(A) The PACE organization shall
involuntarily disenroll a participant from PACE for one or more of the
(1) Failure to pay: The
participant, after a thirty-day grace period, fails to pay (or satisfactorily
arrange to pay) any premium due the PACE organization, any applicable medicaid
patient liability, or any amount due to the PACE organization under the
post-eligibility treatment of income process, 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 has notified the participant of
the participant's outstanding financial obligations and requested
(b) The PACE organization warned the participant that
disenrollment may result from non-payment.
(2) Fraud: The
participant 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
(3) Disruptive or
threatening behavior: The participant (or the participant's caregiver)
engages in disruptive or threatening behavior meeting the following
(a) A participant engages in disruptive or threatening
behavior when he or she jeopardizes his or her health or safety, the safety of
others, or when he or she has decision-making capacity and consistently refuses
to comply with his or her plan of care or the terms of the enrollment
agreement. When a participant with decision making-capacity fails to comply
with his or her plan of care (e.g., repeated non-compliance with medical advice
or repeated failure to keep appointments), the PACE organization shall document
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.
(b) A participant's caregiver engages in disruptive or
threatening behavior when he or she jeopardizes the participant's health
or safety, or the safety of himself, herself, or others.
(c) The PACE organization shall only involuntarily
disenroll a participant for the participant's or caregiver's
disruptive or threatening behavior if the PACE organization retains the
following in the participant's medical record:
(i) The reasons for
proposing to disenroll the participant.
(ii) Documentation of all
efforts to remedy the situation.
(iii) One or both of the
following records regarding at least one incident of disruptive or threatening
(a) A signed statement
from a witness or the provider.
(b) A police report or a
security staff report.
(a) The participant's permanent residence is no longer
located in the service area.
(b) The participant remains 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
(5) Incarceration: The
participant is incarcerated for a period of more than thirty consecutive
(6) Level of care: The participant no
longer meets the level-of-care requirements in rule 173-50-02 of the
Administrative Code and is not deemed eligible.
(7) Providers: The PACE organization is
unable to offer healthcare services because of a loss of state licenses or
contracts with outside providers.
(8) PACE agreement: The agreement between
the PACE organization, ODA, and CMS is not renewed or is
(B) Process to involuntarily disenroll a
(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
(2) In the time between
the request and ODA's decision, the PACE organization shall continue to
provide necessary services to the participant.
(3) ODA shall approve or
deny the request based upon the requirements in paragraph (A) of this rule,
then notify the PACE organization and send the participant a notice of denial
and hearing rights under section 5101.35 of the Revised Code and division
5101:6 of the Administrative Code.
(4) If ODA does not
approve the request, the PACE organization shall continue to provide necessary
services to the participant.
(5) If ODA approves the
(a) A participant's involuntary disenrollment is
effective on the first day of the month beginning thirty days after the day the
PACE organization sends notice of the disenrollment to the
(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
(d) The participant shall continue to obtain necessary
services through the PACE organization and shall continue to remain liable for
any premiums or post-eligibility treatment of income costs incurred through the
last day of enrollment; and,
(e) Before disenrollment, the PACE organization shall
initiate a discharge plan for each participant who is involuntarily
disenrolled. In each discharge plan, it shall state how it plans to do the
(i) Help the participant
obtain necessary transitional care through referrals to other medicaid or
medicare service providers.
(ii) Provide the
participant's medical records to new providers no later than thirty days
(6) After ODA approves an
involuntary disenrollment, ODA does all of the following:
(a) ODA notifies the PACE organization.
(b) ODA sends the participant a notice of denial and
hearing rights under section 5101.35 of the Revised Code and division 5101:6 of
the Administrative Code.
(i) If the participant
requests a hearing within fifteen days after ODA approves the involuntary
disenrollment, ODA places the disenrollment on hold until a state hearing has
(a) If the decision of
the state hearing is that ODA made a correct decision to disenroll, ODA
implements the requirements under paragraph (B)(5) of this rule and enters the
decision into the ODA- and ODM-approved eligibility systems.
(b) If the decision of
the state hearing is that ODA made an incorrect decision to disenroll, the
participant remains enrolled in PACE.
(ii) If the participant
does not request a hearing, ODA proceeds with disenrolling the participant from
PACE and implement the requirements under paragraph (B)(5) of this