PACE Resource Material and Templates

The following resources and templates have been approved by the Department of Health Care Services, Long-Term Care Division for use by California PACE organizations and applicants:

New Applicant Orientation Materials

PACE Organization and Site Listing
CMS Fact Sheet
Required Job Descriptions
Template - Time Basis for Staff Organizational Chart
Time Basis Staff Chart Instructional Sheet
PACE Application - State Requirements
New Applicant - Financial Requirements
Expansion Application - Financial Requirements
Expansion Application Requirements Table
PACE Expansion Application Checklist

PACE Enrollment Agreement: Terms and Conditions Handbook

PACE Member Enrollment Agreement Terms and Conditions Handbook Template
- Updated 03/2012

PACE Contract Boilerplates

PACE Boilerplate Contract
- Updated 10/2022
PACE Subcontract Boilerplate

PACE Marketing

PACE Marketing Representative MOU
PACE Mass Mailer Request Form

PACE Policy Template

Blank Policy Template

PACE Grievance Policy & Templates

Grievance Policy
Attachment 1 Grievance Report Template
Attachment 2 Information for Participants Grievance Process
Attachment 3 Acknowledgement Letter for Receipt of Grievance
Attachment 4 Letter for Resolved Grievance
Attachment 5 Letter for Pending Grievance
Attachment 6 Grievance Log
Legal Services Listing for Medi-Cal Participant Assistance

PACE Appeal Policy & Templates

Appeal Policy
Attachment 1 NOA Request
Attachment 2 Process Info to participants
Attachment 3 Appeal of Denied Service Request
Attachment 4 Appeal Receipt
Attachment 5 Appeal Resolution
Attachment 6 Appeal Decision

Last modified date: 2/24/2023 12:33 PM