Last modified on February 19th, 2025 at 05:32 pm
Eligibility
We Provide Preventative, Primary, Acute, and Long-term Care Services So That Older Adults Can Continue Living Safely Independently.
PACE (Program of All-Inclusive Care for the Elderly) eligibility is determined by specific PACE enrollment criteria as dictated by the Maryland and the Centers for Medicare and Medicaid Services.
To Be Eligible For PACE, You Must:
• Be at least 55 or older
• Live in the Senior CommUnity Care of Maryland service care area
• Are certified as needing a nursing home level of care (as determined by the state)
• Can safely live in the community with PACE services at the time of enrollment
Service Area
Senior CommUnity Care of Maryland provides services to seniors living in the following counties:
Prince George’s County
Enrollment
Intake: To discuss whether Senior CommUnity Care is right for you or a family member, call us today at 301.673.3335 TDD/TTY Number: 711 or 800-735-2258 If you are interested in the program, one of our Enrollment Coordinators will schedule an intake over the phone or in your home to assess your needs, answer your questions and explain the benefits we offer.
Assessment: After the intake is completed, we will invite you to our Center and conduct a clinical assessment with the doctor, nurses and other interdisciplinary team members.
Care Plan: After the clinical assessment, a custom care plan will be developed with you. We will review the care plan, and discuss the best care options.
Our Enrollment team will complete the enrollment paperwork for you to become a participant. Enrollment is voluntary. You may dis-enroll at any time by notifying the Senior CommUnity Care of Maryland staff member.
Who Pays?
Senior CommUnity Care of Maryland services are paid for by Medicare, Medicaid or private payment. If you are eligible for Medicaid and depending on your income, PACE services are free of charge. If your income is over the income limits of Medicaid, you may still be eligible to participate by paying a premium or a Patient Monthly Liability. We can help explain these payment options. Once a participant is enrolled, our experts handle the paperwork and claims for services you receive. Participants must follow the care plan designed by our care team. Participants may be personally liable for the costs of unauthorized or out-of-program services, except for emergency services.
Participant’s Bill of Rights
Your Rights In The Program Of All-Inclusive Care For The Elderly
The Program of All-inclusive Care for the Elderly (PACE) is a special program that combines medical and long-term care services in a community setting. Your PACE program must fully explain your rights to you or someone acting on your behalf in a way you can understand at the time you join.
Your Rights in the Programs of All-Inclusive Care for the Elderly
When you join a PACE program, you have certain rights and protections. Senior CommUnity Care of Maryland, as your PACE program, must fully explain and provide your rights to you or someone acting on your behalf in a way you can understand at the time you join.
At Senior CommUnity Care of Maryland, we are dedicated to providing you with quality health care services so that you may remain as independent as possible. This includes providing all Medicaid and Medicare-covered items and services, and other services determined to be necessary by the interdisciplinary team across all care settings, 24 hours a day,7 days a week.
Our staff and contractors seek to affirm the dignity and worth of each participant by assuring the following rights:
You have the right to treatment.
You have the right to treatment that is both appropriate for your health conditions and provided in a timely manner. You have the right:
• To receive all the care and services you need to improve or maintain your overall health condition, and to achieve the best possible physical, emotional, and social well-being.
• To get emergency services when and where you need them without the PACE program’s approval. A medical emergency is when you think your health is in serious danger— when every second counts. You may have a bad injury, sudden illness or an illness quickly getting much worse. You can get emergency care anywhere in the United States and you do not need to get permission from Senior CommUnity Care of Maryland prior to seeking emergency services.
You have the right to be treated with respect.
You have the right to be treated with dignity and respect at all times, to have all of your care kept private and confidential, and to get compassionate, considerate care. You have the right:
• To get all of your health care in a safe, clean environment and in an accessible manner.
• To be free from harm. This includes excessive medication, physical or mental abuse, neglect, physical punishment, being placed by yourself against your will, and any physical or chemical restraint that is used on you for discipline or convenience of staff and that you do not need to treat your medical symptoms.
• To be encouraged and helped to use your rights in the PACE program.
• To get help, if you need it, to use the Medicare and Medicaid complaint and appeal processes, and your civil and other legal rights.
• To be encouraged and helped in talking to PACE staff about changes in policy and services you think should be made.
• To use a telephone while at the PACE center.
• To not have to do work or services for the PACE program.
• To have all information about your choices for PACE services and treatment explained to you in a language you understand, and in a way that takes into account and respects your cultural beliefs, values, and customs.
You have a right to protection against discrimination.
Discrimination is against the law. Every company or agency that works with Medicare and Medicaid must obey the law. They cannot discriminate against you because of your:
• Race
• Ethnicity
• National Origin
• Religion
• Age
• Sex
• Mental or physical disability
• Sexual Orientation
• Source of payment for your health care (For example, Medicare or Medicaid)
If you think you have been discriminated against for any of these reasons, contact a staff member at the PACE program to help you resolve your problem.
