(1)PACE Participant Requests for Disenrollment:
(a)All PACE participant initiated requests for disenrollment from PACE programs must be initiated by the PACE participant or his or her representative;
(b)An applicant may request disenrollment if he or she has surgery scheduled at the time the PACE enrollment is effective and the provider is not on the PACE program’s provider panel and the participant wishes to have the services performed by that provider; and
(c)PACE participant or representative requests for disenrollment will be effective at the end of the month following the date of request for disenrollment except in the case of (b) above.
(2)PACE program requests for disenrollment:
(a)Causes for disenrollment:
(A)The Department may disenroll PACE participants for the following causes when requested by the PACE program subject to ADA requirements and approval by the Department:
(i)Participant’s behavior is disruptive, unruly, or abusive to the point that his or her enrollment seriously impairs the provider’s ability to furnish services to either the participant or other participants; the participant commits or threatens an act of physical violence directed at PACE staff, other patients, property, or other providers; participant commits fraudulent or illegal acts such as: permitting use of his or her medical ID card by others, altering a prescription, theft or other criminal acts committed in any providers or PACE programs premises. The PACE program will report any illegal acts to law enforcement authorities or to the Medicaid Fraud Unit as appropriate;
(ii)The participant fails to pay the PACE premium or loses Medicaid eligibility and is unable to pay the PACE premium;
(iii)The PACE participant moves out of the PACE program’s service area, and that move was not facilitated by the PACE program; or
(B)Other reasons for the PACE program’s requests for administrative disenrollment include the following:
(i)If a PACE participant is enrolled in the PACE program on the same day the participant is admitted to the hospital, the PACE program will be responsible for said hospitalization. If the participant is enrolled after the first day of the inpatient stay, the participant will be disenrolled, and the date of enrollment will be the next available enrollment date following discharge from inpatient hospital services; or
(ii)The participant is admitted to a state psychiatric institution.
(b)PACE participants will not be disenrolled solely for the following reasons:
(A)Because of a physical or mental disability;
(B)Because of an adverse change in the participant’s health;
(C)Because of the participant’s utilization of services, either excessive or lack thereof;
(D)Because the participant requests an administrative hearing; or
(E)Because the participant makes decisions regarding his or her medical care with which the PACE program disagrees.
(c)Requests by the PACE program for disenrollment of specific PACE participants will be submitted in writing to the Department for approval with copies and verbal communication to the SPD/AAA local office. The PACE program must document the reasons for the request, provide written evidence to support the basis for the request, and document that attempts at intervention were made. The following is the minimal documentation and process the Department will request:
(A)Documentation in the PACE participant’s clinical record at the time the problem is identified;
(B)Documentation regarding how the problem was addressed in the care plan. The PACE program will inform the participant or his or her representative that if the problem persists it may result in disenrollment;
(C)A written request to disenroll the participant to the Department, with a copy to the participant’s SPD/AAA caseworker. Documentation with the request will include the reason the PACE program is requesting disenrollment; a summary of the PACE program’s efforts to resolve the problem and other options attempted before requesting disenrollment; and
(D)If the request is due to a behavioral problem, the following documentation must also be submitted:
(i)A written assessment of the relationship of the behavior to the disability including: current medical knowledge or best available objective evidence to determine the nature, duration and severity of the risk to the health or safety of others; the probability that potential injury to others will actually occur; and whether reasonable modifications of policies, practices, or procedures will mitigate the risk to others;
(ii)An Interdisciplinary Team review that includes a mental health professional or behavioral specialist to assess the behavior, its history, and previous history of efforts to manage behavior;
(iii)If warranted, a clinical assessment that the behavior will not respond to reasonable clinical or social interventions;
(iv)Documentation in the care plan of any accommodations that have been attempted; and
(v)Any additional information or assessments requested by the Department.
(d)Disenrollment requests will be reviewed according to the following process:
(A)The request will be evaluated by a team of Department representatives who may request additional information from the SPD/AAA case manager, or other agencies as needed;
(B)The Department representatives will review the request and notify the PACE program of the decision within ten working days of receipt. Written decisions, including reasons for denials, will be sent to the PACE program within 15 working days from receipt of request;
(C)If the request is approved the disenrollment date is the end of the month after the date of approval. The PACE program must send the participant a letter within 14 days after the request was approved, with a copy to the participant’s SPD/AAA case manager and DMAP’s Health Management Unit (HMU). The letter must give the disenrollment date, the reason for disenrollment, and the notice of participant’s right to an administrative hearing.
(e)If a request for disenrollment is approved the PACE program will be responsible for facilitating a PACE participant’s enrollment into other programs by:
(A)Making appropriate referrals, ensuring clinical records are made available to new providers within 10 days of disenrollment to ensure participant’s needs are met without interruption of care or services; and
(B)Working with CMS and the Department to reinstate the participant in other Medicare and Medicaid programs for which they are eligible.
(f)If a participant requests a hearing, the participant will continue to be enrolled until an administrative hearing decision has been mailed to the participant and the PACE program.
(g)If a disenrollment date is determined from the administrative hearing, the Department sends a letter to the participant with a copy to the participant’s SPD/AAA case manager and the PACE program. The letter will inform the participant of the reason for the disenrollment decision.
(3)Department Initiated disenrollments: The Department may initiate and disenroll PACE participants as follows:
(a)If a Medicaid-only PACE participant moves out of the PACE program’s service area(s), the effective date of disenrollment will be the date specified by the Department and the Department will recoup the balance of that month’s capitation payment. If the participant has Medicare, the effective date of disenrollment will be the first of the month following the move out of the service area. If the participant has neither Medicare or Medicaid, the date of disenrollment will be the date specified by the Department;
(b)If the PACE participant is no longer eligible under SPD’s long-term care criteria or under eligibility criteria for PACE, the effective date of disenrollment will be the date specified by the Department; or
(c)If the PACE participant dies, the effective date of disenrollment will be the end of the month following the date of death, and the Department will recoup any capitation payments made to PACE program after the end of the month.
(4)If the disenrollment is generated by the Department under subsection (3)(a) or subsection (3)(b) of this rule, the Department will inform the participant of the disenrollment decision in writing, including the right to request an administrative hearing. If a participant requests an administrative hearing, the participant will continue to be enrolled until a hearing decision has been mailed to the participant.
Rule 411-045-0060 — Disenrollment,