La. Admin. Code tit. 50 § XXIII-505

Current through Register Vol. 50, No. 11, November 20, 2024

Section XXIII-505 - Disenrollment

A. A PACE organization shall submit proposed denial of enrollment determinations of applicants for health and safety reasons and all involuntary disenrollments of participants to LDH for review prior to notifying applicants/participants of such adverse decisions. The Department shall review denials of PACE enrollment eligibility and disenrollments in a timely manner.

B. Involuntary Disenrollment

1. A participant may be involuntarily disenrolled for any of the following reasons:

a. a participant fails to pay, or to make satisfactory arrangements to pay, any premium due to the PACE organization after a 30 calendar day grace period;

b. the participant engages in disruptive or threatening behavior, as described in Paragraph 2 below;

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 and/or LDH agrees to a longer absence due to extenuating circumstances;

d. the participant is determined to no longer meet the state Medicaid nursing facility level of care requirements and is not deemed eligible;

e. the PACE program agreement with CMS and LDH 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; or

g. the participant who is permanently placed in a nursing facility fails to pay, or to make satisfactory arrangements to pay, the amount of patient liability that would be required to be paid by a Medicaid eligible resident of a nursing facility if he/she was not a participant in a PACE organization.

2. The following are considered disruptive or threatening behavior for purposes of involuntary disenrollment:

a. behavior that jeopardizes his or her health or safety, or the health or safety of others;

b. consistent refusal to comply with his or her individual plan of care or the terms of the PACE enrollment agreement by a participant with decision-making capacity, but not if the behavior is related to a mental or physical condition of the participant. Noncompliant behavior includes repeated noncompliance with medical advice and/or repeated failure to keep appointments; or

3. if a PACE organization proposes to disenroll a participant based on the disruptive or threatening behavior of the participant or the participant's caregiver, the organization shall document the following information in the participant's medical record:

a. the reasons for the proposal to disenroll the participant; and

b. all efforts made to remedy the situation and the outcome of the use of those efforts.

La. Admin. Code tit. 50, § XXIII-505

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:247 (February 2004), LR 33:850 (May 2007), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 50402 (3/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, Title XIX of the Social Security Act, and 42 CFR 460 et seq.