If you have any questions, you can call the Office for Civil Rights at 1-800-368-1019. TTY users should call 1-800-537-7697.
You have a right to information and assistance.
You have the right to get accurate, easy-to-understand information, to have this information shared with your designated representative, who is the person you choose to act on your behalf, and to have someone help you make informed health care decisions. You have the right:
• To have someone help you if you have a language or communication barrier so you can understand all information given to you.
• To have the PACE program interpret the information into your preferred language in a culturally competent manner, if your first language is not English and you can’t speak English well enough to understand the information being given to you.
• To get marketing materials and PACE participant rights in English and in any other frequently used language in your community. You can also get these materials in Braille, if necessary.
• To have the enrollment agreement fully explained to you in a manner understood by you.
• To get a written copy of your rights from the PACE program. The PACE program must also post these rights in a public place in the PACE center where it is easy to see them.
• To be fully informed, in writing, of the services offered by the PACE program. This includes telling you which services are provided by contractors instead of the PACE staff. You must be given this information before you join, at the time you join, and when you need to make a choice about what services to receive.
• To be provided with a copy of individuals who provide care-related services not provided directly by Senior CommUnity Care of Maryland upon request.
• To look at, or get help to look at, the results of the most recent review of your PACE program. Federal and State agencies review all PACE programs. You also have a right to review how the PACE program plans to correct any problems that are found at inspection.
Before Senior CommUnity Care of Maryland starts providing palliative care, comfort care, and end-of-life care services, you have the right to have information about these services fully explained to you. This includes your right to be given, in writing, a complete description of these services and how they are different from the care you have been receiving, and whether these services are in addition to, or instead of, your current services. The information must also explain, in detail, how your current services will be affected if you choose to begin palliative care, comfort care, or end-of-life services. Specifically, it must explain any impact to:
• Physician services, including specialist services.
• Hospital services
• Long-term care services
• Nursing services
• Social services
• Dietary services
• Transportation
• Home care
• Therapy, including physical, occupational, and speech therapy
• Behavioral health
• Diagnostic testing, including imaging and laboratory services
• Medications
• Preventative healthcare services
• PACE center attendance
You have the right to change your mind and take back your consent to receive palliative care, comfort care, or end-of-life care services at any time and for any reason by letting Senior CommUnity Care of Maryland know either verbally or in writing.
You have a right to a choice of providers.
You have the right to choose a health care provider, including your primary care provider and specialists, from within the PACE program’s network and to get quality health care. Women have the right to get services from a qualified women’s health care specialist for routine or preventive women’s health care services.
You have the right to have reasonable and timely access to specialists as indicated by your health condition.
You also have the right to receive care across all care settings, up to and including placement in a long-term care facility when Senior CommUnity Care of Maryland can no longer maintain you safely in the community.
You have a right to participate in treatment decisions.
You have the right to fully participate in all decisions related to your health care. If you cannot fully participate in your treatment decisions or you want to have someone you trust help you, you have the right to choose that person to act on your behalf as your designated representative. You have the right:
• To be fully informed of your health status and how well you are doing, to make health care decisions, and to have all treatment options fully explained to you. This includes the right not to get treatment or take medications. If you choose not to get treatment, you must be told how this may affect your physical and mental health.
• To fully understand Senior CommUnity Care of Maryland’s palliative care, comfort care, and end-of-life care services. Before Senior CommUnity Care of Maryland can start providing you with palliative care, comfort care, and end-of-life care services, the PACE program must explain all of your treatment options, give you written information about these options, and get written consent from you or your designated representative.
• To have the PACE program help you create an advance directive, if you choose. An advance directive is a written document that says how you want medical decisions to be made in case you cannot speak for yourself. You should give it to the person who will
carry out your instructions and make health care decisions for you. • To participate in making and carrying out your plan of care. You can ask for your plan of care to be reviewed at any time.
• To be given advance notice, in writing, of any plan to move you to another treatment setting and the reason you are being moved.
You have a right to have your health information kept private.
• You have the right to talk with health care providers in private and to have your personal health care information kept private and confidential, including health data that is collected and kept electronically, as protected under State and Federal laws.
• You have the right to look at and receive copies of your medical records and request amendments.
• You have the right to be assured that your written consent will be obtained for the release of information to persons not otherwise authorized under law to receive it.
• You have the right to provide written consent that limits the degree of information and the persons to whom information may be given.
There is a patient privacy rule that gives you more access to your own medical records and more control over how your personal health information is used. If you have any questions about this privacy rule, call the Office for Civil Rights at 1-800-368-1019. TTY users should call 1-800- 537- 7697.
