The FY 2025 CMS Final Rule for MA, Part-D, and Programs of All-Inclusive Care for the Elderly (PACE) introduced significant changes aimed at improving participant outcomes, enhancing compliance requirements, and increasing accountability across the board. As we reach the midpoint of 2025, now is the time for PACE organizations to assess their operational response to the rising expectations – particularly around the 7-day service delivery timeframes.
Below, we recap key regulatory themes from the 2025 rule and take a deep dive into the 7-day requirement, offering practical steps your team can take to implement the changes effectively and avoid sanctions. *Note – we will add a follow on post to review the 2026 rule which focuses predominantly on HCC changes.
Review: Key Themes in the FY 2025 CMS Rule for PACE
The 2025 rule reflects CMS’s push for greater oversight and higher quality standards in PACE operations. Four central themes emerged:
1. Stronger Compliance and Oversight
CMS has instituted a point-based compliance evaluation system. Accumulated violations—like late Corrective Action Plans or repeat audit findings—can now block applications for new service areas.
2. Defined Service Delivery Timeframes
PACE organizations must now adhere to strict timelines for care coordination, including acting on team recommendations and delivering services within specific windows (e.g., 7 days).
3. Mandatory Immunizations for Staff
To reduce clinical risk, CMS now requires that staff with direct participant contact have up-to-date immunizations.
4. Elevated Participant Rights and Protections
New guidelines clarify participant rights and streamline the grievance process, with clear timelines for resolution and follow-up.
Focus Area: The 7-Day Service Arrangement Requirement
Under the FY 2025 CMS Final Rule, PACE organizations are required to arrange or schedule the delivery of interdisciplinary team (IDT) approved services within 7 calendar days of the service being approved.
“The PACE organization must arrange or schedule the delivery of interdisciplinary team approved services, other than medications, as expeditiously as the participant’s health condition requires, but no later than 7 calendar days after the date the interdisciplinary team or member of the interdisciplinary team first approves the service.”
This requirement ensures that participants receive timely access to necessary services, reflecting CMS’s commitment to prompt and coordinated care.
It’s important to note that this 7-day timeframe applies to the arrangement or scheduling of services, not necessarily their delivery. However, services must still be provided as expeditiously as the participant’s health condition requires.
There are exceptions for routine or preventive services when specific conditions are met, such as circumstances beyond the control of the PACE organization or when the participant’s condition does not necessitate expedited service.
Compliance with this requirement is crucial, as failure to arrange or schedule services within the specified timeframe may result in sanctions or impact the organization’s performance evaluations.
By focusing on timely arrangement and scheduling of services, PACE organizations can enhance care coordination and ensure compliance with CMS regulations.
Learn how Dina helps PACE organizations maintain compliance, performance manage in-home service vendors, and reduce administrative spend.
Set up a quick meet and greet call today.
Implementing Change: 4 Tactical Moves to Meet the New Requirements
To thrive under the new rules, PACE organizations must rethink how they build networks, coordinate care, and manage service data. Here’s a practical framework:
1. Rethink Contracting: From Rate to Performance
Don’t just negotiate rates—negotiate responsiveness and performance.
- Set SLAs (Service Level Agreements): Build performance-based clauses into contracts that require partners to initiate services within 72–96 hours of authorization.
- Monitor Compliance: Use regular scorecards to assess timeliness and escalate non-performance.
2. Modernize Network Management
Thin networks fail under pressure from rising demand, market changes, staffing shortages, and other external factors. PACE organizations need resilience, not singular coverage.
- Build Bench Strength: Don’t rely on a single provider per service type. Develop multiple contracting layers (primary, secondary, and on-demand).
- Prioritize Top Performers: Reward agencies that deliver fast, high-quality care. De-prioritize or de-contract with those who consistently miss timelines.
3. Streamline Coordination
If care coordination feels chaotic, has significant manual effort, and is operationally expensive, that’s a warning sign. As rising demand for in-home services increases, workflows need to remain one step ahead.
- Digitize Referrals: Replace faxes and phone calls with electronic referrals that auto-track receipt, status, and delivery.
- Use Integrated Workflows: Bring scheduling, authorization, and communication into one unified system to reduce lag and human error.
- Slash Administrative Burden: Every extra handoff adds risk. Streamlined workflows not only improve compliance—they reduce operational costs.
4. Eliminate Manual Visit and Service Delivery Data Collection
Manual visit data collection processes aren’t just inefficient—they’re risky. Failing to capture confirmation opens the door for compliance challenges and overpayments while limiting a PACE organization’s opportunity to manage their network via key performance data.
- Seamlessly Capture Data: Use systems that collect service documentation at the point of care and integrate it directly into your EHR.
- Chip Away at Fraud, Waste, and Abuse: Streamlined data collection deters falsification, ensures audit readiness, and saves your team countless hours.
Final Thoughts: Compliance Is the Floor, Not the Ceiling
The 7-day rule is more than a compliance benchmark—it’s a proxy for organizational agility and participant-centered care. CMS is signaling that timely, reliable service is the new standard, not a stretch goal.
PACE organizations that proactively modernize their contracting, network, and coordination infrastructure will not only avoid sanctions—they’ll outperform in participant satisfaction, clinical outcomes, and operational efficiency.
Now is the time to act. Mid-year is the perfect checkpoint to ensure your systems, processes, and people are aligned to meet the moment.
