42 CFR 460.70 – Contracted services
(a) General rule. The PACE organization must have a written contract with each outside organization, agency, or individual that furnishes administrative or care-related services not furnished directly by the PACE organization, including, at a minimum, the medical specialties identified in paragraph (a)(1) of this section. The PACE organization does not need to have a written contract with entities that provide emergency services as described in § 460.100.
(1) At a minimum, except as noted in paragraph (a)(4) of this section, PACE organizations must have contracts in place for the following medical specialties:
(i) Anesthesiology.
(ii) Audiology.
(iii) Cardiology.
(iv) Dentistry.
(v) Dermatology.
(vi) Gastroenterology.
(vii) Gynecology.
(viii) Internal Medicine.
(ix) Nephrology.
(x) Neurosurgery.
(xi) Oncology.
(xii) Ophthalmology.
(xiii) Oral surgery.
(xiv) Orthopedic surgery.
(xv) Otorhinolaryngology.
(xvi) Palliative Medicine.
(xvii) Plastic surgery.
(xviii) Pharmacy consulting services.
(xix) Podiatry.
(xx) Psychiatry.
(xxi) Pulmonology.
(xxii) Radiology.
(xxiii) Rheumatology.
(xxiv) General Surgery.
(xxv) Thoracic and vascular surgery.
(xxvi) Urology.
(2) Contracts with medical specialists must be executed prior to enrollment of participants and must be maintained on an ongoing basis to ensure participants receive appropriate and timely access to all medically necessary care and services.
(3) A PACE organization is responsible for making all reasonable and timely attempts to contract with medical specialists. If at any time a PACE organization is unable to directly contract or maintain a contract with a specific specialty, the PACE organization must—
(i) Ensure care and services that would otherwise be provided to participants by a contracted specialist are provided and that the participant’s needs are met through a different mechanism to include hospitalization; and
(ii) Promptly report the contracting issue to CMS and the State Administering Agency, including the attempts made to contract, the reason why the contract was not effectuated, and the PACE organization’s plan to provide access to the necessary services.
(4) A PACE organization is not required to have a contract with a particular medical specialty if the PACE organization directly employs one or more individuals prior to contracting who are legally authorized, and if applicable, board certified in the particular medical specialty.
(b) Contract requirements. A contract between a PACE organization and a contractor must meet the following requirements:
(1) The PACE organization must contract only with an entity that meets all applicable Federal and State requirements, including, but not limited to, the following:
(i) An institutional contractor, such as a hospital or skilled nursing facility, must meet Medicare or Medicaid participation requirements.
(ii) A practitioner or supplier must meet Medicare or Medicaid requirements applicable to the services it furnishes.
(iii) A contractor must comply with the requirements of this part with respect to service delivery, participant rights, and quality improvement activities.
(2) A contractor must be accessible to participants, located either within or near the PACE organization’s service area.
(3) A PACE organization must designate an official liaison to coordinate activities between contractors and the organization.
(c) List of contractors. A current list of contractors must be on file at the PACE center and a copy must be provided to anyone upon request.
(d) Content of contract. Each contract must be in writing and include the following information:
(1) Name of contractor.
(2) Services furnished (including work schedule if appropriate).
(3) Payment rate and method.
(4) Terms of the contract, including beginning and ending dates, methods of extension, renegotiation, and termination.
(5) Contractor agreement to do the following:
(i) Furnish only those services authorized by the PACE interdisciplinary team.
(ii) Accept payment from the PACE organization as payment in full, and not bill participants, CMS, the State administering agency, or private insurers.
(iii) Hold harmless CMS, the State, and PACE participants if the PACE organization does not pay for services performed by the contractor in accordance with the contract.
(iv) Not assign the contract or delegate duties under the contract unless it obtains prior written approval from the PACE organization.
(v) Submit reports required by the PACE organization.
(6) With respect to an individual who is contracting as a program director or medical director or to be part of the interdisciplinary team as set forth at § 460.60(a) and (b) and § 460.102(b), the contract must specify that the individual agrees to:
(i) Perform all the duties related to its position as specified in this part.
(ii) Participate in interdisciplinary team meetings as required.
(iii) Be accountable to the PACE organization.
(iv) Cooperate with the competency evaluation program and direct participant care requirements specified in § 460.71.
(e) Contracting with another entity to furnish PACE center services. (1) A PACE organization may only contract for PACE center services if it is fiscally sound as defined in § 460.80(a) of this part and has demonstrated competence with the PACE model as evidenced by successful monitoring by CMS and the State administering agency.
(2) The PACE organization retains responsibility for all participants and may only contract for the PACE Center services identified in § 460.98(c).