You have a right to make a complaint.
You have a right to complain about the services you receive or that you need and don’t receive, the quality of your care, or any other concerns or problems you have with your PACE program. You have the right to a fair and timely process for resolving concerns with your PACE program. You have the right:
• To a full explanation of the complaint process.
• To be encouraged and helped to freely explain your complaints to PACE staff and outside representatives of your choice. You must not be harmed in any way for telling someone your concerns. This includes being punished, threatened, or discriminated against.
• To contact 1-800-Medicare for information and assistance, including to make a complaint related to the quality of care or the delivery of a service.
You have the right to request additional services or file an appeal.
You have the right to request services from Senior CommUnity Care of Maryland, its employees, or contractors, that you believe are necessary. You have the right to a comprehensive and timely process for determining whether those services should be provided.
You also have the right to appeal any denial of a service or treatment decision by the PACE program, staff, or contractors.
You have a right to leave the program.
If, for any reason, you do not feel that the PACE program is what you want, you have the right to leave the program at any time and have such disenrollment be effective the first day of the month following the date Senior CommUnity Care of Maryland receives your notice of voluntary disenrollment.
Additional Help:
If you have complaints about your PACE program, think your rights have been violated, or want to talk with someone outside your PACE program about your concerns, call 1-800-MEDICARE (1-800-633-4227) to get the name and phone number of someone in your State Administering Agency.
Grievances and Appeals
Our Participant Grievance and Appeal Process is Outlined Below
I. Grievance Process
A grievance is defined as a written or oral expression of dissatisfaction with service delivery or quality of care furnished. VOANS Senior CommUnity Care of Maryland shares the responsibility for assuring you are satisfied with the care you receive.
We understand that sometimes there are areas of dissatisfaction that require our attention and response. If you are dissatisfied, we encourage you to express any complaints or concerns you may have. If you do not speak English, a staff member, professional, or volunteer who speaks your language will facilitate the grievance process.
Senior CommUnity Care of Maryland will discuss the grievance with you and provide you with written information about the specific steps that will take place to resolve your grievance. You can discuss your concerns or send a letter expressing them to any member of the staff or administration of Senior CommUnity Care of Maryland. All services will be continued during the grievance process.
The staff member who receives your grievance will forward it to the Senior CommUnity Care of Maryland Quality Assurance Department and see that action is taken. You will receive a written acknowledgment of the grievance within five (5) working days of receiving it.
If a solution is found by the staff and agreed upon by you, your family, or significant other within thirty (30) working days, the grievance will be considered resolved.
If you are not satisfied with the outcome, you may take your grievance to the Executive Director or send it in writing to:
Executive Director
VOANS Senior CommUnity Care of Maryland
831 Brightseat Rd, Hyattsville, MD 20785
301.673.3335 | TDD/TTY Number: 711 or 800-735-2258
MD*******@*oa.org
This must be done within thirty (30 days) of the final decision of your original grievance.
The Senior CommUnity Care of Maryland Executive Director will send a written acknowledgment of receipt of the grievance within five (5) business days to you, your family, or your significant other. The Senior CommUnity Care of Maryland Executive Director will then investigate and take action.
The grievance should be resolved within thirty (30) days from the date it was received by the Senior CommUnity Care of Maryland Executive Director. Following the resolution of the grievance, a copy of the report will be sent to you or your representative.
II. Appeals Process
An appeal is defined as a participant’s and/or representative’s action concerning VOANS Senior CommUnity Care of Maryland’s non-coverage of or non-payment for denials, reductions, or termination of services.
If Senior CommUnity Care of Maryland decides not to cover a service you requested and you don’t agree with that decision, you can ask us to change it. This request is called an “appeal.” You have the right to appeal any decision we make to deny, reduce, or stop services you believe should be covered or to pay for services you think we should cover. You can make your appeal either verbally or in writing. You will be given written information on the appeals process when you enroll, at least annually after that, and whenever we deny or partially deny a request for services or payment. You or your family or caregiver may request information on our appeal process at any time.
If Senior CommUnity Care of Maryland denies a service or payment for a service that you or your representative have requested or denies a request to modify or continue a service you were already receiving, you may appeal the decision. A written notification will be provided to you and/or your representative that will explain the reason for the denial of your service request or request for payment, and you will also receive verbal notification. You, or your family, caregiver, or designated representative, may file an appeal by:
- Sending an email to MD*******@*oa.org
- Verbally informing a member of the Senior CommUnity Care of Maryland Care Team
- Telephoning the PACE Center at 301-673-3335 between the hours of 8:30 am to 4:30 pm and indicating your desire to file an appeal[CA(2] . For the hearing impaired (TTY/TDD), please dial 711 OR 800-735-2258
- Sending a written letter to Senior CommUnity Care of Maryland at the following address:
Senior CommUnity Care of Maryland
831 Brightseat Rd Hyattsville, MD 20785[CA(3]
Attention: Quality Department
Your appeal will be reviewed by an impartial third party who is appropriately credentialed in the field(s) or discipline(s) related to your appeal and who was not involved in the initial decision. The third-party reviewer or committee will be unbiased, appropriately qualified, and will not have a stake in the outcome of the appeal. You, your family, caregiver, or designated representative may present or submit relevant facts and/or evidence to us in person, as well as in writing, for review and consideration during the appeal process.
