[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

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

[CITE: 42CFR460.40]



[Page 431]

 

                         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 

 

        Subpart D_Sanctions, Enforcement Actions, and Termination

 

Sec.  460.40  Violations for which CMS may impose sanctions.





    In addition to other remedies authorized by law, CMS may impose any 

of the sanctions specified in Sec. Sec.  460.42 and 460.46 if CMS 

determines that a PACE organization commits any of the following 

violations:

    (a) Fails substantially to provide to a participant medically 

necessary items and services that are covered PACE services, if the 

failure has adversely affected (or has substantial likelihood of 

adversely affecting) the participant.

    (b) Involuntarily disenrolls a participant in violation of Sec.  

460.164.

    (c) Discriminates in enrollment or disenrollment among Medicare 

beneficiaries or Medicaid recipients, or both, who are eligible to 

enroll in a PACE program, on the basis of an individual's health status 

or need for health care services.

    (d) Engages in any practice that would reasonably be expected to 

have the effect of denying or discouraging enrollment, except as 

permitted by Sec.  460.150, by Medicare beneficiaries or Medicaid 

recipients whose medical condition or history indicates a need for 

substantial future medical services.

    (e) Imposes charges on participants enrolled under Medicare or 

Medicaid for premiums in excess of the premiums permitted.

    (f) Misrepresents or falsifies information that is furnished--

    (1) To CMS or the State under this part; or

    (2) To an individual or any other entity under this part.

    (g) Prohibits or otherwise restricts a covered health care 

professional from advising a participant who is a patient of the 

professional about the participant's health status, medical care, or 

treatment for the participant's condition or disease, regardless of 

whether the PACE program provides benefits for that care or treatment, 

if the professional is acting within his or her lawful scope of 

practice.

    (h) Operates a physician incentive plan that does not meet the 

requirements of section 1876(i)(8) of the Act.

    (i) Employs or contracts with any individual who is excluded from 

participation in Medicare or Medicaid under section 1128 or section 

1128A of the Act (or with any entity that employs or contracts with that 

individual) for the provision of health care, utilization review, 

medical social work, or administrative services.