CMS Pub. 100-11, ch. 6, § 30

Emergency care is appropriate when services are needed immediately because of an

injury or sudden illness and the time required to reach the PACE organization, or one of

its contract providers, would cause risk of permanent damage to the participant’s health.

Emergency services include inpatient and outpatient services that meet the following

requirements:

• Are furnished by a qualified emergency services provider, other than the

PACE organization or one of its contract providers, either in or out of the

PACE organization’s service area;

• Are needed to evaluate or stabilize an emergency medical condition. An

emergency medical condition means a condition manifesting itself by acute

symptoms of sufficient severity (including severe pain) such that a prudent

layperson, with an average knowledge of health and medicine, could

reasonably expect the absence of immediate medical attention to result in

serious jeopardy to health of the participant, serious impairment to bodily

functions, or serious dysfunction of any bodily organ or part.

The organization must ensure that the participant or caregiver, or both, understand when

and how to access emergency services and that no prior authorization is needed.

A PACE organization must establish and maintain a written plan to handle emergency

care. The plan must ensure that CMS, the State, and PACE participants are held harmless

if the PACE organization does not pay for emergency services. The written plan also

must provide for an on-call provider to be available 24-hours per day to address

participant questions about emergency services and respond to requests for authorization

of urgently needed out-of-network services and post stabilization care services following

emergency services.

[42 CFR §§ 460.100(a), (b), (c), (d), and (e)(1)]