PACE in St. Louis

New Horizons PACE services accepts Medicare, Medicaid, or private payment. If you are eligible for Medicaid, our enrollment team will assist in determining if you will have a monthly premium and explain payment options.

• What you pay for PACE depends on your eligibility under Medicare and Medicaid.
• If you are eligible for Medicaid, or dually eligible for both Medicare and Medicaid, you won’t pay a monthly premium for PACE.

Once enrolled, our team handles all paperwork and claims.

An appeal is a participant’s action taken with respect to New Horizons PACE’s decision not to cover or pay for a service, including denials, reduction, or termination of services. A request to initiate, modify or continue service must first be processed as a service determination request before New Horizons PACE can process an appeal.

If you disagree with a denial or partial denial of a service determination request made by the New Horizons PACE, you may file an appeal. The service determination request is the first step of the appeals process.

If a service determination request is denied or partially denied you will receive the following: Verbal and written reasons for the denial including:

– Why the service is not necessary to maintain or improve your overall health status, considering your medical, physical, emotional and social needs.
– The results of the interdisciplinary team member’s reassessment in an understandable language.
– Your right to appeal the decision under the appeals process.

New Horizons PACE provides written instructions of our appeal process. You will be given this at the time of your enrollment. You will also be given this yearly and on every occasion the interdisciplinary team denies, reduces, or suspends a service. Adaptive, interpretive, and translation services will be available to assist you if you have vision or hearing impairment or do not speak English.

If you do not speak English, a bilingual interpreter, or translation service will be available to assist you. The appeals process can be complex but remember that your New Horizons PACE interdisciplinary team is available to help.

A standard appeal is the most common type of appeal. A standard appeal is not considered to be urgent in nature. All standard appeals will be resolved as quickly as is required by the condition of your health. Standard appeals will be resolved within 30 calendar days from when we received your appeal.

An expedited appeal is used only if you believe that your life, health, or ability to regain or maintain maximum function will be seriously at risk by waiting 30 calendar days for the decision.

If your request for an expedited appeal does not rise to this level, it will be considered a standard appeal. Expedited appeals are resolved as quickly as your health condition requires, but no later than 72 hours after receipt.

New Horizons PACE may extend the time up to 14 calendar days if we can show that additional time is needed to the State of Missouri (MO HealthNet) in order for us to collect information and it is in your best interest to take the additional time. You can also request us to extend the time.

You will receive verbal and written notification of the denial or partial denial of service determination request from a New Horizons PACE interdisciplinary team member, you may request an appeal at that time by telling a staff member, telephoning the PACE Center at 314-897-7223 (TTY: 711) or by writing a letter and mailing/faxing it to:

New Horizons PACE
Director of Quality and Compliance
5035 Manchester Ave.
St. Louis, MO 63110
Fax: 314-558-6021

New Horizons PACE will respond to your request for an appeal as quickly as possible. You or your designated representative will be notified of our decision to approve or deny the appeal as quickly as your condition requires. For a standard appeal- no later than 30 calendar days. For an Expedited appeal no later than 72 hours of the decision. New Horizons PACE’s starts the appeal s process when appeal is received.

You have the right to file an appeal if New Horizons PACE:

– Denies or partially denies your service determination request or enrollment.

You or your designated representative can file a standard or expedited appeal verbally or in writing. We suggest requesting an Appeal Submission Form from New Horizons PACE staff. You may also file an appeal in a letter. If you need assistance putting your appeal in writing, please ask for help from one of your interdisciplinary team members.

When a standard appeal has been filed, New Horizons PACE will work with you and do our best to address your concerns with a solution that satisfies all parties involved.

The appeals process includes:

A reasonable opportunity for you to present evidence related to the disputed service, in person, as well as in writing.

A review of an appeal by an appropriate third-party reviewer or committee. An appropriate third-party reviewer or member of a review committee must be a person who meets the following:

– Have specialized certification (credentialing) in the field related to the appeal.
– Was not involved in the original service determination request process.
– Does not have a stake in the outcome of the appeal.

All appeals and documentation related to the appeal remains confidential.

