CMS Pub. 100-11, ch. 9, § 40

Authorization is required for services a participant may need while temporarily absent

from the PACE organization’s service area that are not emergency services but cannot be

delayed until the participant returns.

A PACE organization must establish a written plan for handling emergency health care

needs. The plan must include that the participants and their caregiver know:

• When and how to access emergency services;

• That no prior approval is necessary for emergency services;

• That CMS, the State and PACE participants are held harmless for emergency

services;

• That the PACE organization must provide for availability of on-call providers

to address any participant questions about accessing emergency services and

respond to requests for authorization of urgently needed out-of network

services or post-stabilization.

Listed below are the types of services that fall under this special rule category:

• 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 a network provider would cause the risk of permanent damage

to the participant’s health. Thus, emergency care services include inpatient

and outpatient services, 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 and that are needed to evaluate or

stabilize an emergency medical condition. Emergency services that fall within

this description do not require authorization by the PACE organization.

Determination of the need for emergency care is dependent on the prudent

layperson standard with average knowledge of health and medicine;

• Urgent care means the care provided to a PACE participant who is out of the

PACE services 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. Participants are expected to seek prior

approval from the PACE organization in order for urgent care services to be

covered by the PACE organization;

• 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. Prior approval of these services is

intended to ensure efficient and timely coordination of appropriate post

emergency care by the IDT. In order to ensure that unforeseen circumstances

do not result in delays in needed care, CMS clarified that the PACE

organization must cover urgently needed out-of-network or post-stabilization

care services if it does not respond to a request for approval within one hour

after being contacted or cannot be contacted for approval.

[42 CFR § 460.100(b), (c), (d) and (e); 71 FR 71284 (Dec. 8, 2006)]