Criteria & Legalities at Senior CommUnity Care of North Carolina

5400 South Miami Boulevard: Suite 150, Durham, NC 27703

Last modified on February 8th, 2024 at 05:30 pm

Website Pending CMS Review

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 State of North Carolina 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 North Carolina service care area
• Meet criteria for nursing home level of care
• Be able to live safely in the community with the help of our services

A PACE enrollee may be, but is not required to be, any or all of the following:

Senior CommUnity Care of North Carolina will not restrict enrollment based on Medicare or Medicaid eligibility

Service Area

Senior CommUnity Care of North Carolina provides services to seniors living in select Wake, Durham and Granville County zip codes:

Durham County: 27503, 27613, 27701, 27703, 27704, 27705, 27706, 27707, 27712, 27713

Wake County: 27502, 27511, 27511, 27513, 27518, 27519, 27523, 27526, 27523, 27526, 27529, 27539, 27540, 27545, 27560, 27562, 27571, 27587, 27591, 27592, 27597, 27601, 27603, 27604, 27605, 27606, 27607, 27608, 27609, 27610, 27612, 27613, 27614, 27615, 27616, 27617

Granville County: 27509, 27522

Enrollment

Intake: To discuss whether Senior CommUnity Care is right for you or a family member, call us today at 919-425-3050 or Relay 711 or 877-735-8200. 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 North Carolina social worker.

Costs Of Service

Senior CommUnity Care Pace is designed to utilize Medicare and Medicaid funds to provide Coordinated Healthcare, Social Engagement, Medication Management, Transportation, In-Home Assistance and other Specialty care options. We can assist you in the application process for Medicaid.

A PACE organization may not charge a premium to a participant who is eligible for both Medicare and Medicaid, or who is only eligible for Medicaid.

A PACE organization may charge a premium to a participant who is only eligible for Medicare.

There is also a private pay option for participants who are not eligible for either Medicare or Medicaid.


The amount that a PACE organization can charge a participant as a monthly premium depends on the participant’s eligibility under Medicare and Medicaid. The PACE organization will provide a description of participant premiums, if any, and procedures for payment of premiums during the enrollment process.

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.

  • 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 to get compassionate, considerate care. You have the right:
    • To get all of your health care in a safe, clean environment.
    • To be free from harm. This includes 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 or to prevent injury.
    • To be encouraged to exercise your rights at VOANS Senior CommUnity Care of North Carolina.
    • 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 VOANS Senior CommUnity Care of North Carolina staff about changes in policy and services you think should be made.
    • To use a telephone while at the VOANS Senior CommUnity Care of North Carolina Center.
    • To not have to perform work or services for Senior CommUnity Care of North Carolina.
  • 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 / Ethnic Origin
    • Religion
    • Age
    • Sex
    • Mental or physical ability
    • 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 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 VOANS Senior CommUnity Care of North Carolina interpret the information into your preferred language in a culturally competent manner. If your first language is not English and you cannot speak English well enough to understand the information being given to you.
    • To get marketing materials and your PACE rights in English or in any other frequently used language in your community, including Braille, if necessary.
    • To get a written copy of your rights from VOANS Senior CommUnity Care of North Carolina. These rights must be posted in a public place in the VOANS Senior CommUnity Care of North Carolina center where it is accessible to all participants.
    • To be fully informed, in writing, of the services offered by VOANS Senior CommUnity Care of North Carolina. This includes telling you which services are provided by contractors instead of the VOANS Senior CommUnity Care of North Carolina 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 review the results of the most recent reviews of VOANS Senior CommUnity Care of North Carolina. Federal and State agencies review all PACE programs. You also have a right to review how VOANS Senior CommUnity Care of North Carolina plans to correct any problems that are found at inspection.
  • You have a right to a choice of providers.
  • You have the right to choose a health care provider within VOANS Senior CommUnity Care of North Carolina’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 a right to access emergency services.
  • You have the right to get emergency services when and where you need them without VOANS Senior CommUnity Care of North Carolina’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.
  • 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. You have the right:
    • To have all treatment options explained to you in a language you understand, to be fully informed of your health status and how well you are doing, and to make health care decisions. This includes the right not to get treatment or take medications. If you choose not to get treatment or take medications, you must be told how this will affect your health.
    • To have VOANS Senior CommUnity Care of North Carolina help you create an Advance Directive. 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 provide this 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 as protected under State and Federal laws. You also have the right to look at and receive copies of your medical records.
  • 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 file 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 VOANS Senior CommUnity Care of North Carolina. You have the right to a fair and timely process for resolving concerns with VOANS Senior CommUnity Care of North Carolina. You have the right:
    • To a full explanation of the complaint process.
    • To be encouraged and helped to freely explain your complaints to VOANS Senior CommUnity Care of North Carolina 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 appeal any treatment decision by VOANS Senior CommUnity Care of North Carolina, staff, or contractors.
  • You have a right to leave the program.
  • If for any reason, you do not feel that VOANS Senior CommUnity Care of North Carolina is what you want, you have the right to leave the program at any time.

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 North Carolina 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.

SCCNC 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 SCCNC. All services will be continued during the grievance process.

The staff member who receives your grievance will forward it to the SCCNC 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 North Carolina
4022 Stirrup Creek Drive, Suite 315
Durham, NC 27703
Telephone: 919.425.2970 Fax 919.425.3001

This must be done within thirty (30 days) of the final decision of your original grievance.

