Section 471-37-006 - PARTICIPANT DISENROLLMENTReasons for disenrollment, either voluntary or involuntary, shall be documented by the PACE organization.
006.01 Voluntary Disenrollment A participant may voluntarily disenroll from the program without cause at any time, including if he/she no longer meets NF LOC criteria.
006.02 Involuntary Disenrollment A PACE organization may involuntarily disenroll a participant for any of the following reasons:
1. The participant fails to pay, or make satisfactory arrangements to pay, any premium due the PACE organization after a 30-day grace period.2. The participant engages in disruptive or threatening behavior. Disruptive or threatening behavior is either of the following: a. Behavior that jeopardizes a participant's health or safety or the safety of others; orb. Consistent refusal to comply with an individual plan of care or the terms of the PACE enrollment agreement while having decision-making capacity.3. 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.4. The participant is determined to no longer meet nursing facility level of care and is not deemed eligible under section 37-002.06 of this chapter.5. The PACE organization's agreement with CMS and the SAA is not renewed or is terminated.6. The PACE organization is unable to offer required services because of the loss of State licenses or outside provider contracts. 37-006.02ASAA Review and Final Determination: Before an involuntary disenrollment is effective, it shall be reviewed by the SAA and a determination made that acceptable grounds for disenrollment have been documented by the PACE organization.37-006.02BReinstatement in PACE: A previously disenrolled PACE participant may re-enroll but shall do so as a new applicant. A participant scheduled to be disenrolled for failure to pay his/her premium may be reinstated with no break in coverage if payment is made prior to the effective date of disenrollment. If payment is received after the effective date of disenrollment, the participant shall re-enroll as a new applicant.
006.03 Transition from PACE Upon either voluntary or involuntary disenrollment, the PACE organization shall:
1. Facilitate a participant's reinstatement in other Medicare and Medicaid programs for which the participant is eligible;2. Coordinate the disenrollment date between Medicare and Medicaid for participants who are eligible for both programs;3. Give reasonable advance notice of the disenrollment date to the participant; and4. Continue to furnish all needed services as identified in the participant's plan of care until the disenrollment date.37-006.03AEffective Date: The participant shall be allowed to continue to use PACE organization services and will remain liable for any premiums due until the disenrollment date.006.04 Appeals of Involuntary Disenrollment Participants who are involuntarily disenrolled may appeal using the SAA's appeal process (465 NAC 2-001).
37-006.04AAppeal Process for Medicare-only Beneficiaries: Medicare does not have an appeals process that permits challenges of disenrollment determinations of Medicare-only beneficiaries within PACE. Medicare-only eligible participants, as well as private pay participants, must use the appeals process provided by the SAA (71 Fed. Reg. 71244, 71303, 71312, 71317 (Dec. 8, 2006)).471 Neb. Admin. Code, ch. 37, § 006