Enrollment Agreement Table of ContentsImportant Information about Rocky Mountain PACEProgram Description . 2Important Contacts. 3Getting started as a Rocky Mountain PACE ParticipantInitial Eligibility. 4Enrollment and Effective Dates of Coverage . 4Special Features of Rocky Mountain PACE . 5-8Advantages of Enrolling in Rocky Mountain Pace . 8BenefitsServices . 9-12Emergency Care . 12-14PACE Day Center . 15-16Service Exclusions and Limitations . 16-17Enrollment, Renewal and DisenrollmentIntake Process and Assessment . 17-20Enrollment . 20Continuation of Enrollment . 21Termination of Benefits . 22-24Renewal Provisions . 24Monthly Payments, if applicable . 25-28Veterans Enrolled Through the Veteran Affairs Contract with Rocky Mountain PACE . 28Rights and Responsibilities as a Rocky Mountain PACE participantParticipant Bill of Rights and responsibilities . 29-34Participant Grievances and Appeals . 34-38Appendix ADefinitions and Explanations . 39-42Appendix BAdvance Directives . 43Appendix CNotice of Privacy Practices . 44-51Enrollment FormEnrollment Form . 52-55H5167 EnrollmentAgreement 04012018Page 1 of 55

Important Information about Rocky Mountain PACEProgram DescriptionPACE stands for the Program of All Inclusive Care for the Elderly. We are pleasedto introduce you to this program and welcome you as a potential participant inthe program. Please review this booklet carefully. Feel free to ask questions aboutany of the sections. We will be happy to answer them for you. If you decide toenroll in the PACE Program, this booklet becomes your ENROLLMENTAGREEMENT.The purpose of Rocky Mountain PACE is to help you remain as independent aspossible. We believe that everyone deserves to be treated with dignity and tohave the opportunity to live in the community as independently as possible. Theprogram coordinates a complete range of health and health-related services, alldesigned to keep you living in the community and preferably in your own homefor as long as it is safe and feasible. We are dedicated to providing a personalizedapproach to your care. This means that our health care staff will get to know youand your health needs well.Rocky Mountain PACE provides access to services 24 hours a day, seven days aweek, 365 days a year. To treat the multiple chronic health problems of ourparticipants, Rocky Mountain PACE health care professionals monitor changes inyour health status, provide appropriate care and encourage self-determination.Medical, nursing and nutrition services, physical therapy, occupational therapy,recreation therapy, social work and in-home support are provided, along withmedical specialty services. All services must be provided through the RockyMountain PACE contract network. Rocky Mountain PACE coordinates hospital andnursing facility care in its contracted facilities.H5167 EnrollmentAgreement 04012018Page 2 of 55

Please reference Appendix A that includes important words that are used in thisbooklet.Important Contact Information:If you have any questions about the contents of this booklet, call our office anytime at:719.314.2327 Regular Business Hours and After Business HoursTTY 800.659.2656Business Hours of Operation: Monday- Friday 8 A.M. to 5 P.M.You may also write us at:RMHCS/RM PACE310 S. 14th StreetColorado Springs, CO 80904You may contact Medicare directly by calling:1.800.MEDICARE (1.800.633.4227) 24 hours per dayTTY 1.800.633.4227You may contact Medicaid directly by calling:1.303.866.2993TTY 1.855.225.1731 AT&T Relay Services #711H5167 EnrollmentAgreement 04012018Page 3 of 55

Getting Started as a Rocky Mountain PACE ParticipantInitial Eligibility:You are eligible to enroll in Rocky Mountain PACE if you meet all of the followingcriteria: At least 55 years of age. Capable of safely residing in the community setting without jeopardizingyour health and safety. Certified by the local Single Entry Point (SEP) case management agency tomeet the level of care required for coverage of long term services. Living in the Rocky Mountain PACE service area.Rocky Mountain PACE will enroll persons age 55 or older of any race, color,national origin, sexual orientation, source of payment or disability, withoutdiscrimination. It is important to note that the PACE regulations stipulated by theFederal Government require a person to be 55 and over to be eligible for PACE.In addition to meeting these criteria, you must also sign an EnrollmentAgreement Form and agree to abide by the conditions of Rocky Mountain PACE,as explained in the Enrollment Agreement.Enrollment and Effective Dates of CoverageEnrolling in Rocky Mountain PACE is a five-step process:1.Intake Referral2.Intake Assessment3.Final Approval4.Enrollment Conference5.Continuation of EnrollmentH5167 EnrollmentAgreement 04012018Page 4 of 55

