Ala. Admin. Code r. 560-X-53-.05

Current through Register Vol. 42, No. 12, September 30, 2024

Section 560-X-53-.05 - Participant Voluntary And Involuntary Disenrollment

(A) Voluntary Disenrollment

(1) A PACE participant may voluntarily disenroll from the program without cause at any time.

(B) Involuntary Disenrollment

(1) Reasons for involuntary disenrollment. A participant may be involuntarily disenrolled for any of the following reasons.

(a) The Participant fails to pay or to make satisfactory arrangements to pay, any premium due to the PACE organization after a 30-day grace period;

(b) The participant engages in disruptive or threatening behavior, as described below:

(i) For purposes of this section, a participant who engages in disruptive or threatening behavior refers to a participant who exhibits either of the following:

1. A participant whose behavior jeopardizes his or her health or safety, or the safety of others; or

2. A participant with decision-making capacity who consistently refuses to comply with his or her individual plan of care or the terms of the PACE enrollment agreement.

(ii) Documentation of disruptive or threatening behavior. If a PACE organization proposes to disenroll a participant who is disruptive or threatening, the organization must document the following information in the participant's medical record:

1. The reasons for proposing to disenroll the participant; and

2. All efforts to remedy the situation.

(c) The participant moves out of the PACE program service area or is out of the service area for more than 30 consecutive days, unless the PACE organization agrees to a longer absence due to extenuating circumstances;

(d) The participant is determined to no longer meet the Alabama Medicaid Agency nursing facility level of care requirements as set forth in Rule No. 560-x-10-.10;

(e) The PACE program agreement with CMS and the Alabama Medicaid Agency is not renewed or is terminated;

(f) The PACE organization is unable to offer health care services due to the loss of State licenses or contracts with outside providers.

(2) Noncompliant behavior.

(a) A PACE organization may not disenroll a PACE participant on the grounds that the participant has engaged in noncompliant behavior if the behavior is related to a mental or physical condition of the participant, unless the participant's behavior jeopardizes his or her health or safety, or the safety of others.

(b) For purposes of this section, noncompliant behavior includes repeated noncompliance with medical advice and repeated failure to keep appointments.

(3) Alabama Medicaid Agency review and final determination. Before an involuntary disenrollment is effective, the Alabama Medicaid Agency must review it and determine in a timely manner that the PACE organization has adequately documented acceptable grounds for disenrollment.

(C) (A PACE organization must meet the following requirements:

(1) Have a procedure in place to document the reasons for all voluntary and involuntary disenrollments;

(2) Make documentation available for review by CMS and the Alabama Medicaid Agency; and

(3) Use the information on voluntary disenrollments in the PACE organization's internal quality assessment and performance improvement program.

(D) Effective date of disenrollment.

(1) In disenrolling a participant, the PACE organization must take the following actions:

(a) Use the most expedient process allowed under Medicare and Medicaid procedures, as set forth in the PACE program agreement

(b) Coordinate the disenrollment date between Medicare and Medicaid (for a participant who is eligible for both Medicare and Medicaid).

(c) An advance notice of at least 10 days prior to the disenrollment date is to be provided to the participant.

(2) Until the date enrollment is terminated, the following requirements must be met:

(a) PACE participants must continue to use PACE organization services and remain liable for any premiums.

(b) The PACE organization must continue to furnish all needed services.

(E) To facilitate a participant's reinstatement in other Medicare and Medicaid programs after disenrollment, the PACE organization must do the following:

(1) Make appropriate referrals and ensure medical records are made available to new providers in a timely manner.

(2) Work with CMS and the Alabama Medicaid Agency to reinstate the participant in other Medicare and Medicaid programs for which the participant is eligible.

(F) A previously disenrolled participant may be reinstated in a PACE program if all eligibility and enrollment criteria met upon reapplication. If the reason for disenrollment is failure to pay the premium and the participant pays the premium before the effective date of disenrollment, the participant is reinstated in the PACE program with no break in coverage.

Ala. Admin. Code r. 560-X-53-.05

Emergency rule effective May 1, 1991. Permanent rule effective August 14, 1991. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed November 10, 2011; effective December 15, 2011. Amended: Filed May 9, 2013; effective June 13, 2013.

Author: Linda Lackey, Medicaid Administrator, LTC Project Development Unit.

Statutory Authority: State Plan, Attachment 2.2-A, Attachment 3.1-A and Supplement 3; 42 CFR 460 Subpart I.