Appeals can be either in your favor (approved, upheld, agreed to) or not in your favor (denied, not in agreement). Notice of any favorable decision must explain the conditions of the approval in an understandable language. If we decide in your favor on a standard appeal, we will provide or arrange for services as quickly as your health condition requires, but in no later than thirty (30) calendar days from your initial request for an appeal.

If New Horizons PACE decides in your favor on an expedited appeal, we will give permission for you to get the service or provide the service as quickly as your health condition requires, but no later than 72 hours from your initial request for an appeal.
If New Horizons PACE does not decide in your favor on a standard or expedited appeal, you have a right to file an external appeal. New Horizons PACE will notify you, the Centers for Medicare and Medicaid Services (CMS), and MO HealthNet in writing of the denial or partial denial of the appeal. Notice of the partially or fully adverse decision must:

– State the specific reason(s) for the denial.
– State the specific reason(s) why the service would not improve or maintain the participant’s overall health status.
– Inform the participant of his or her right to appeal the decision; and
– Describe the external appeal rights listed below including the Medicare Appeal and Medicaid Appeal process

If you receive Medicaid, New Horizons PACE will continue to furnish the disputed services until the decision if the final determination of the appeal is made if the following conditions are met:

– New Horizons PACE must continue to furnish to the participant all other required services.
– New Horizons PACE is proposing to terminate or reduce services currently being furnished to you.
– You request the continuation of the services being furnished by New Horizons PACE and that you may be liable for the costs of the disputed services if the appeal decision is not in your favor.

Additional Appeal Rights

New Horizons PACE will help you or your designated representative to file an appeal for Medicare or Medicaid. The process you choose depends upon whether you are eligible for Medicaid only, Medicare and Medicaid (dually eligible), Medicare only or pay privately for New Horizons PACE’s services. If you are enrolled in Medicaid only and are appealing a Denial of Enrollment or an Involuntary Disenrollment, you can appeal at any time during the appeals process by contacting:

MO HealthNet Division Attn: Participant Appeals
615 Howerton Court, 2nd Floor
Jefferson City, MO 65109

If you are enrolled in Medicare only, you may appeal using Medicare’s external appeal process as described in Option 1 below.

If you are enrolled in Medicaid and Medicare, we will help you choose which appeals process you should follow as you can choose only one process. If you are enrolled in Medicaid ONLY you can appeal at any time during the appeals process using the State’s Fair Hearing Process.

If you are not sure which program(s) you are eligible for, you may call New Horizons PACE at (833) 654 -7223 (TTY: 711) for assistance.

Medicare Appeal
If you are currently enrolled in New Horizons PACE and enrolled in both Medicare and Medicaid or Medicare only, you may choose to appeal using Medicare’s external appeals process.

The federal Medicare program contracts with an Independent Review Entity (IRE) to provide external review on appeals involving PACE programs. This review organization is completely independent of New Horizons PACE. We will send your case file to Medicare’s IRE for you within 60 calendar days from the date of the decision by the third-party reviewer.

The IRE will conduct the review as expeditiously as your health condition requires:

– 72 hours or up to 17 calendar days in certain cases, for an expedited review.
– 30 to 44 calendar days for healthcare you are waiting for.
– 30 to 60 calendar days for payment of a denied bill.

If the IRE disagrees with New Horizons PACE (over turns the denial), the IRE will send you a letter and a letter to New Horizons PACE telling New Horizons PACE to pay for or provide for services requested in the appeal.

If the IRE agrees with New Horizons PACE’s original decision (upholds the denial of the appeal) the IRE will send you a letter to tell you what you can do.

Medicaid Appeal

NEW HORIZONS PACE operates as your MO HealthNet Medicaid benefit provider under the Missouri Department of Social Services. If you would like a further appeal after a negative decision of a New Horizons PACE appeal, you may have the right to a hearing with the Division of Legal Services.

The hearing may be your only opportunity to present evidence and show why you believe the wrong decision was made. The Hearings Unit can only use the evidence provided during the hearing in their decision. The Hearings Unit cannot discuss the facts of your case before or after the hearing.

