Current through Register Vol. 43, No. 02, November 27, 2024
(A) Voluntary Disenrollment
(1) A PACE participant may voluntarily
disenroll from the program without cause at any time.
(B) Involuntary Disenrollment
(1) Reasons for involuntary disenrollment. A
participant may be involuntarily disenrolled for any of the following reasons.
(a) The Participant fails to pay or to make
satisfactory arrangements to pay, any premium due to the PACE organization
after a 30-day grace period;
(b)
The participant engages in disruptive or threatening behavior, as described
below:
(i) For purposes of this section, a
participant who engages in disruptive or threatening behavior refers to a
participant who exhibits either of the following:
1. A participant whose behavior jeopardizes
his or her health or safety, or the safety of others; or
2. A participant with decision-making
capacity who consistently refuses to comply with his or her individual plan of
care or the terms of the PACE enrollment agreement.
(ii) Documentation of disruptive or
threatening behavior. If a PACE organization proposes to disenroll a
participant who is disruptive or threatening, the organization must document
the following information in the participant's medical record:
1. The reasons for proposing to disenroll the
participant; and
2. All efforts to
remedy the situation.
(c) The participant moves out of the PACE
program service area or is out of the service area for more than 30 consecutive
days, unless the PACE organization agrees to a longer absence due to
extenuating circumstances;
(d) The
participant is determined to no longer meet the Alabama Medicaid Agency nursing
facility level of care requirements as set forth in Rule No.
560-x-10-.10;
(e) The PACE program agreement with CMS and
the Alabama Medicaid Agency is not renewed or is terminated;
(f) The PACE organization is unable to offer
health care services due to the loss of State licenses or contracts with
outside providers.
(2)
Noncompliant behavior.
(a) A PACE organization
may not disenroll a PACE participant on the grounds that the participant has
engaged in noncompliant behavior if the behavior is related to a mental or
physical condition of the participant, unless the participant's behavior
jeopardizes his or her health or safety, or the safety of others.
(b) For purposes of this section,
noncompliant behavior includes repeated noncompliance with medical advice and
repeated failure to keep appointments.
(3) Alabama Medicaid Agency review and final
determination. Before an involuntary disenrollment is effective, the Alabama
Medicaid Agency must review it and determine in a timely manner that the PACE
organization has adequately documented acceptable grounds for
disenrollment.
(C) (A
PACE organization must meet the following requirements:
(1) Have a procedure in place to document the
reasons for all voluntary and involuntary disenrollments;
(2) Make documentation available for review
by CMS and the Alabama Medicaid Agency; and
(3) Use the information on voluntary
disenrollments in the PACE organization's internal quality assessment and
performance improvement program.
(D) Effective date of disenrollment.
(1) In disenrolling a participant, the PACE
organization must take the following actions:
(a) Use the most expedient process allowed
under Medicare and Medicaid procedures, as set forth in the PACE program
agreement
(b) Coordinate the
disenrollment date between Medicare and Medicaid (for a participant who is
eligible for both Medicare and Medicaid).
(c) An advance notice of at least 10 days
prior to the disenrollment date is to be provided to the participant.
(2) Until the date enrollment is
terminated, the following requirements must be met:
(a) PACE participants must continue to use
PACE organization services and remain liable for any premiums.
(b) The PACE organization must continue to
furnish all needed services.
(E) To facilitate a participant's
reinstatement in other Medicare and Medicaid programs after disenrollment, the
PACE organization must do the following:
(1)
Make appropriate referrals and ensure medical records are made available to new
providers in a timely manner.
(2)
Work with CMS and the Alabama Medicaid Agency to reinstate the participant in
other Medicare and Medicaid programs for which the participant is
eligible.
(F) A
previously disenrolled participant may be reinstated in a PACE program if all
eligibility and enrollment criteria met upon reapplication. If the reason for
disenrollment is failure to pay the premium and the participant pays the
premium before the effective date of disenrollment, the participant is
reinstated in the PACE program with no break in coverage.
Author: Linda Lackey, Medicaid Administrator,
LTC Project Development Unit.
Statutory Authority: State Plan, Attachment
2.2-A, Attachment 3.1-A and Supplement 3; 42 CFR 460 Subpart I.