The SCCNC 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 SCCNC 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 SCCNC 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 action concerning VOANS Senior CommUnity Care of North Carolina non-coverage of or non-payment for denials, reductions, or termination of services.

VOANS Senior CommUnity Care of North Carolina’s decision to involuntary disenroll a participant may also be appealed.

You have a right to appeal a denial of enrollment and/or treatment decisions made by VOANS Senior CommUnity Care of North Carolina or its contracted Providers, including decisions not to authorize or pay for items and services which you believe are covered by VOANS Senior CommUnity Care of North Carolina.

You may request an appeal at any time by simply telling an employee, telephoning the PACE Center at (919-425-3000), or by writing a letter and mailing/faxing it to:

Quality Assurance Manager

VOANS Senior CommUnity Care of North Carolina
4022 Stirrup Creek Drive, Suite 315
Durham, NC 27703
(Fax No. 919-425-3001)

A written description of the appeals process will be reviewed with you or your representative at enrollment, at least annually, and any time the Team denies any request for service or payment. The written information will explain how long it will take to decide on your appeal and what factors will be considered in the decision. You will be assisted to complete an appeal by VOANS Senior CommUnity Care of North Carolina if you choose to do so.

VOANS Senior CommUnity Care of North Carolina will continue to furnish the disputed services until issuance of the final determination if the following conditions are met:
A. VOANS Senior CommUnity Care of North Carolina proposes to terminate or reduce services currently being furnished to the participant;
B. You may request continuation with the understanding that you may be liable for the costs of the contested services if the determination is not made in your favor.

VOANS Senior CommUnity Care of North Carolina will continue to furnish you with all other required services during the appeals process. There will be no discrimination by VOANS Senior CommUnity Care of North Carolina against you because you or your representative filed an appeal.

Participant requests for appeal will be treated by all VOANS Senior CommUnity Care of North Carolina employees in a confidential manner and violations of confidentiality will result in disciplinary action.
How to File an Appeal:

You or someone you name to act for you may file an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you.

If you appeal, we will appoint an appropriately credentialed impartial third party who was not involved in the original action and who does not have a stake in the outcome of the appeal to review your appeal.

All appeals will be resolved as expeditiously as is required by the condition of your health, but no later than 30 days from our receipt of your appeal. You will have the opportunity to present additional evidence on your case, in person, as well as in writing.

If the appeal is resolved in your favor, VOANS Senior CommUnity Care of North Carolina will provide or pay for the disputed service immediately. You will be notified verbally and in writing of the decision.

If you believe that your life or health will be in immediate danger if you do not receive the service denied, your appeal will be expedited.

If your appeal is expedited, VOANS Senior CommUnity Care of North Carolina will respond within 72 hours of receipt of your appeal. If your health condition allows and we can show you that we need more time to review the case, we may take up to 14 days to decide on your expedited appeal.

If the credentialed impartial third party does not find in your favor, you have additional appeal rights through Medicaid or Medicare. If the decision is not made in your favor, SCCNC must notify you, the Center for Medicare and Medicaid Services, and the state Medicaid Agency in writing.

Additional Appeal Rights under Medicaid or Medicare
If you choose, you may file an appeal under Medicare or Medicaid, SCCNC will help you or your representative to file an appeal for either.

The process you choose depends upon whether you are eligible for Medicaid, Medicare, and Medicaid (dually eligible) or Medicare only. If you are enrolled in both Medicaid and Medicare (dually eligible), or Medicaid ONLY, you can appeal at any time during the appeals process using the State of North Carolina’s Fair Hearing Process by contacting:

Office of Administrative Hearings (OAH)
Attention: Clerk of Court
6714 Mail Service Center
Raleigh, NC 27699-6714
Office: (919) 431-3000
Fax: (919) 431-3100

You or your authorized representative must send a written appeal request within 30 days of the date of the adverse notification.

Your appeal must be postmarked or received by OAH within 30 days of the adverse decision.

If you file an appeal before the effective date of this action, services may continue during the appeal process.

However, if the decision by OAH is not in your favor, you may be required to reimburse the VOANS program for the cost of services paid on your behalf during the appeal period.

If you wish to file an appeal, we will assist you with the forms. We will forward the adverse notice you received to OAH along with the DMA Form #2003 “Medicaid Services Recipient Hearing Request Form. If you wish to inquire about the status or progress of the appeal, you may call 919-855-4350 or you may send a fax to 919-733-2796.

If the decision is in your favor, we will provide or pay for the service(s) in question as quickly as your health requires, but no more than 30 days after the decision.

If you are eligible for Medicare only and you choose to appeal, the appeal must be made to the Medicare Independent Review Entity (IRE). We will send your appeal to that agency for you.

If Medicare’s decision is in your favor, we will continue to provide or pay for the service(s) in question as quickly as your health requires, but no more than 30 days after the decision.

If you want to appeal a denial of enrollment or disenrollment, you must appeal to the North Carolina Office of Administrative Hearings at the above address.
Please click here to fill out the CMS Appointment Representative Form. By clicking this link, you are acknowledging that you are leaving SCC PACE website.


IF YOU OR SOMEONE YOU KNOW NEEDS TO APPOINT A REPRESENTATIVE TO ASSIST YOU, PLEASE UTILIZE THIS LINK TO ACCESS THE CMS FORM 1696

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