173-50-05 Involuntary disenrollment.

(A) Criteria for involuntary disenrollment of a participant from PACE:

(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 after a thirty-day grace period; and, the PACE organization has documentation that it made at least one attempt in writing to:

(a) Collect the unpaid costs;

(b) Warn that the non-payment of costs may lead to disenrollment; and,

(c) Explain 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 participant commits medicaid fraud or medicaid eligibility fraud, as described in sections 2913.40 and 2913.401 of the Revised Code, and the PACE organization has a signed narrative of the events from the staff person who discovered the fraud;

(3) Abusive behavior: The participant engages in abusive behavior (e.g. threats with a weapon, physical abuse, or recurrent verbal abuse) that jeopardizes the participant's safety, other participants' safety, or the safety of employees of the PACE organization, an affiliate, or a subcontractor; and, the PACE organization has the following documentation of 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;

(5) Physician-patient relationship: The participant fails to maintain a satisfactory physician-patient relationship (e.g., repeated non-compliance with medical advice or repeated failure to keep appointments);

(6) Care plan: The participant is not compliant with the interdisciplinary team's care plan; and:

(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 at least two attempts 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) Level of care: The participant is determined to no longer meet the level-of-care requirements and is not deemed eligible;

(8) Providers: The PACE organization is unable to offer healthcare services because of a loss of state licenses or contracts with outside providers; or,

(9) PACE agreement: The agreement between the PACE organization, ODA, and CMS is not renewed or is terminated.

(B) Process for involuntary disenrollment:

(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 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 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: 02/17/2013
R.C. 119.032 review dates: 11/21/2012 and 02/17/2018
Promulgated Under: 119.03
Statutory Authority: 173.01 , 173.02 , 173.50
Rule Amplifies: 173.50 ; 42 C.F.R. 460.164 (10/01/2011 edition)
Prior Effective Dates: 03/28/2009