1. (1) The Participants Bill of Rights is to be written to promote and protect the rights of participants. Written policies and procedures are to be implemented to ensure that participants, their representatives, and PO staff understand the rights of the participant. Upon enrollment, a participant must be verbally informed of his or her rights and all rules and regulations regarding participation in the PACE program. These must also be provided in writing to the participant.
2. (2) The participants’ rights are to be written in English, as well as in any other language that is prominent in the area covered by the PO. The rights are to be displayed in a prominent location within the center.

3. (3) At a minimum, the rights for participants are to include the rights specified in 42 CFR 460.112. These rights include, but are not limited to:

   1. (a) Respect and nondiscrimination;
   2. (b) Disclosure of information;
   3. (c) Choice of providers within the PO network;
   4. (d) Access to emergency services;
   5. (e) Participation in decisions for treatment;
   6. (f) Confidentiality and protection of healthcare information;
   7. (g) Fair and efficient process for resolving complaints and appeals.
4. (4) The use of physical and/or chemical restraints, as described in 42 CFR 460.114, for a participant must be limited to the most effective and least restrictive restraint available for the safety of the participant or the safety of others. The decision to use restraints must be made by the Interdisciplinary Team. Use of any restraint must meet the conditions listed in §460.114. The participant’s condition must be assessed, monitored, and re-evaluated on a continuous basis until the restraints are removed.

5. (5) Written grievance procedures must be established by the PO to respond to and rectify a written or verbal complaint of a medical or nonmedical violation of a participant’s rights. Refer to §460.120 for the requirements of the grievance process to be included in the procedures.

   The procedures must be verbally explained and provided in writing to the participant upon enrollment into the PACE program and on an annual basis thereafter. Required services for the participant must continue to be provided during the grievance process

   The PO must maintain, aggregate, and analyze information on grievance proceedings for use in their internal quality assessment and performance improvement program.

6. (6) Written appeal procedures must be established by the PO regarding the non-coverage or non-payment of a service for a participant, including denials of services, reductions in services, and termination of services. Minimum requirements for the appeals procedures are listed in §460.122.

   The procedures are to be provided to the participant upon enrollment into the PACE program and on an annual basis thereafter, as well as at the time of any denial or non-payment of a service. All appropriate parties are to be provided written notification of the appeal of a participant and allowed sufficient time present evidence pertaining to the dispute. Guidelines for the continuation of services during the appeal process are provided in §460.122.

   A PO must have procedures in place to expedite the appeals process, as specified in §460.122, if a participant believes that his or her life, health, or ability to regain and or maintain maximum function are jeopardized without the service(s) in dispute.

   If the outcome of the appeal is in favor of the participant, the disputed service(s) is to be furnished by the PO as quickly as the health condition of the participant determines it is needed. If the outcome of the appeal is not in favor of the participant, in part or in whole, the PO must notify CMS, AMA, and the participant. The participant must also be notified in writing of the appeal rights under Medicare and/or Medicaid. If the participant wishes to appeal at that time, and both entities are applicable, the PO is to assist the participant in choosing which to pursue and is to forward the appeal to the appropriate entity (§460.124).

   The PO must maintain, aggregate, and analyze information on grievance proceedings for use in their internal quality assessment and performance improvement program.

Author: Linda Lackey, Medicaid Administrator, LTC Project Development Unit.

Statutory Authority: State Plan, Attachment 2.2-A, Attachment 3.1-A and Supplement 3; 42 CFR 460 Subpart G.

History: Emergency rule effective May 1, 1991. Permanent rule effective August 14, 1991. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed November 10, 2011; effective December 15, 2011.