As of the 1st of the month of your enrollment, your coverage through RockyMountain PACE begins. You must get all of your healthcare from RockyMountain PACE, except for emergency or urgently needed services or out of thearea dialysis service. Services authorized by Rocky Mountain PACE and otherservices contained under this program will be covered. Without AuthorizationNEITHER PACE WILL NOT PAY FOR THE SERVICES.Special Features of Rocky Mountain PACE:Interdisciplinary TeamYour care is planned and provided by a team of specialists. The team includesphysicians and nurse practitioners, registered nurses, case managers/ socialworkers, physical and occupational therapists, recreation therapist and aides,dietician, home care coordinators, personal care workers/home health aides,transportation representatives and PACE Center managers who will assist you.Each team member’s special expertise is employed to assess your health careneeds and to call upon additional specialists, if necessary. Together, with you andyour family, we create a plan of care designed just for you. All the services youreceive are coordinated and arranged by the team.Authorization of CareThe Interdisciplinary Team must review, approve and authorize all care andservices and any changes in your care plan, whether adding, changing ordiscontinuing a service. You will get to know each of the members of your teamvery well. They will work closely with you so you can be as healthy andindependent as possible. The team will reassess your needs at least every sixmonths, but more frequently, if necessary. If you disagree with a change in yourservices, you can appeal that change.H5167 EnrollmentAgreement 04012018Page 5 of 55

The PACE CenterThe primary focus of the PACE Center is to provide you with a social environmentwith an emphasis on Wellness.You will have the opportunity to work with Physical, Occupational, andRecreational therapy staff on a regular schedule, as defined by your care plan. Wewill support your desire to maintain your independence by encouraging you totake an active role in working towards the goals in your care plan. The PACEmedical clinic is also located at the PACE Center. The Clinic is where you willreceive the majority of your health care services. In addition to social,rehabilitation, and medical services, you may receive other services at the PACECenter, such as behavioral health counseling and spiritual support.Our Wellness model, with a focus on preventative care and programming, meansthat we have designated our PACE Center to be a Smoke-Free program. It is not arequirement of PACE that participants who smoke stop smoking, but we dorequire that smokers who choose to take a break during their Center serviceprogramming, sign in and out with our front desk receptionist, leave any oxygenapparatus with the receptionist until they sign back in from a smoking break, andonly smoke in the one area designated within the distance required underColorado law. Please let us know if you would like to participate in a smokingcessation program at the PACE Center.The PACE Center is not a public facility. The PACE Center offers services toenrolled participants. All of the services provided in our Center are designed tomaintain or increase independence and support overall health in accordance withindividual treatment plans. Rocky Mountain Health Care Services has anobligation to protect the confidentiality of those individuals enrolled in theprogram. It is preferred that visitation by friends and family take place outside ofH5167 EnrollmentAgreement 04012018Page 6 of 55

