D.C. Mun. Regs. tit. 29, r. 29-8802

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-8802 - PARTICIPANT DISENROLLMENT

8802.1

A PACE participant may voluntarily disenroll from the program without cause at any time, in accordance with the following:

(a) Requests for voluntary disenrollment from PACE shall be initiated by the PACE participant or the participant's authorized representative;

(b) A PACE participant's voluntary disenrollment is effective on the first day of the month following the date the PACE organization receives the participant's notice of voluntary disenrollment; and

(c) The PACE organization shall 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.

8802.2

In accordance with 42 CFR § 460.164, a PACE participant may be involuntarily disenrolled from the program for any of the following reasons:

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

(b) The participant, after a thirty (30) day grace period, fails to pay or make satisfactory arrangements to pay any applicable Medicaid spenddown liability or any amount due under the post-eligibility treatment of income process, as permitted under 42 CFR §§ 460.182 and 460.184.

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

(d) The participant is determined to no longer require a nursing facility level of care as described in 29 DCMR § 989.12;

(e) The participant engages in disruptive or threatening behavior, which means that he or she exhibits either of the following:

(1) The participant's behavior jeopardizes his or her health or safety, or the safety of others; or

(2) The participant has decision-making capacity but consistently refuses to comply with his or her individual plan of care or the terms of the PACE enrollment agreement;

(f) The participant's caregiver engages in disruptive or threatening behavior, which means that he or she exhibits behavior that jeopardizes the participant's health or safety, or the safety of the caregiver or others;

(g) The PACE program agreement with CMS and DHCF is not renewed or is terminated; or

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

8802.3

In accordance with 42 CFR § 460.164, the involuntary disenrollment of a participant shall not be effective until:

(a) After the PACE organization has notified DHCF and, based on its review, DHCF has determined in a timely manner that the PACE organization has adequately documented acceptable grounds for disenrollment consistent with § 8802.4; and

(b) The first day of the next month that begins thirty (30) days after the date the PACE organization sends notice of the disenrollment to the participant.

8802.4

Prior to the involuntary disenrollment of a participant based on the disruptive or threatening behavior of the participant or the participant's caregiver, the PACE organization shall document the following information in the participant's medical record:

(a) The reasons for proposing to disenroll the participant; and

(b) All efforts made to remedy the situation.

8802.5

The PACE organization may not disenroll a participant on the grounds that the participant 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 the purposes of this section, noncompliant behavior includes repeated noncompliance with medical advice and repeated failure to keep appointments.

8802.6

In disenrolling a participant, the PACE organization shall take the following actions, in accordance with 42 CFR § 460.166:

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

(b) Coordinate the disenrollment date between Medicaid and Medicare, if a participant is eligible for both;

(c) Give reasonable advance written notice to the participant, in accordance with § 8802.3(b), which shall include the following information:

(1) The intended disenrollment;

(2) The reason(s) for the intended disenrollment;

(3) Citations to the specific law(s) and regulations supporting the intended disenrollment;

(4) An explanation of the participant's right to request a hearing, and when reason for disenrollment is that described at § 8802.2, information regarding the participant's right to request a reconsideration; and

(5) The circumstances under which the participant's current services will be continued if a hearing is requested.

8802.7

To facilitate a disenrolled participant's reinstatement in other Medicaid and Medicare programs, the PACE organization shall do the following:

(a) Make appropriate referrals and ensure medical records are made available to new providers within thirty (30) days; and

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

8802.8

Until the effective date of the disenrollment, the PACE organization and participants shall meet the following requirements:

(a) The PACE organization shall continue to furnish all needed services; and

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

8802.9

A previously disenrolled participant may be reinstated in the PACE program.

8802.10

If the reason for a PACE participant's disenrollment is failure to pay the premium and the participant pays the premium before the effective date of disenrollment, the participant shall be reinstated in the PACE program with no break in coverage.

8802.11

The PACE organization shall have a procedure in place to document the reasons for all voluntary and involuntary disenrollment, and shall make this documentation available for review by CMS and DHCF.

D.C. Mun. Regs. tit. 29, r. 29-8802

Final Rulemaking published at 69 DCR 6400 (6/3/2022)