A decision will be made on your appeal as quickly as your health condition requires but no later than 30 calendar days after we receive your request for an appeal.
If you believe your life, health or ability to regain or maintain maximum function will be seriously in danger if the appealed service is not provided, you may request an expedited appeal. The third-party reviewer will review your case immediately and respond back to you as quickly as your health condition requires but no later than 72 hours after receiving your appeal.
We may extend this timeframe by up to 14 calendar days if you request the extension, or if we can justify to the Maryland Department of Health (MDH) the need for additional information and how it would be to your benefit.
If you file an appeal, you will continue to receive the same health care services as before you filed the appeal. If you have Medicaid and your appeal is because we are proposing to reduce or stop a service you have been receiving, you can request to continue to receive the service during the appeal. However, if the result of the appeal is not in your favor, you may be responsible for payment of the services in question. Senior CommUnity Care of Maryland employees will not discuss your appeal with anyone not involved in investigating your appeal.
THE DECISION ON YOUR APPEAL
Whether you submit a standard appeal or an expedited appeal, you will be notified in writing of the decision on your appeal. If the decision is favorable to you, we will notify you and arrange for you to get the appealed service or payment as quickly as your health condition requires.
If the decision is not fully in your favor, your written notification will include the specific reason(s) for the denial, an explanation as to why the service would not improve or maintain your overall health, information about your right to appeal the decision, and a description of your external appeal rights. We are also required to notify the federal Centers for Medicare and Medicaid Services (CMS) and MDH.
EXTERNAL APPEALS
If Senior CommUnity Care of Maryland does not decide fully in your favor for the appeal of a service or payment of a service, you have the right to an additional appeal called an external appeal.
You must complete the Senior CommUnity Care of Maryland appeal process before filing an external appeal. Your request to file an external appeal can be made either verbally or in writing. The Care Team at Senior CommUnity Care of Maryland will assist you in filing your external appeal.
The next level of appeal involves a new and impartial review of your case through either the Medicare or Medicaid program. The Medicare program contracts with an independent review entity to provide an external review of appeals involving PACE organizations. This review organization is completely independent of Senior CommUnity Care of Maryland.
The Medicaid program conducts their next level of appeal through the state’s fair hearing process. Until you receive the final decision, you may choose to continue to receive these appealed services; however, you may have to pay for these services if the decision is not in your favor. (Please see details below under Medicaid Appeals)
If you are enrolled in both Medicare and Medicaid, you may choose which appeals process you wish to follow. If you are not sure which program applies to you, ask us. You must choose either Medicare review or Medicaid fair hearing process. The External Appeal may only be made to one or the other (Medicare or Medicaid) but not both. Senior CommUnity Care of Maryland can help you choose which external Appeals process to pursue.
MEDICARE APPEALS
If you are enrolled in both Medicare and Medicaid (dual eligible) OR Medicare only, you may choose to file an external appeal through Medicare’s external appeal process, which consists of sending your appeal to an independent review entity that Medicare has designated as the agency for reviewing external appeals. A written request for reconsideration must be filed with the independent review entity within 60 calendar days from the date of the decision by the third-party reviewer. This independent review entity will either maintain our original decision or change our decision and rule in your favor.
MEDICAID APPEALS
If you are enrolled in both Medicaid and Medicare (dually eligible) OR Medicaid only, you can choose file an external appeal through Medicaid using the fair hearing process. You or your authorized representative must send an appeal request within 90 calendar days of receipt of the notification of a full or partial denial by the third-party reviewer. If the issue involves a reduction in your current level of services or termination of a service, and you file an appeal within 10 calendar days of the date of the notice, you may continue to receive services during the appeal process. However, if this action is upheld by the Office of Administrative Hearings, you may be required to reimburse Senior CommUnity Care of Maryland for the cost of services paid on your behalf during the appeal period.
Medicaid appeals may be filed by mail, fax, or email to:
Maryland Department of Health Attention: Appeals
201 West Preston St., 5th floor Baltimore, MD 21201
md*****************@******nd.gov
Fax: (410) 333-5154
The Office of Administrative Hearings will respond with a written notice informing you of the result of your appeal.