the PACE program Day Center. For visitations to be considered, they must beprearranged and pre-approved by the Interdisciplinary Team. Your family andcaregivers may learn how they can best support you and your health byparticipating in care plan reviews and speaking with the PACE team about specifictreatments with your permission.We will work with you and your family to determine your schedule of attendanceat the Rocky Mountain PACE Center. If you need transportation to and from theCenter, we will provide it.The Interdisciplinary Team may authorize services to be provided in your home, ina hospital or a nursing facility. We have contracts with physician specialists (suchas cardiologists, urologists and orthopedists), with a pharmacy, laboratory, andXray services, and with hospitals, assisted living facilities, and nursing facilities.The Intake and Enrollment Specialist will provide you with a copy of all of RockyMountain PACE contract providers.We offer access to care on a 24-hour basis, 365 days of the year.Physicians and ProvidersYour PACE physician and the other providers of Rocky Mountain PACE areresponsible for your care, as are the other Interdisciplinary Team members of thePACE Center.Coordinated, Comprehensive CareWe have flexibility in providing care according to your needs. The InterdisciplinaryTeam will be able to determine the appropriate medical services for your care. Inhome care will also be evaluated and provided by the team as determined bytheir assessment of your needs.H5167 EnrollmentAgreement 04012018Page 7 of 55

Services are Provided Exclusively Through Rocky Mountain PACEThe services offered by Rocky Mountain PACE are available to you because of aspecial agreement among Rocky Mountain Health Care Services, the State ofColorado Department of Health Care Policy and Financing (HCPF), and Centers forMedicare and Medicaid Services (CMS). Once you have enrolled in RockyMountain PACE, you agree to receive services exclusively from Rocky MountainPACE and contracted providers in the Rocky Mountain PACE network.Therefore, you will no longer be able to obtain services from the otherphysicians or medical providers you had under your previous Medicare andMedicaid coverage, unless they are contracted with PACE.Advantages of Enrolling in Rocky Mountain PACE:Rocky Mountain PACE was designed and developed specifically to maintainindependence for frail elders by offering comprehensive, coordinated alternativeservices through a single organization. Our unique organizational and financingarrangements allow us to provide flexible benefits and coordinated care.Other advantages to participating in the PACE plan include: Rocky Mountain Health Care Service’s history of serving the community andthe elderly since 1973, and Rocky Mountain PACE since 2008. Dedicated, qualified health care professionals Lower prescriber to patient ratio than most doctors’ offices Long-term care coverage Coordinated care 24 hours a day, 365 days a year Support for family caregivers Individualized care Through-the-Door Transportation to your appointmentsH5167 EnrollmentAgreement 04012018Page 8 of 55

BenefitsPACE ServicesThe following services are fully covered when approved by the InterdisciplinaryTeam and provided by Rocky Mountain PACE contractors and in RockyMountain PACE contracted facilities. Approval is not required for healthemergencies. Services you can receive from Rocky Mountain PACE include thefollowing:1. Outpatient Health Services Primary care and specialists care, including consultation, routine care,preventive health care and physical examinations. See the Rocky MountainPACE Contract Provider list of medical specialties and provider names. Nursing care Laboratory tests, X-rays and other diagnostic procedures Prescription drugs (only if obtained from a pharmacy designated by RMPACE) Foot care Vision Care, including examinations to diagnose and treat diseases andcondition of the eye, treatment and eyeglasses after cataract surgery. RMPACE may provide eyeglasses if recommended by a PACE networkoptometrist, no more than one pair every two years with a 250 limit. Urgent care in the Rocky Mountain PACE medical clinic. Dental care Audiology2. Supportive Services and Personal Care Social Services Mental Health Counseling Spiritual CareH5167 EnrollmentAgreement 04012018Page 9 of 55

Physical, Occupational, and Speech therapiesRecreation therapy, including Memory CareProstheses, orthotics and durable medical equipmentNutrition counseling and educationTransportation to and from the Rocky Mountain PACE Day Center, and toand from medical specialty appointments preauthorized and scheduled byRocky Mountain PACE’s medical clinic.3. Hospital Inpatient Care** Ambulance Emergency room care and treatment room services Semi-private room and board, as available General medical and nursing services Medical, surgical, intensive care and coronary care units, as necessary Laboratory tests, X-rays and other diagnostic procedures Medications Blood and blood derivatives Surgical care, including anesthesia Use of oxygen Physical, speech, occupational, respiratory therapies Social services** Under hospital care, the plan does not include: private room and private dutynursing, unless medically necessary and non-medical items for your personalconvenience such as telephone charges and radio or television rental.4. Nursing Facility Care Semi-private room and board, when available Physician and nursing servicesH5167 EnrollmentAgreement 04012018Page 10 of 55

