Current through Register Vol. 35, No. 18, September 24, 2024
A.
The effective date for the recipient's enrollment in the program is the first
day of the calendar month following the signing of the enrollment agreement, if
an approved level of care (LOC) and all financial and non-financial eligibility
criteria have been approved by the income support division (ISD).
B. The potential participant signs an
enrollment agreement which includes, but is not limited to, the following
information:
(1) enrollment and disenrollment
data that will be collected and submitted to the HCA, including, but not
limited to, the following:
(a) social security
number;
(b) health insurance claim
number (HIC);
(c) last name, first
name, middle initial;
(d) date of
birth;
(e) address of current
residence;
(f) assigned ISD office
address;
(g) medicare number (part
A and part B) for medicare beneficiaries;
(h) medicaid number; and
(i) effective date of enrollment in the PACE
program;
(2) benefits
available, including all medicare and medicaid covered services, and how
services are allocated or can be obtained from the PACE program provider,
including, but not limited to:
(a) appropriate
use of the referral system;
(b)
after hours call-in system;
(c)
provisions for emergency treatment;
(d) hospitals to be used; and
(e) the restriction that enrollees may not
seek services or items from medicaid and medicare providers without
authorization from the interdisciplinary team;
(3) participant premiums and procedures for
payment, if any; this includes the medical care credit if the participant
enters a nursing home;
(4)
participant rights, grievance procedures, conditions for enrollment and
disenrollment and medicare and medicaid appeal processes;
(5) participants obligation to notify the
PACE program provider of a move or absence from the providers service
area;
(6) procedures to assure that
applicants understand that all medicaid services must be received through the
PACE program provider (the "lock-in" provision);
(7) procedures for obtaining emergency
services and urgent care;
(8)
statements that the PACE program provider has a program agreement with CMS and
the state medicaid agency that may be subject to periodic renewal, and that
termination of that agreement may result in termination of enrollment in the
PACE program; statement that the PACE program provider and the state medicaid
agency enter into a contract, which must be periodically renewed, and that
failure to renew the contract may result in termination of enrollment in the
PACE program;
(9) participants
authorization for the disclosure and exchange of information between CMS, its
agent, the state medicaid agency and the PACE program provider; and
(10) participant's signature and
date.
C. Once the
participant signs the enrollment agreement, the participant receives the
following:
(1) a copy of the enrollment
agreement;
(2) participant/
provider contract or evidence of coverage, if this is different from the
enrollment agreement;
(3) a PACE
program membership card; and
(4) an
emergency sticker to be posted in the participants home in case of emergency.
D. The provider will
inform the participant and the ISD office when enrollment is
completed.
E. Enrollment and
services continue unless eligibility of recipient changes or until the
participant either voluntarily disenrolls or involuntary disenrollment occurs
as described below.
