6. Program benefits

317:35-18-6. Program benefits

Revised 9-1-21

(a) The PACE program offers a comprehensive benefit plan. A provider agency must provide a participant all the services listed in Section (') 460.92 of Title 42 of the Code of Federal Regulations (C.F.R.) that are approved by the interdisciplinary team (IDT). The PACE benefit package for all participants, regardless of the source of payment, must include but is not limited to the following:

(1) All SoonerCare-covered services, as specified in the State's approved Medicaid State Plan;

(2) IDT and treatment planning;

(3) Primary care, including physician and nursing services;

(4) Social work services;

(5) Restorative therapies, including physical therapy, occupational therapy, and speech-language pathology services;

(6) Personal care and supportive services;

(7) Nutritional counseling;

(8) Recreational therapy;

(9) Transportation;

(10) Meals;

(11) Medical specialty services including, but not limited to the following:

(A) Anesthesiology;

(B) Audiology;

(C) Cardiology;

(D) Dentistry;

(E) Dermatology;

(F) Gastroenterology;

(G) Gynecology;

(H) Internal medicine;

(I) Nephrology;

(J) Neurosurgery;

(K) Oncology;

(L) Ophthalmology;

(M) Oral surgery;

(N) Orthopedic surgery;

(O) Otorhinolaryngology;

(P) Plastic surgery;

(Q) Pharmacy consulting services;

(R) Podiatry;

(S) Psychiatry;

(T) Pulmonary disease;

(U) Radiology;

(V) Rheumatology;

(W) General surgery;

(X) Thoracic and vascular surgery; and

(Y) Urology.

(12) Laboratory tests, x-rays, and other diagnostic procedures;

(13) Drugs and biologicals;

(14) Prosthetics, orthotics, medical supplies, equipment, and appliances, corrective vision devices, such as eyeglasses and lenses, hearing aids, dentures, and repair and maintenance of these items;

(15) Acute inpatient care, including the following:

(A) Ambulance;

(B) Emergency room care and treatment room services;

(C) Semi-private room and board;

(D) General medical and nursing services;

(E) Medical surgical/intensive care/coronary care unit;

(F) Laboratory tests, x-rays, and other diagnostic procedures;

(G) Drugs and biologicals;

(H) Blood and blood derivatives;

(I) Surgical care, including the use of anesthesia;

(J) Use of oxygen;

(K) Physical, occupational, respiratory therapies, and speech-language pathology services; and

(L) Social services.

(16) Nursing facility (NF) care, including:

(A) Semi-private room and board;

(B) Physician and skilled nursing services;

(C) Custodial care;

(D) Personal care and assistance;

(E) Drugs and biologicals;

(F) Physical, occupational, recreational therapies, and speech-language pathology, if necessary;

(G) Social services; and

(H) Medical supplies, equipment, and appliances.

(17) Other services determined necessary by the IDT to improve and maintain the participant's overall health status.

(b) The following services are excluded from coverage under PACE:

(1) Any service that is not authorized by the IDT, even if it is a required service, unless it is an emergency service.

(2) In an inpatient facility, private room and private duty nursing (PDN) 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 IDT as part of the participant's plan of care).

(3) Cosmetic surgery, which does not include surgery that is required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction following mastectomy.

(4) Experimental medical, surgical, or other health procedures.

(5) Services furnished outside of the United States, except as follows:

(A) In accordance with 42 C.F.R. ' 424.122 through 42 C.F.R. ' 424.124, and

(B) As permitted under the State's approved Medicaid State Plan.

(c) In the event that a PACE participant is in need of permanent placement in a NF, a Medicaid premium will be imposed. OKDHS will calculate a vendor co-payment for those participants using the same methodology as is used for any Oklahoma Medicaid member who is accessing NF level of care. However, for a PACE participant, the participant's responsibility will be to make payment directly to the PACE provider, the amount to be specified by the OKDHS worker. There are no other share of costs requirements for PACE.

(d) All PACE program benefits are offered through the duration of the PACE participant's enrollment in the PACE program. PACE enrollment does not cease once a participant's condition necessitates or the PACE IDT recommends that he or she be institutionalized.