Personal care and assistanceMedicationsPhysical, occupational and speech therapies as authorized by theInterdisciplinary TeamMedical suppliesSocial services5. Home Health Care Skilled home care nursing services, including after hour services asdetermined by the Rocky Mountain PACE physician and on-call RN Physical and occupational therapies Home health aide services Homemaker and personal care services Personal alert systems, if deemed necessary Incontinence supplies6. Palliative and End-of-Life CarePalliative care is care provided to individuals who need aggressive painmanagement or other symptom control. It usually is provided when people are nolonger receiving cure-oriented treatment for their illness. Palliative care isprovided by the Rocky Mountain PACE team.We also want to make sure, when the time comes, that you get the best end-oflife care. The Rocky Mountain PACE team will work with you and your family sothat we can meet your needs and honor your wishes. You may receive this care inmany places, such as your home, an assisted living facility that agrees to supportyour wish to stay in their facility at end-of-life, or a nursing facility.H5167 EnrollmentAgreement 04012018Page 11 of 55

7. Dental ServicesOur priorities for dental care are to treat pain, acute infection, and to maintaindental functioning.Emergency CareEmergency Care is for an emergency medical condition. In an emergency, pleasecall 911.Emergency care is appropriate when services are needed immediately because ofan injury or sudden illness, and the time required to reach the PACE organizationor one of its contract providers would cause risk of permanent damage to yourhealth.If you call 911, it is important that you have someone notify Rocky MountainPACE as soon as possible and let us know what has happened. Your physician atRocky Mountain PACE will be called immediately to coordinate your care. Alwayscarry your Rocky Mountain PACE identification card with you and show it to thepatient registration representative in the Emergency Room or Hospital.Access to After Hours Care and Urgent CareAfter hours care non-emergency care is defined as any urgent care needed from 5PM- 8 AM weekdays and 24 hours on weekends and holidays.There may be times when you need to speak with a nurse or physician andreceive advice or treatment for an injury or onset of an illness, which simply can’twait until regular Rocky Mountain PACE Center hours.H5167 EnrollmentAgreement 04012018Page 12 of 55

When you need non-emergency care after hours, there will always be a nurse(with physician back up) available 24 hours a day, 7 days a week, 365 days a year.For after hour non-urgent medical care: Call Rocky Mountain PACE719.314.2327 /TTY 800.659.2656. The answering service will transfer your call tothe RM PACE on call nurse on duty.Urgent CareRocky Mountain PACE also covers urgent care for an urgent medical condition.Urgent Care is one in which medical services are required promptly to preventimpairment of health due to symptoms that a prudent layperson would believerequired immediate attention, but are not life-threatening and do not pose a highrisk of permanent damage to an individual’s health.Urgent care is appropriately provided in a clinic, physician’s office or in a hospitalemergency department if a clinic or physician’s office is inaccessible. Urgent caredoes not include services provided to treat an emergency condition nor does itinclude primary care services.Out-of-area Emergency or Urgently Needed CareCarry the Rocky Mountain PACE identification card with you at all times and showit to the urgent care or hospital admitting person. The out-of-town physician whotreats you should give you a written report explaining your condition andtreatments. Please provide a copy of that report to your Rocky Mountain PACEmedical provider when you return to the area.Rocky Mountain PACE also covers emergency or urgent care when you aretemporarily out of the service area for a period up to 30 days. If you are out ofH5167 EnrollmentAgreement 04012018Page 13 of 55