Please click here to fill out the CMS Appointment Representative Form. By clinking this link, you are acknowledging that you are leaving the New Horizons PACE website.

A grievance is defined as a complaint, which you can make either verbally or in writing, expressing dissatisfaction with the services provided or the quality of your care.

All grievances will be kept confidential. New Horizons PACE will continue to provide all required services during the grievance process. New Horizons PACE must discuss with and provide the participant in writing the specific steps, including time frames for response, that will be taken to resolve the grievance.

How do I file a Grievance?

Participants are encouraged to use the New Horizons PACE internal grievance process for any concerns. Many times, these concerns can be resolved informally.

However, if your interdisciplinary team is not able to resolve your concern you can file a grievance by following the instructions below. You or your designated representative may file a grievance.

To submit a grievance verbally, simply voice your grievance in person or by telephone to any interdisciplinary team member. Be clear that you would like to use the New Horizons PACE grievance process. To submit your grievance in writing, please ask a New Horizons PACE interdisciplinary team member for assistance completing a New Horizons PACE Grievance Form.

You can mail the grievance to:

New Horizons PACE
Director of Quality and Compliance
5035 Manchester Road
St. Louis, MO 63110

When submitting a grievance be sure to provide complete and accurate information so the appropriate interdisciplinary team members can help resolve the issue in a timely manner.

You can receive a free copy of your records if you believe they will be helpful with your grievance.

You will continue to receive all required services while your grievance is being processed.

What happens next?

Once your grievance has been submitted, your New Horizons PACE interdisciplinary team will provide you written verification of receipt within 5 business days. This verification will be in the form of a signed copy of your New Horizons PACE Grievance Form.

New Horizons PACE staff will then coordinate an investigation to determine solutions and take appropriate action. All information gathered during the investigation will be kept confidential.

Within 30 calendar days of receipt of your grievance the interdisciplinary team will provide a written report describing their investigation. The resolution of the problems and the reason for the resolution to your grievance by giving you a Notice of Grievance Resolution.

If you are not satisfied with the interdisciplinary team’s resolution, you and/or your designated representative have the right to report your grievance to the state administering agency (SAA).

Further Action

New Horizons PACE operates as your MO HealthNet Division benefit provider under the Department of Social Services. MO HealthNet encourages you to bring your grievance to the attention of New Horizons PACE first. After your grievance decision with New Horizons PACE is finalized, if you are not satisfied with the response, you may then submit your grievance to the State of Missouri.

When submitting a grievance to the State of Missouri, provide as much detail as possible including names and contact information, date of the incident(s), location and specific concern(s). The MO Health Net will contact the participant if additional information is needed.

Grievances may be submitted verbally or in writing to:

MO HealthNet Division
615 Howerton Court, 2nd Floor
Jefferson City, MO 65109
Attn: Hearings

Complaint information helps with oversight activities and allows New Horizons PACE the opportunity to improve the quality of care we provide. The State of Missouri will address all complaints that relate to patient rights, quality of care, safety, and infection control. Upon the receipt of the grievance form, the state will send a letter of acknowledgement. They will then determine the appropriate steps necessary to respond to the complaint.

Quality improvement

Our Quality Improvement Program (QIP) team collects, maintains, and analyzes all grievances to identify areas where there is room for growth. This data is used in the ongoing development of performance improvement initiatives to ensure New Horizons PACE participants receive the highest quality care possible.

Your Rights in the Program of All-Inclusive Care for the Elderly

The Program of All-inclusive Care for the Elderly, also called PACE, is a special program that combines medical and long-term care services in a community setting. New Horizons PACE is a PACE program.

When you join New Horizons PACE, you have certain rights and protections. New Horizons PACE shall fully explain your rights and all the rules and regulations governing the PACE program, to you or someone acting on your behalf in a way you can understand at the time you join. New Horizons PACE shall protect and provide you with the ability to exercise your rights.

– You have the right to always receive considerate, respectful care from all New Horizons PACE associates and contractors in all circumstances. Each participant has the right not to be discriminated against in the delivery of required PACE services based on race, ethnicity, national origin, religion, sex, age, sexual orientation, mental or physical disability, or source of payment.

