Current through September 17, 2024
Reasons for disenrollment, either voluntary or involuntary,
shall be documented by the PACE organization.
006.01 Voluntary Disenrollment
A participant may voluntarily disenroll from the program
without cause at any time, including if he/she no longer meets NF LOC
criteria.
006.02 Involuntary
Disenrollment
A PACE organization may involuntarily disenroll a participant
for any of the following reasons:
1.
The participant fails to pay, or make satisfactory arrangements to pay, any
premium due the PACE organization after a 30-day grace period.
2. The participant engages in disruptive or
threatening behavior. Disruptive or threatening behavior is either of the
following:
a. Behavior that jeopardizes a
participant's health or safety or the safety of others; or
b. Consistent refusal to comply with an
individual plan of care or the terms of the PACE enrollment agreement while
having decision-making capacity.
3. 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.
4. The
participant is determined to no longer meet nursing facility level of care and
is not deemed eligible under section 37-002.06 of this chapter.
5. The PACE organization's agreement with CMS
and the SAA is not renewed or is terminated.
6. The PACE organization is unable to offer
required services because of the loss of State licenses or outside provider
contracts.
37-006.02A
SAA Review and Final Determination: Before an
involuntary disenrollment is effective, it shall be reviewed by the SAA and a
determination made that acceptable grounds for disenrollment have been
documented by the PACE organization.
37-006.02B
Reinstatement in
PACE: A previously disenrolled PACE participant may re-enroll but
shall do so as a new applicant.
A participant scheduled to be disenrolled for failure to pay
his/her premium may be reinstated with no break in coverage if payment is made
prior to the effective date of disenrollment. If payment is received after the
effective date of disenrollment, the participant shall re-enroll as a new
applicant.
006.03
Transition from PACE
Upon either voluntary or involuntary disenrollment, the PACE
organization shall:
1. Facilitate a
participant's reinstatement in other Medicare and Medicaid programs for which
the participant is eligible;
2.
Coordinate the disenrollment date between Medicare and Medicaid for
participants who are eligible for both programs;
3. Give reasonable advance notice of the
disenrollment date to the participant; and
4. Continue to furnish all needed services as
identified in the participant's plan of care until the disenrollment
date.
37-006.03A
Effective Date: The participant shall be allowed to
continue to use PACE organization services and will remain liable for any
premiums due until the disenrollment date.
006.04 Appeals of Involuntary Disenrollment
Participants who are involuntarily disenrolled may appeal
using the SAA's appeal process (465 NAC
2-001).
37-006.04A
Appeal Process for
Medicare-only Beneficiaries: Medicare does not have an appeals
process that permits challenges of disenrollment determinations of
Medicare-only beneficiaries within PACE. Medicare-only eligible participants,
as well as private pay participants, must use the appeals process provided by
the SAA (71 Fed. Reg. 71244, 71303, 71312, 71317 (Dec. 8, 2006)).
