(A) Unless restricted from doing so by
CMS, the PACE organization shall involuntarily disenroll a participant from
PACE for one or more of the following reasons:
(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
(a) Behavior is disruptive or threatening when either of
the following occur:
(i) A participant with decision-making capacity and
consistently refuses to comply with his or her plan of care or the terms of the
enrollment agreement (e.g., repeated non-compliance with medical advice or
repeated failure to keep appointments).
(ii) 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.
(b) 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, including the following:
(a) For a participant
with decision making-capacity who fails to comply with his or her plan of care:
At least two attempts the PACE organization 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 participant are examples of acceptable documentation.
(b) For a participant who jeopardizes the
participant's health or safety, or the safety of himself, herself, or
others: One or both of the following records regarding at least one incident of
disruptive or threatening behavior:
(i) A signed statement from a witness or the
(ii) A police report or a security staff
(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 circumstances.
(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 both of the following:
(a) Documentation supporting one or more reasons listed under
paragraph (A) of this rule.
(b) The participant's utilization profile.
(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
(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
request, all of the following apply:
(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 participant.
(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.
(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 following:
(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
(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