If you are an ElderPlace/PACE participant and you have a question and you have a question about your enrollment in the program, please contact your primary care team, or your PACE center manager.
As an ElderPlace participant, you have the right to:
- Respect and Non-discrimination. You have the right to considerate, respectful care at all times and under all circumstances. You have the right to not be discriminated against based on race, ethnicity, national origin, religion, sex, sexual orientation, age, mental or physical disability, or source of payment.
- Information Disclosure. You have the right to receive accurate, easily understood information and to receive assistance in making informed health care decisions.
- Choice of Providers. You have the right to a choice of health care providers, within the ElderPlace organization’s network, that is sufficient to ensure access to appropriate high-quality health care.
- Access to Urgent and Emergency Services. You have the right to access urgent and emergency health care services when and where the need arises.
- Participation in Treatment Decisions. You or your designated representative have the right to participate fully in all decisions related to your treatment.
- Confidentiality of Health Information. You have the right to communicate with health care providers in confidence and to have the confidentiality of your health care information protected. You also have the right to review, copy, and request amendments to your own medical records.
- Grievance and Appeals. You have the right to a fair and efficient process for resolving differences with ElderPlace.
A complete copy of the ElderPlace Participant Bill of Rights is available upon request.
Providence ElderPlace/PACE is a voluntary program. Once you are determined eligible for ElderPlace/PACE, you may enroll at any time. You can also disenroll at any time by following the simple steps outlined in your Enrollment Agreement handbook.
To receive a copy of the ElderPlace/PACE Enrollment Agreement handbook please contact a member of your primary care team, your PACE center manager, or call our administrative office at 503-215-6556 (toll free at 1-855-415-6048). Those with a Text Telephone (TTY) can call 1-800-848-4442.
Participant Grievance Process
Definition of a grievance: A grievance is an oral or written expression of dissatisfaction related to the quality of care or services received from Providence ElderPlace.
All of us at Providence ElderPlace share the responsibility for assuring that you are satisfied with the care you receive. We encourage you to express any grievance or appeal you have with services at the time and place it occurs. All information regarding the grievance process will be treated confidentially.
You may discuss your concern with any member of the Providence ElderPlace team. An ElderPlace employee will gather complete information and will give this information to your Health & Social Center manager. The manager, or another supervisor, will follow up with you regarding your concern.
For more detailed information about the Grievance Process, please refer to your ElderPlace Enrollment Agreement.
Participant Appeals Process
Definition of an appeal: An appeal is a written or oral request to review Providence ElderPlace’s denial of a requested service, non-payment of a covered service, reduction or termination of an existing service, or an involuntary disenrollment.
As an ElderPlace Participant, you have the right to:
- You have the right to a fair and efficient process for resolving differences with Providence ElderPlace, including a rigorous system of internal review by the organization and an independent system of external reviews.
- Specifically, you have the following right to appeal any denial of a requested service, non-payment of a service, discontinuation or reduction of a service, or an involuntary disenrollment to ElderPlace Administration. You have a right to file a state Administrative hearing, or if you receive Medicare, to file to MAXIMUS Federal Services, Inc.
- If services are being reduced or stopped and you wish to have the services continued, you must file an appeal with Providence ElderPlace or request an Administrative Hearing with the state before the date the services end.
- In situations where you feel your life, health, or ability to maintain function will be jeopardized without continuation of the denied service, ElderPlace will make a determination regarding the appeal as expeditiously as your health condition requires, but no later than 72-hours after receipt of your appeal.
You can file an appeal directly with your Health & Social Center manager (PACE center manager) or with Providence ElderPlace Administration, or if you are a Medicare beneficiary, contact MAXIMUS Federal Services, Inc, or request a state Administrative Hearing from Aging and Disability Services. Your Health & Social Center manager will help you decide which one to appeal to and assist you in filing the appeal.
Providence ElderPlace, in consultation with Providence Health Plans Ambulatory Pharmacy and Therapeutic Committee, has selected a list of medications that represent the prescription therapies believed to be a necessary part of a quality treatment program. This list, called a formulary, is updated every three months.
Over-the-counter medications are included in the formulary and are provided to all ElderPlace participants.
Can the formulary change?
Yes. Providence ElderPlace may add or remove medications from the formulary. If drugs are removed from the formulary, or pre-authorization are requirements added, ElderPlace will notify participants who use that medication at least 60 days before the change becomes effective. If the Food & Drug Administration determines that an item on the formulary list is unsafe, ElderPlace will immediately remove the item from the formulary and notify participants who use it.
What if my medication is not on the formulary?
You and your primary care physician can ask Providence ElderPlace to make an exception and cover the medication even if it is not on our formulary. Providence ElderPlace will provide time for you to transition to our formulary. The Transition Process for Medicare Part D Policy describes the transition period and how you can obtain a temporary supply of your drug if it is currently not on the formulary. Generally Providence ElderPlace will only approve your request for an exception if the alternative medications included on the formulary would not treat your condition as effectively and/or would cause you to have adverse medical effects. Coverage decisions will be made within 24 to 72 hours.
Are there other restrictions on coverage?
Providence ElderPlace requires prior authorization for certain medications. This means your primary care physician must get approval from Providence ElderPlace before the pharmacy will fill your prescription. The Prior Authorization Criteria outlines most medications that require prior authorization.
How much will I pay for prescription medications?
ElderPlace participants are not charged co-payments or deductibles. There are no hidden costs.
How do I use the formulary?
The formulary is available as a downloadable PDF attachment. The formulary list is in alphabetical order. The far right column of the formulary indicates whether ElderPlace must pre-authorize the medication.
Medicare Complaint Form
If you have complaints or concerns about Providence ElderPlace Plan and would like to contact Medicare directly please use the following link:
The Medicare Beneficiary Ombudsman
The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests.
Do you need additional information?
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048 or visit www.medicare.gov.