Ala. Admin. Code r. 560-X-53-.04

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-53-.04 - Participant Enrollment

(A) Enrollment Process

(1) Intake Process. Intake is an intensive process during which PACE staff members make one or more visits to a potential participant's place of residence and the potential participant may make one or more visits to the PACE center. At a minimum, the intake process must include the following activities:

(a) The PACE staff must explain to the potential participant and his or her representative or caregiver the following information:

(i) The PACE program, using a copy of the enrollment agreement, specifically references the elements of the agreement, including but not limited to 42 CFR §§ 460.154(e), (i) through (m), and (r);

(ii) The requirement that the PACE organization would be the participant's sole service provider and clarification that the PACE organization guarantees access to services, but not to a specific provider;

(iii) A list of the employees of the PACE organization who furnish care and the most current list of contracted health care providers;

(iv) Monthly premiums, if any;

(v) Any Medicaid spenddown obligations; and

(vi) Post-eligibility treatment of income.

(b) The potential participant must sign a release to allow the PACE organization to obtain his or her medical and financial information and eligibility status for Medicare and Medicaid.

(c) All services provided to a Medicaid recipient must be medically necessary in order to receive reimbursement.

(d) The Alabama Medicaid Agency must assess the potential participant, including any individual who is not eligible for Medicaid, to ensure that he or she meets the nursing facility level of care as set forth in Rule No. 560-X-10-.10.

(e) The PACE staff must assess the potential participant to ensure that he or she can be cared for appropriately in a community setting and that he or she meets all requirements for PACE eligibility as specified in 42 CFR §§ 460.150 - 460.172.

(2) Denial of Enrollment. When an enrollment is denied because his or her health or safety would be jeopardized by living in a community setting, the PACE organization is required to complete the following steps:

(a) Notify the individual in writing of the reason for enrollment denial and their appeal rights;

(b) Refer the individual to alternative services as appropriate;

(c) Maintain supporting documentation of the reason for the denial; and

(d) Notify CMS and the Alabama Medicaid Agency and make the documentation available for review.

(B) Enrollment Agreement and Procedures.

(1) The enrollment agreement must, at a minimum, contain the information required by 42 CFR § 460.154, as may be amended.

(2) After the participant signs the enrollment agreement, the PACE organization must give the participant the following:

(a) A copy of the enrollment agreement;

(b) A PACE membership card;

(c) Emergency information to be posted in his or her home identifying the individual as a PACE participant and explaining how to access emergency services; and

(d) Stickers for the participant's Medicare and Medicaid cards, as applicable, which indicate that he or she is a PACE participant and which include the phone number of the PACE organization.

(3) The PACE organization must submit participant information to CMS and AMA in accordance with established procedures.

(4) If there are changes in the enrollment agreement information at any time during the participant's enrollment, the PACE organization must meet the following requirements:

(a) Give an updated copy of the information to the participant; and

(b) Explain the changes to the participant and his or her representative or caregiver in a manner they understand.

(5) If the prospective PACE enrollee meets the eligibility requirements and signs the PACE enrollment agreement, the effective date of enrollment in the PACE program is on the first day of the calendar month following the date the PACE organization receives the participant's signed enrollment agreement.

(C) Continuation of Enrollment

(1) Duration of enrollment. Enrollment continues until the participant's death, regardless of changes in health status, unless either of the following actions occur:

(a) The participant voluntarily disenrolls.

(b) The participant is involuntarily disenrolled, as described in Rule No. 560-X-53.05.

(c) Annual recertification requirement. At least annually, the Alabama Medicaid Agency must reevaluate whether a participant meets the nursing facility level of care as set forth in Rule No. 560-X-10-.10 and all services provided to a Medicaid recipient must be medically necessary in order to receive reimbursement.

(2) Continued Eligibility

(a) Deemed continued eligibility. If the Alabama Medicaid Agency determines that a PACE participant no longer meets the Alabama Medicaid Agency nursing facility level of care requirements, the participant may be deemed to continue to be eligible for the PACE program until the next annual reevaluation, if, in the absence of continued coverage under this program, the participant reasonably would be expected to meet the nursing facility level of care requirement within the next 6 months.

(b) Continued eligibility criteria.

(i) The Alabama Medicaid Agency must establish criteria to use in making the determination of "deemed continued eligibility." The Alabama Medicaid Agency, in consultation with the PACE organization, makes a determination of deemed continued eligibility based on a review of the participant's medical record and plan of care. These criteria must be applied in reviewing the participant's medical record and plan of care.

(ii) The criteria used to make the determination of continued eligibility must be specified in the program agreement.

Ala. Admin. Code r. 560-X-53-.04

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.