditions relating to amount, duration,

scope of services, deductibles, copayments, coinsurance, or other cost-sharing do not

apply. The amount, duration and scope of services provided to PACE participants are

participant-specific and are specified by the IDT in the plan of care. The scope of benefits

under PACE includes any other item or service determined necessary by the IDT to

improve and maintain the participant’s overall health status.

Under Sections 1894(a) and 1934(a) of the Act, PACE participants must receive

Medicare and Medicaid benefits solely through the PACE organization. PACE

organizations are required to provide enrollees with all medically necessary services,

including drugs, without any limitation or condition as to the amount, duration, or scope.

The PACE benefit includes all outpatient prescription drugs, as well as over-the-counter

medications indicated by the participant’s care plan. PACE programs cannot charge

deductibles, copayments, coinsurance or other cost-sharing for medications.

The PACE organization may contract with other providers for specialty medical or other

services to meet participant needs. The PACE organization must maintain primary

responsibility and accountability for participant care in all settings and for all provided

services. Refer to Chapter 9 for a description of PACE organization oversight

requirements for all services.

[42 CFR § 460.90; 71 FR 71248 and 71280 (Dec. 8, 2006)]