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317:35-18-6. Program benefits
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Issued 7-1-06
(a) A provider agency must provide a participant all the services listed in 42 CFR 460.92 that are approved by the IDT. The PACE benefit package for all participants, regardless of the source of payment, must include but is not limited to the following:
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(1) All Medicaid-covered services, as specified in the State's approved Medicaid plan.
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(2) Interdisciplinary assessment and treatment planning.
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(3) Primary care, including physician and nursing services.
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(4) Social work services.
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(5) Restorative therapies, including physical therapy, occupational therapy, and speech-language pathology services.
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(6) Personal care and supportive services.
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(7) Nutritional counseling.
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(8) Recreational therapy.
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(9) Transportation.
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(10) Meals.
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(11) Medical specialty services including, but not limited to the following:
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(12) Laboratory tests, x-rays and other diagnostic procedures.
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(13) Drugs and biologicals.
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(14) Prosthetics, orthotics, durable medical equipment, corrective vision devices, such as eyeglasses and lenses, hearing aids, dentures, and repair and maintenance of these items.
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(15) Acute inpatient care, including the following:
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(A) Ambulance.
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(B) Emergency room care and treatment room services.
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(C) Semi-private room and board.
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(D) General medical and nursing services.
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(E) Medical surgical/intensive care/coronary care unit.
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(F) Laboratory tests, x-rays and other diagnostic procedures.
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(G) Drugs and biologicals.
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(H) Blood and blood derivatives.
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(I) Surgical care, including the use of anesthesia.
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(J) Use of oxygen.
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(K) Physical, occupational, respiratory therapies, and speech-language pathology services.
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(L) Social services.
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(16) Nursing facility care including:
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(A) Semi-private room and board;
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(B) Physician and skilled nursing services;
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(C) Custodial care;
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(D) Personal care and assistance;
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(E) Drugs and biologicals;
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(F) Physical, occupational, recreational therapies, and speech-language pathology, if necessary;
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(G) Social services; and
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(H) Medical supplies and appliances.
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(17) Other services determined necessary by the interdisciplinary team to improve and maintain the participant's overall health status.
(b) The following services are excluded from coverage under PACE:
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(1) Any service that is not authorized by the interdisciplinary team, even if it is a required service, unless it is an emergency service.
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(2) In an inpatient facility, private room and private duty nursing services (unless medically necessary), and non-medical items for personal convenience such as telephone charges and radio or television rental (unless specifically authorized by the interdisciplinary team as part of the participant's plan of care).
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(3) Cosmetic surgery, which does not include surgery that is required for improved functioning of a malformed part of the body resulting fran an accidental injury or for reconstruction following mastectomy.
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(4) Experimental medical, surgical, or other health procedures.
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(5) Services furnished outside of the United States, except as follows:
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