CMS Pub. 100-11, ch. 16, § 30

There are specific violations for which CMS may impose sanctions on the PACE

organization and they are as follows:

• The PACE organization fails substantially in furnishing the medically

necessary items and services to the participant that are covered by PACE if

the failure has adversely affected (or has a substantial likelihood of adversely

affecting) the participant;

• The PACE organization involuntary disenrolls a participant in violation of 42

CFR § 460.164;

• The PACE organization discriminates on the basis of an individual’s health

status or need for health care services in the enrollment or disenrollment

process, among Medicare beneficiaries or Medicaid recipients, or both, who

are eligible to enroll in a PACE program;

• The PACE organization engages in any practice that would reasonably be

expected to have the effect of denying or discouraging enrollment, except as

permitted by 42 CFR § 460.150 by Medicare beneficiaries or Medicaid

recipients whose medical condition or history indicates a need for substantial

future medical services;

• The PACE organization imposes premium charges on a participant enrolled

under Medicare or Medicaid that is more than the allowable amount;

• The PACE organization misrepresents or falsifies information that is

furnished to CMS or the State or, to an individual or any other entity under

Part 460;

• The PACE organization prohibits or restricts a covered healthcare

professional, who is acting within their lawful scope of practice, from

advising a participant (their patient) about the patient’s health status, medical

care, or treatment for the participant’s condition or disease, regardless of

whether the PACE program provides the benefits for that care or treatment;

• The PACE organization operates a physician incentive plan that does not meet

the requirements of Section 1876(i)(8) of the Act;

• The PACE organization employs or contracts with any individual who is

excluded from participation in Medicare or Medicaid under Section 1128 or

1128A of the Act (or with any entity that employs or contracts with such an

individual) for the provision of health care, utilization review, medical social

work, or administrative services.

[42 CFR § 460.40]