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Disenrollment

Rocky Mountain PACE participants may disenroll at the end of any month.

To download the Voluntary Disenrollment Policy, Click Here.

4.40 Voluntary Disenrollment

PURPOSE:

Rocky Mountain Health Care Services PACE Program voluntary disenrollments are based on policies and procedures that are fair, nondiscriminatory, and are not based on a participant’s increased needs or use of services.

POLICY:

I. Voluntary Disenrollments

  1. A RM PACE participant may voluntarily disenroll from the program without cause at any time. For example, a participant who elects another Medicare or Medicaid prepayment plan or optional benefit, including the hospice benefit, after enrolling as a RM PACE participant is considered a voluntary disenrollment. The State Administering Agency (SAA) does not review a voluntary disenrollment before it is effective; however, RM PACE must make documentation available for review upon request.
  2. A participant’s voluntary disenrollment is effective on the first day of the month following the date the Rocky Mountain PACE receives the participant’s notice of voluntary disenrollment. RM PACE participants attempting to disenroll are required to continue to use RM PACE providers and remain liable for any premiums until enrollment is terminated.
  3. As appropriate, RM PACE will involve the PACE Ombudsman when reviewing a possible voluntary disenrollment. Early involvement may help to prevent disenrollment.
  4. RM PACE must conduct an exit survey for each RM PACE participant who voluntarily disenrolls from the program and provide an aggregate of all responses per center to the SAA annually, or upon request. If a participant chooses not to complete the exit survey or refuses to sign voluntary disenrollment paperwork, RM PACE must document the refusal on the respective paperwork and in the participant’s medical record.
  5. In addition, RM PACE staff conducting exit survey will explain the right to file a grievance and provide the necessary steps if applicable.
    RM PACE will ensure that its employees or contractors do not engage in any practice that would reasonably be expected to have the effect of steering or encouraging disenrollment of participants due to a change in health status.
    RM PACE will use the information on voluntary disenrollments in the PACE organization’s internal quality improvement program.

To download the Involuntary Disenrollment Policy, Click Here.

4.41 Involuntary Disenrollment

PURPOSE:

Rocky Mountain Health Care Services PACE Program involuntary disenrollments are based on policies and procedures that are fair, nondiscriminatory, and are not based on a participant’s increased needs or use of services.

PROCESS:

Involuntary Disenrollments:

1. Reasons for involuntary disenrollment:

  • If after a 30-day grace period, the participant fails to pay or make satisfactory arrangements to pay any applicable Medicaid spend down liability or any amount due under the post-eligibility treatment of income process.
  • The participant, or the participant’s caregiver, engages in disruptive or threatening behavior.
    • Behavior that jeopardized the participants own health or safety, or the safety of others
    • Consistent refusal to comply with an individual plan of care of the terms of the PACE enrollment agreement by a participant with decision-making capacity
  • The participant moves out of the PACE program service area without notifying the PACE program.
  • The participant is out of the service area for more than 30 consecutive days, unless RM PACE agrees to a longer absence due to extenuating circumstances.
  • The participant is determined to no longer meet the State Medicaid nursing facility level of care requirements and is not deemed eligible.
  • The PACE program agreement with CMS and the State administering agency is not renewed or is terminated.
  • RM PACE is unable to offer health care services due to the loss of State licenses or contracts with outside providers.

2. Disruptive or threatening behavior – For purposes of this section, a participant who engages in disruptive or threatening behavior refers to a participant who exhibits either of the following:

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

3. Documentation of disruptive or threatening behavior – if RM PACE proposes to disenroll a participant who is disruptive or threatening, PACE must document the following information in the participant’s electronic health record:

  • The reasons for proposing to disenroll the participant.
  • All efforts to remedy the situation.

4. Noncompliant behavior:

  • RM PACE 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.
    • For purposes of this section, noncompliant behavior includes repeated noncompliance with medical advice and repeated failure to keep appointments.

5. State Administering Agency (SAA) review and final determination:

  • Before an involuntary disenrollment is effective, the SAA must review it and determine that RM PACE has adequately documented acceptable grounds for disenrollment. When disenrolling a participant, Rocky Mountain PACE must use the most expedient process allowed under Medicare and Medicaid procedures, as set forth in the PACE program agreement.
  • Rocky Mountain PACE will work with CMS and the State administering agency to reinstate the participant in other Medicare and Medicaid programs for which the participant is eligible.
  • Until enrollment is terminated, Rocky Mountain PACE participants are required to continue to use Rocky Mountain PACE provider services and remain liable for any premiums. Rocky Mountain PACE will continue to provide all needed services until the date of termination.
  • Rocky Mountain PACE will make appropriate referrals and ensure medical records are made available to new providers within 30 days.
  • All involuntary disenrollment’s will be discussed for timely processing based on final SAA administrator decision.
  • Rocky Mountain PACE must coordinate the disenrollment date between Medicare and Medicaid (for a participant who is eligible for both Medicare and Medicaid).

6. RM PACE has an agreement with the Centers for Medicare and Medicaid Services (CMS) and the State administering agency that is subject to renewal on a periodic basis. Termination may be initiated as follows:

  • Termination of agreement by CMS or SAA –
    • If this contract is terminated, RM PACE will work with each Participant as to the availability of other services. Each participant will be reinstated back into the traditional fee-for-service Medicaid or Medicare programs, if eligible. RM PACE will assist each participant with this transition to help each Participant find appropriate care and help each understand their options.
    • If CMS and/or the State Administering Agency does not renew and/or terminates the contract, RM PACE will provide our Participants at least 60 days advanced written notice.
  • Termination of agreement by RM PACE – to provide timely notice to CMS, the State administering agency, and participants, RM PACE shall allow 90 days before program termination.

7. A previously disenrolled participant may be reinstated in a PACE program.

8. If the reason for disenrollment is failure to pay the premium and the participant pa pays the premium before the effective date of disenrollment, the participant is reinstated in the PACE program with no break in coverage.

9. The Quality and Compliance Department will review disenrollment data to monitor for trends. If trends are identified, action may be taken as part of the quality improvement process.

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