Section 350. PACE enrollee responsibilities

A. Enrollees shall access services through an assigned PCP. Enrollees shall be given the opportunity to choose a PCP affiliated with the applicable PACE provider. In the event an enrollee fails to choose a PCP, one shall be assigned by the provider.

B. Enrollees shall be responsible for copayments, if any.

C. Enrollees shall raise complaints relating to PACE plan coverage and services directly with the PACE provider. The provider shall have a DMAS-approved enrollee complaint process in place at all times.

D. Enrollees shall raise complaints pertaining to Medicaid eligibility and PACE plan eligibility directly to DMAS. These complaints shall be considered under DMAS' Client Appeals regulations (12VAC30-110).

E. The PACE provider shall have a grievance process in place including procedures for filing an enrollee's grievance, documenting the grievance, responding to and resolving the grievance in a timely manner, and maintaining confidentiality of the agreement pursuant to 42 CFR 460.120.

Historical Notes

Derived from Volume 25, Issue 08, eff. February 5, 2009.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396.