the Rocky Mountain PACE service area temporarily for more than 30 days, youwill be automatically disenrolled unless prior arrangements have beenapproved. Emergency or urgent care coverage is only available to you if: The care you receive is needed as a result of an unforeseen illness, injury orcondition Your illness or injury requires medical attention to prevent seriousdeterioration in your health You cannot delay necessary medical attention until you return to theservice areaPrior authorization is not needed in seeking out of area emergency care.However, out of area urgently needed services do require that Rocky MountainPACE provide authorization within one hour of notification of your need forurgent care or it is deemed unauthorized. As soon as possible, you should callRocky Mountain PACE when you receive out-of area emergency or urgentlyneeded care.If you receive emergency medical care while out of town, you or your familymember or caregiver should call 719.314.2327 /TTY 800.659.2656 as soon aspossible and notify the PACE medical clinic (during business hours) or theanswering service (between 5 p.m. and 8 a.m. Monday through Friday, all daySaturday and Sunday and major holidays). The answering service will transferyour call directly to the after hour nurse on duty.Rocky Mountain PACE will cover urgently needed out-of-network services if (a)theservices are pre-approved by Rocky Mountain PACE or (b)the services are notpreapproved because Rocky Mountain PACE did not answer a request for serviceapproval within one hour after being contacted or if the health service providerwas unable to contact Rocky Mountain PACE.H5167 EnrollmentAgreement 04012018Page 14 of 55

If you receive any medical care outside of the United States, Rocky MountainPACE will not be responsible for the charges.PACE Day CenterThe Rocky Mountain PACE Center is open Monday through Friday. The Centeroffers a wide variety of Wellness activities for our participants, as well as access torehabilitation, nutrition, medical, and counseling services, as indicated by yourindividualized care plan. Lunch and snacks are available at no charge.Holidays:The days during the year that the Rocky Mountain PACE Center is closed forholidays are: New Year’s Day Memorial Day Fourth of July Labor Day Thanksgiving Day Christmas DayYou may call the regular number 719.314.2327/ TTY 800.659.2656 if you haveany medical concerns or emergencies, and the answering service will direct yourcall to the appropriate person.Rocky Mountain PACE will close occasionally to provide all of the staff withtraining that will improve our ability to care for you. We will post a notice in ourCenter at least one week in advance so you will have plenty of notice. If you needto be seen for an urgent medical need, our Clinic will make sure you are seen byone of our medical providers in the PACE medical clinic.H5167 EnrollmentAgreement 04012018Page 15 of 55

Bad Weather:We will close the PACE Center in the case of extremely cold temperatures (0degrees with or without wind-chill) or ice and/or snow in amounts that wouldcause it to be too dangerous for the transportation department to send the PACEbuses to get you.In the event of this sort of bad weather, please call the main office for RockyMountain Health Care Services for recorded information regarding weatherrelated delays or closures. The recording will be posted by 6:30 a.m.719.314.2327/ TTY 800.659.2656You may also watch KKTV Channel 11 for updates about Rocky Mountain PACEclosures scrolling on the bottom of the screen.Service Exclusions and Limitations1.Any service which has not been authorized by the Interdisciplinary Team,even if it is listed as a covered benefit, unless for emergency care.2.Services rendered in a non-emergency setting or for a non-emergencyreason without Rocky Mountain PACE authorization.3.Medications not prescribed by Rocky Mountain PACE and/or not suppliedby our contracted pharmacies.4.Cosmetic surgery unless required for improved functioning of a malformedpart of the body resulting from an accidental injury or for reconstructionfollowing mastectomy.5.Experimental, medical, surgical or other health treatments or proceduresnot generally accepted medical practice in the geographic area, asdetermined by the Rocky Mountain PACE Medical Director.6.Care in any hospital other than Rocky Mountain PACE’s contractedhospitals, unless authorized, except for emergency care.H5167 EnrollmentAgreement 04012018Page 16 of 55