You have the right:

– To receive comprehensive health care in a safe and clean environment and in an accessible manner.

– To be treated with dignity and respect, be afforded privacy and confidentiality in all aspects of care, and to be provided humane care.

– Not to be required to perform services for New Horizons PACE.

– To have reasonable access to a telephone.

– To be free from harm, including physical or mental abuse, neglect, corporal punishment, involuntary seclusion, excessive medication, and any physical or chemical restraint imposed for purposes of discipline or convenience and not to treat your medical symptoms or to prevent injury.

– To be encouraged and assisted to exercise your rights as a participant, including Medicare and Medicaid appeals processes as well as civil and other legal rights.

– To be encouraged and assisted to recommend changes in policies and services to New Horizons PACE associates.

– To receive accurate, easily understood information and to receive assistance in making informed health care decisions. Specifically:

– To be fully informed in writing of the services available from New Horizons PACE, including identification of all services that are delivered through contracts, rather than furnished directly by New Horizons PACE at the following times:

– Prior to and upon enrollment in New Horizons PACE program.

– At the time your needs require the disclosure of such information in order to allow you to make an informed choice.

– To have the enrollment agreement, fully explained in a manner that you can understand.

– To examine, or upon reasonable request, to be helped to examine the results of the most recent review of New Horizons PACE conducted by CMS or MO HealthNet Division and any plan of correction in effect.

– To contact 1-800-MEDICARE or 1-800-633-4227 (TTY: 1-877-486-2048) for information and assistance, including to make a complaint related to the quality of care or the delivery of a service.

– To Choose your healthcare provider, within the New Horizons PACE network, that is enough to ensure access to appropriate high-quality healthcare. Specifically, you have the right to:

– Choose your primary healthcare provider and specialist from within New Horizons PACE network.

– Request that a qualified specialist for women’s health services furnish routine or preventive women’s health services.

– Have reasonable and timely access to specialist as indicated by your health condition and consistent with current clinical practice guidelines.

– Receive necessary care in all care settings, up to and including placement in a long-term care facility when New Horizons PACE can no longer provide the services necessary to maintain you safely in the community.

– Disenroll from New Horizons PACE at any time and have such disenrollment be effective the first day of the month following the date New Horizons PACE receives your notice of voluntary disenrollment.

– You have the right to access Emergency Health Care Services when and where you the need arises without prior to authorization by the New Horizons PACE’s interdisciplinary team.

– You have the right to participate fully in all decisions related to your treatment. If you are unable to participant fully in treatment decisions, you have the right to designate a representative. Specifically, you have the right to the following:

– To have all treatment options explained in a culturally competent manner and to make health care decisions, including the right to refuse treatment, and to be informed of the consequences of the decisions.

– To have an associate at New Horizons PACE explain advance directives and to establish them if you desire to do so.

– To be fully informed of your health and functional status by the interdisciplinary team.

– To participate in the development and implementation of your plan of care.

– To request a reassessment by the interdisciplinary team.

– To be given reasonable advance notice, in writing, of any transfer to another treatment setting and the justification for the transfer (that is, due to medical reasons for your welfare, or that of other participants). New Horizons PACE must document the justification in your medical record.

– You have the right to communicate with health care providers in confidence and to have the confidentiality of your individually identifiable health care information protected. You also have the right to review and copy your own medical records and request amendments to those records. Specifically, you have the right to:

– To be assured of confidential treatment of all information contained in the health record, including information contained in an automated data bank.

– 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.

– To provide written consent that limits the degree of information and the persons to whom information may be given.

– You have the right to a fair and efficient process for resolving differences (grievances) with New Horizons PACE, including a rigorous system for internal review by New Horizons PACE and an independent system of external review. Specifically, you have the right to:

– To be encouraged and assisted to voice complaints (grievances) to New Horizons PACE associates and outside representatives of your choice, free of any restraint, interference, coercion, discrimination, or reprisal by New Horizons PACE associates.

– To appeal any treatment decision of New Horizons PACE, our associates, or contractors through the process of the appeals process.