317:35-18-10. Disenrollment (voluntary and involuntary)

(a) A participant may voluntarily disenroll from PACE at any time without cause however, the effective date of disenrollment must be the last day of the month that the participant elects to disenroll.

(b) A participant may be involuntarily disenrolled for any of the following reasons:

(1) The participant/caregiver or guardian fails to pay, or to make satisfactory arrangements to pay, any premium due the PACE organization after a 30-day grace period.

(2) The participant/caregiver or guardian engages in disruptive or threatening behavior, as described in subsection (c) of this section.

(3) 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 agrees to a longer absence due to extenuating circumstances.

(4) The participant is determined to no longer meet the SoonerCare nursing facility level of care requirements and is not deemed eligible.

(5) The PACE program agreement with CMS and OHCA 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.

(c) Requirements for involuntary disenrollment due to disruptive or threatening behavior.

(1) 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) A participant whose behavior jeopardizes his or her health or safety, or the safety of others; or

(B) 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.

(2) If a PACE organization proposes to disenroll a participant who is disruptive or threatening, the organization must document the following information in the participant’s medical record:

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

(B) All efforts to remedy the situation.

(d) A participant may be disenrolled involuntarily for noncompliant behavior.

(1) PACE organization 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.

(2) For purposes of this section, noncompliant behavior includes repeated noncompliance with medical advice and repeated failure to keep appointments.

(e) Before an involuntary disenrollment is effective, OHCA will review the participant's medical record and determine in a timely manner if the PACE organization has adequately documented acceptable grounds for disenrollment. Once OHCA confirms receipt of the involuntary disenrollment form from the PACE organization, the PACE organization must submit the following documentation within fourteen (14) days.

(1) A justification summary for involuntary disenrollment;

(2) Documentation of all efforts made to resolve the issue(s) underlying the request for involuntary disenrollment and the anticipated date of involuntary disenrollment;

(3) The two (2) most recent assessments by the Interdisciplinary Team (IDT). If the participant has not been enrolled long enough to have completed two IDT assessments, the participant’s UCAT should be submitted;

(4) The two (2) most recent IDT care plans;

(5) Initial and most recent Nursing Level of Care (NF LOC) assessments;

(A) The PACE organization must complete a new level of care assessment for a disenrolling participant whose most recent assessment was completed more than 12 months prior to the anticipated date of disenrollment.

(B) The PACE organization must complete a new level of care assessment for a disenrolling participant who is Deemed Continued Eligibility/waived.

(6) Any related assessments and documentation by specialists relevant to the criteria for involuntary disenrollment;

(7) A list of the participant’s medications; and

(8) A transition plan indicating how care and services will be coordinated between the PACE organization and the participant’s new providers as PACE enrollment ends and new provider enrollment begins.

(i) If the participant withdraws from PACE without enrollment into a Medicaid waiver program, such as ADvantage waiver services, this may result in loss of eligibility for Medicaid State Plan services due to the financial eligibility requirement;

(ii) The PACE and/or State Plan services that will be lost or unavailable as a result of the involuntary withdrawal;

(iii) What the participant must do to remain eligible to receive SoonerCare, if applicable;

(iv) Other services or programs for which the participant may be eligible, including information about contacting the Oklahoma Human Services (OHS) and Community Living, Aging, and Protective Services (CAP);

(v) How to access PACE services in the future; and

(vi) The withdrawal process, timeframes, and outcomes and the need for the participant to sign applicable consent forms.

(3) Disenrollment documentation. The PACE organization shall complete the following applicable disenrollment forms and documentation requirements with the participant and shall submit them to OHCA.

(A) Disenrollment form;

(B) Nursing facility level of care (NC LOC) status;

(i) The PACE organization must complete a new level of care assessment for a disenrolling participant whose most recent assessment was completed more than 12 months prior to the anticipated date of disenrollment.

(ii) The PACE organization must complete a new level of care assessment for a disenrolling participant who is Deemed Continued Eligibility/waived.

(C) The two (2) most recent assessments by the Interdisciplinary Team (IDT); and

(D) The two (2) most recent IDT care plans.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.