Section 441.88.24. Enrollment and disenrollment.

A PACE organization must comply with the federal enrollment requirements stated in 42 CFR Sections 460.152 through 460.156 as amended to December 8, 2006.

         88.24(1) Eligibility for Medicaid enrollees. To enroll in a PACE program as an Iowa Medicaid enrollee, a person must meet the eligibility requirements specified in this subrule.

            a.                Basic eligibility requirements.

             (1)             The person must be 55 years of age or older.

             (2)             The person must reside in the service area of the PACE organization.

             (3)             The person must be eligible for Medicaid pursuant to the provisions in 441—Chapter 75 for persons in a medical institution.

             (4)             The department must determine that the person is eligible for Iowa Medicaid pursuant to 441—Chapter 76.

             (5)             The department must determine that the person needs the nursing facility level of care.

             (6)             The person must meet any additional program-specific eligibility conditions imposed under the PACE program agreement. These additional conditions shall not modify the requirements stated in this subrule.

            b.                Other eligibility requirements.

             (1)             At the time of enrollment, the person must be able to live in a community setting without jeopardizing the person’s health or safety, pursuant to the criteria specified in the PACE program agreement.

             (2)             To continue to be eligible for PACE as an Iowa Medicaid enrollee, a person must meet the annual recertification requirements specified in subrule 88.24(4).

         88.24(2) Effective date of enrollment. A person’s enrollment in the program is effective on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement.

         88.24(3) Duration of enrollment. Enrollment continues until the enrollee’s death unless either of the following actions occurs:

            a.               The enrollee voluntarily disenrolls. An enrollee may voluntarily disenroll from the program without cause at any time.

            b.               The enrollee is involuntarily disenrolled, as described in subrule 88.24(5).

         88.24(4) Annual recertification.

            a.               At least annually, the department shall:

             (1)             Reevaluate whether each enrollee continues to need the nursing facility level of care; and

             (2)             Review all financial and nonfinancial eligibility requirements for Medicaid enrollees. The enrollee shall complete Form 470-3118 or 470-3118(S), Medicaid Review.

            b.               Deemed continued eligibility. If the department determines that an enrollee no longer needs the nursing facility level of care, the department, in consultation with the PACE organization, shall determine whether, in the absence of continued PACE coverage, the enrollee reasonably would be expected to meet the nursing facility level-of-care requirement within the next six months. This determination shall be based on a review of the enrollee’s medical record and plan of care, applying criteria specified in the PACE program agreement. If the enrollee reasonably would be expected to meet the level-of-care requirement within six months, the enrollee’s eligibility for the PACE program may continue until the next annual reevaluation.

         88.24(5) Involuntary disenrollment. An involuntary disenrollment shall not become effective until the Department has determined that the PACE organization has adequately documented acceptable grounds for disenrollment.

            a.                Reasons for involuntary disenrollment. An enrollee may be involuntarily disenrolled for any of the following reasons:

             (1)             After a 30-day grace period, the enrollee fails to pay any amount due to the PACE organization pursuant to subrule 88.28(2) or refuses to make satisfactory arrangements to pay.

             (2)             The enrollee engages in disruptive or threatening behavior as described in paragraph 88.24(5)“b.”

             (3)             The enrollee 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 department determines that the enrollee no longer needs the nursing facility level of care and the enrollee is not deemed eligible pursuant to paragraph 88.24(4)“b.”

             (5)             The PACE program agreement with CMS and the department is not renewed or is terminated.

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

            b.                Disruptive or threatening behavior. “Disruptive or threatening behavior” refers to either of the following:

             (1)             Behavior that jeopardizes the enrollee’s health or safety or the safety of others; or

             (2)             Consistent refusal by the enrollee to comply with the enrollee’s individual plan of care or the terms of the PACE enrollment agreement when the enrollee has decision-making capacity.

            c.                Documentation of disruptive or threatening behavior. If a PACE organization proposes to disenroll an enrollee who is disruptive or threatening, the organization must document the following information in the enrollee’s medical record:

             (1)             The reasons for proposing to disenroll the enrollee.

             (2)             All efforts to remedy the situation.

            d.                Noncompliant behavior. A PACE organization may not disenroll an enrollee on the grounds that the enrollee has engaged in noncompliant behavior if the behavior is related to a mental or physical condition of the enrollee, unless the enrollee’s behavior jeopardizes the enrollee’s health or safety or the safety of others. “Noncompliant behavior” includes repeated noncompliance with medical advice and repeated failure to keep appointments.

         88.24(6) Effective date of disenrollment.

            a.               In disenrolling a Medicaid enrollee, the PACE organization must:

             (1)             Use the most expedient process allowed under the PACE program agreement;

             (2)             Coordinate the disenrollment date between Medicare and Medicaid for an enrollee who is eligible for both Medicare and Medicaid; and

             (3)             Give reasonable advance notice to the enrollee.

            b.               Until the date when enrollment is terminated, the following requirements must be met:

             (1)             The PACE organization must continue to furnish all needed services.

             (2)             The enrollee must continue to use PACE organization services.

         88.24(7) Documentation of disenrollment. A PACE organization must meet the following requirements:

            a.               Have a procedure in place to document the reasons for all voluntary and involuntary disenrollments.

            b.               Make documentation available for review by CMS and the department.

            c.               Use the information on voluntary disenrollments in the PACE organization’s internal quality assessment and performance improvement program.

         88.24(8) Reinstatement in other Medicare and Medicaid programs. After a disenrollment, the PACE organization shall work with CMS and the department to facilitate the former enrollee’s reinstatement in other Medicare and Medicaid programs by:

            a.               Making appropriate referrals to other Medicare and Medicaid programs for which the enrollee may be eligible; and

            b.               Ensuring that medical records are made available to new providers in a timely manner.

         88.24(9) Reinstatement in PACE. A previously disenrolled enrollee may be reinstated in a PACE program.

[ARC 0758C, IAB 5/29/13, effective 8/1/13; ARC 2358C, IAB 1/6/16, effective 1/1/16]