173-50-05 PACE: involuntary disenrollment.

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

(1) Failure to pay: 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 if the PACE organization documented at least one attempt it made in writing to the participant containing all the following components:

(a) The PACE organization requested all unpaid costs .

(b) The PACE organization warned the participant that disenrollment may result from non-payment .

(c) The PACE organization 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, 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) jeopardizing the participant's safety, other participants' safety, or the safety of employees of the PACE organization, an affiliate, or a subcontractor if the PACE organization has the following documentation retains one or both of the following records regarding at least one incident:

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

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

(4) Geography:

(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.

(6) Physician-patient relationship: The PACE organization shall involuntarily disenroll a participant for not maintaining a satisfactory physician-patient relationship (e.g., repeated non-compliance with medical advice or repeated failure to keep appointments) .

(7) Care plan: The PACE organization shall involuntarily disenroll a participant for not complying with the interdisciplinary team's care plan 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 .

(c) The PACE organization 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.

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

(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 .

(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 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 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 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: 8/1/2016
Five Year Review (FYR) Dates: 04/18/2016 and 08/01/2021
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