7.8.9.Any services rendered outside the United States.Services received outside the Rocky Mountain PACE service area, (exceptfor emergency or urgently needed medical care).Personal comfort items provided such as: private room and private dutynurse, unless medically necessary, and any non-medical items for your usesuch as telephone charges and TV rental.Other Coverage ProvisionsBefore you leave the Rocky Mountain PACE service area, we encourage you tonotify the Interdisciplinary Team. They will explain what to do if you become ill orinjured while away from the Rocky Mountain PACE service area.The Interdisciplinary Team must approve any non-emergent services you receiveor Rocky Mountain PACE will not be responsible for paying for the services.Intake Process:The intake process begins when you or someone on your behalf makes a call toRocky Mountain PACE. If it appears from this first conversation that you arepotentially eligible, the Rocky Mountain PACE Intake Specialist will visit you inyour home to explain our program and obtain further information about you.During this visit you will learn: How Rocky Mountain PACE works The types of services we offer The answers to any questions you may have about PACE That when you enroll you must agree to receive all your medical and healthcare exclusively from Rocky Mountain PACE and our contracted providers,with the exception of emergency services Your monthly payment, if anyH5167 EnrollmentAgreement 04012018Page 17 of 55

After this visit, if you are interested in touring the Rocky Mountain PACE Center,the Intake Specialist will set up your visit. This will allow you to attend the Centerso you can see some of the services provided in our recreation, physical andoccupational therapy program, meet some of the members of theInterdisciplinary Team, and be introduced to some of our program participants.We will also ask that you sign a release allowing us to obtain your past medicalrecords so our team has complete information about your health conditions. Ifyou are enrolling with Medicaid, we will require financial information, as well.Intake Assessment:If you want to become a participant in Rocky Mountain PACE, you will begin theassessment process. One of the RM PACE Home Care nurses will meet with you in your home tocomplete your initial assessment. As well, a home safety assessment will becompleted by another member of the Home Care department, who willmost likely accompany the Home Care nurse on this home visit. The goal ofthe home safety assessment will include determining what your needs are,if any, for durable medical equipment or supplies. The Intake Specialist will discuss your health care needs with the team andarrangements will be made for you to come to the PACE Center to meetwith some of the other members of the Interdisciplinary Team. The local Single Entry Point case management agency will decide whetheryou meet the criteria for admission into the program, that is, whether yourproblems and needs appear to meet the functional eligibility criteria fornursing facility level-of-care and whether you are found to be able toremain safely in your home or in the community with support. During the entire Intake Assessment process, the Interdisciplinary Team isassessing whether Rocky Mountain PACE can meet your medical, nursing,psychological and social needs, whether you have a family or informalH5167 EnrollmentAgreement 04012018Page 18 of 55

support network, and whether remaining in your home or the communitywould jeopardize your health and safety. At the time of enrollment, anindividual must be able to live in a community setting without jeopardizinghis or her safety. The following constitutes unsafe behaviors that may causea denial of enrollment if they cannot be remediated:1.2.WanderingRisk for setting fire to self or dwelling due to:a.Unsafe smokingb.Unsafe cookingc.Unsafe use of oxygend.Other dangerous fire-setting behavior3.Disruptive or violent behavior that jeopardizes the participant’s health orsafety, or that of others.4.A physician-documented condition that requires 24 hour skilled care.5.Living in a dwelling that has been condemned or ruled unsafe by a localauthority.6.A physical or mental condition that requires constant supervision outside ofthe PACE Center hours and no caregiver to meet this need.7.A physical or mental condition that requires constant supervision duringPACE Center hours and the participant refuses to come to the PACE Center.8.Inability to transport participant to PACE Center for needed care by normalPACE organization transportation due to the physical condition ofparticipant or lack of safe access to home.In such cases, Rocky Mountain PACE will provide written notification explainingthe reason for the denial and refer the individual to appropriate alternativeservices.H5167 EnrollmentAgreement 04012018Page 19 of 55

Final ApprovalBecause Rocky Mountain PACE is authorized to serve only those aged 55 andolder who need long-term care, an outside opinion from the local Single EntryPoint case management agency designated for this service area must confirm thatyour health situation in fact qualifies you f

Rocky Mountain PACE provides access to services 24 hours a day, seven days a week, 365 days a year. To treat the multiple chronic health problems of our participants, Rocky Mountain PACE health care professionals monitor changes in your health status, p