173-50-05 Involuntary disenrollment.

 

 

 

173-50-05                    PACE: Involuntary disenrollment.

 

 

 

(A)   Criteria for involuntary disenrollment of The PACE organization shall involuntarily disenroll a participant from PACE for one or more of the following reasons:

 

(1)   Failure to pay: The participant fails to pay (or satisfactorily arrange to pay) any premium or patient-liability cost owed to the PACE organization shall involuntarily disenroll a participant after a thirty-day grace period for not paying (or satisfactorily arranging to pay) any premium or patient-liability costs owed to the PACE organization; and, if the PACE organization has documentation that it made documented at least one attempt it made in writing to the participant containing all the following components:

 

(a)   The PACE organization Collect requested the all unpaid costs;.

 

(b)       The PACE organization Warn that warned the participant that disenrollment may result from the non-payment of costs may lead to disenrollment; and,.

 

(c)   The PACE organization Explain explained that no right to file a grievance exists for a participant who is disenrolled because he or she did not pay patient-liability costs.

 

(2)   Fraud: The PACE organization shall involuntarily disenroll a participant who commits medicaid fraud or medicaid eligibility fraud, as described in sections

2913.40 and 2913.401 of the Revised Code, and if the PACE organization has a signed narrative of the events from the staff person who discovered the fraud;.

 

(3)     Abusive behavior: The PACE organization shall involuntarily disenroll a participant who engages in abusive behavior (e.g. threats with a weapon, physical abuse, or recurrent verbal abuse) that jeopardizes jeopardizing the participant's safety, other participants' safety, or the safety of employees of the PACE organization, an affiliate, or a subcontractor; and, if the PACE organization has the following documentation retains one or both of the following records of regarding at least one incident:

 

(a)   A signed statement from a witness or the provider; and,.

 

(b)   A police report or a security staff report.

 

(4)    Geography: The participant's permanent residence is no longer located in the service area, the participant is outside the service area or is incarcerated for

 

 

more than thirty consecutive days, unless the PACE organization authorizes a longer period of absence for extenuating circumstances;

(a) The PACE organization shall involuntarily disenroll a participant whose permanent residence is no longer located in the service area.

(b) The PACE organization shall involuntarily disenroll a participant for remaining outside the service area for a period of more than thirty consecutive days, unless the PACE organization authorizes a longer period of absence for extenuating circumstances.

(5) Incarceration: The PACE organization shall involuntarily disenroll a participant for being incarcerated for a period of more than thirty consecutive days.

(5)(6) Physician-patient relationship: The PACE organization shall involuntarily

disenroll a participant

fails to maintain for not maintaining a satisfactory

physician-patient relationship (e.g., repeated non-compliance with medical advice or repeated failure to keep appointments);.

(6)(7) Care plan: The PACE organization shall involuntarily disenroll a participant is not for not compliant complying with the interdisciplinary team's care plan; and if all the following apply:

(a)   The participant is capable of making informed decisions;.

(b)     Non-compliance with the care plan may result in a negative health outcome; and,.

(c)    The PACE organization has documentation that it made documented at least two attempts it made in the past six months to educate the participant on the importance of following the care plan, the negative health consequences of not doing so, and a warning that not doing so may result in disenrollment. Medical records and copies of letters written to the participation are examples of acceptable documentation.

(7)(8) Level of care: The PACE organization shall involuntarily disenroll a participant is determined to who no longer meet meets the level-of-care requirements and is not deemed eligible;.

(8)(9) Providers: The PACE organization shall involuntarily disenroll a participant if the PACE organization is unable to offer healthcare services because of a loss of state licenses or contracts with outside providers; or,.

(9)(10) PACE agreement: The PACE organization shall involuntarily disenroll a participant if the agreement between the PACE organization, ODA, and CMS is not renewed or is terminated.

(B)  Process for involuntary disenrollment to involuntarily disenroll a PACE participant:

(1)   If a PACE organization requests permission to disenroll a participant under this rule, it shall submit the request to ODA along with:

(a)   Documentation supporting one or more criteria requirements in paragraph

(A)  of this rule; and,

(b)   The participant's utilization profile.

(2)   In the time between the request and ODA's decision:

(a)     The  PACE  organization  shall  continue  to  provide  for  the  necessary services to the participant; and,

(b)   The participant shall continue to obtain necessary services under medicaid only through the PACE organization.

(3)   ODA shall approve or deny the request based upon the criteria requirements in paragraph (A) of this rule, then notify the PACE organization and the participant.

(4)   If ODA does not approve the request:

(a)   The PACE organization shall continue to provide necessary services to the participant; and,

(b)   The participant shall continue to obtain necessary services under medicaid only through the PACE organization.

(5)   If ODA approves the request:

(a)   It shall establish the last date of enrollment for the participant as:

(i)   The last day of the month in which the request was made;

(ii)    The date of death, if the participant dies before the last day of the month in which the request was made; or,

(iii)     The date on which the PACE agreement terminates, if the date occurs before the last day of the month in which the request was made.

(b)   The PACE organization shall notify the participant in writing of the last day of enrollment;

(c)     The PACE organization shall continue to provide for the necessary services to the participant through the last day of enrollment;

(d)  The participant shall continue to obtain necessary services under medicaid only through the PACE organization and shall continue to remain liable for any premiums or patient-liability costs incurred through the last day of enrollment; and,

(e)   The PACE organization shall create a discharge plan for each participant who is involuntarily disenrolled, regardless of the reason for the disenrollment. In each discharge plan, it shall state how it plans to:

(i)   Help the participant obtain necessary transitional care;

(ii)   Provide medical records to new providers;

(iii)    Initiate the process of returning the participant to a fee-for-service medicaid program if the participant was enrolled in a fee-for-service medicaid program before enrolling into PACE.

Effective:                                                             08/01/2016

Five Year Review (FYR) Dates:                         04/18/2016 and 08/01/2021

CERTIFIED ELECTRONICALLY

Certification

06/23/2016

Date

Promulgated Under:                           119.03

Statutory Authority:                           173.01, 173.02, 173.50

Rule Amplifies:                                  173.50, 173.55; 42 C.F.R. 460.164 (October, 2015 edition)

Prior Effective Dates:                         03/28/2009, 02/17/2013