US · guidance
CMS Pub. 100-11, ch. 6, § 40
Urgently Needed and Post Stabilization Care
Urgent care means the care provided to a PACE participant who is out of the PACE
service area, and who believes their illness or injury is too severe to postpone treatment
until they return to the service area, but their life or functioning is not in severe jeopardy.
Post-stabilization care means services provided subsequent to an emergency that a
treating physician views as medically necessary after an emergency medical condition
has been stabilized. They are not emergency services, which PACE organizations are
obligated to cover. Rather, they are non-emergency services that the PACE organization
should approve before they are provided outside of the service area.
The PACE organization must establish and maintain a written plan which provides for
coverage of urgently needed out-of-network and post-stabilization care services when
either of the following conditions is met:
• The services are preapproved by the PACE organization; or
• The services are not preapproved by the PACE organization because the
PACE organization did not respond to a request for approval within one hour
after being contacted or cannot be contacted for approval.
An on-call provider must 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.
Periodic education of participants is necessary to ensure they and their caretakers can
distinguish between urgent and emergent care needs, and to emphasize that PACE
authorization is never required before seeking emergency care. The PACE organization
needs to educate its participants in the difference between emergency care (where prior
authorization is not required), and urgent care (where prior authorization is appropriate).
Participants need to understand when to request prior authorization and when to request
urgent care.
[42 CFR §§ 460.100(e)(2) and (3); 71 FR 71284 and 71297 (Dec. 8, 2006)]
History
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
2aec6889bdbd17e23e83570559a74817a51950ed84bf7c1b536fb5c08b4fcb14
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.