[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR460.100]



[Page 430]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 460_PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)--Table 

of Contents

 

                         Subpart F_PACE Services

 

Sec. 460.100  Emergency care.



    (a) Written plan. A PACE organization must establish and maintain a 

written plan to handle emergency care. The plan must ensure that CMS, 

the State, and PACE participants are held harmless if the PACE 

organization does not pay for emergency services.

    (b) Emergency care. Emergency care is appropriate when services are 

needed immediately because of an injury or sudden illness and the time 

required to reach the PACE organization or one of its contract 

providers, would cause risk of permanent damage to the participant's 

health. Emergency services include inpatient and outpatient services 

that meet the following requirements:

    (1) Are furnished by a qualified emergency services provider, other 

than the PACE organization or one of its contract providers, either in 

or out of the PACE organization's service area.

    (2) Are needed to evaluate or stabilize an emergency medical 

condition.

    (c) An emergency medical condition means a condition manifesting 

itself by acute symptoms of sufficient severity (including severe pain) 

such that a prudent layperson, with an average knowledge of health and 

medicine, could reasonably expect the absence of immediate medical 

attention to result in the following:

    (1) Serious jeopardy to the health of the participant.

    (2) Serious impairment to bodily functions.

    (3) Serious dysfunction of any bodily organ or part.

    (d) Explanation to participant. The organization must ensure that 

the participant or caregiver, or both, understand when and how to get 

access to emergency services.

    (e) On-call providers. The plan must provide for the following:

    (1) An on-call provider, available 24-hours per day to address 

participant questions about emergency services and respond to requests 

for authorization of urgently needed out-of-network services and post 

stabilization care services following emergency services.

    (2) Coverage of urgently needed out-of-network and post-

stabilization care services when either of the following conditions are 

met:

    (i) The services are preapproved by the PACE organization.

    (ii) The services are not preapproved by the PACE organization 

because the PACE organization did not respond to a request for approval 

within 1 hour after being contacted or cannot be contacted for approval.