Sec. 10.09.44.07. Termination of Participant's Enrollment

A. Termination of a participant's enrollment may be initiated by the:

(1) PACE provider;

(2) Department;

(3) Participant; or

(4) Participant's legal guardian or legal representative.

B. All enrollment terminations require prior approval by the Department.

C. General Requirements for Processing Disenrollments.

(1) The Department shall establish a monthly cut-off date for the receipt of disenrollment forms as follows:

(a) Disenrollments received by the monthly cut-off date shall be processed the next payment processing date and disenrollment is effective the first day of the following month; and

(b) Disenrollments received after the monthly cut-off date shall be processed the following month's payment processing date and disenrollment is effective the first day of the following month.

(2) Disenrollment requests shall be submitted to the Department by the PACE provider within 3 working days from completion, except if the participant requests that the form be mailed to the participant's home address for completion.

(3) The PACE provider shall send the participant a copy of the completed disenrollment forms, regardless of who initiated the disenrollment process.

D. Voluntary Disenrollment by Participant.

(1) In general, participants may disenroll from the PACE provider at their discretion at any time without cause, by completing or having completed by a legal guardian or legal representative a disenrollment form provided by the Department.

(2) The PACE provider shall act to facilitate disenrollment, including mailing disenrollment request forms to participants desiring to disenroll but having difficulty accessing the PACE provider's office.

(3) The PACE provider shall date-stamp participants' disenrollment requests upon receipt.

(4) A disenrollment request completed by a participant before or on the Department's monthly cut-off date shall be submitted by the PACE provider to the Department before that month's processing date for capitation payments.

(5) A disenrollment request completed by a participant and received by the PACE provider by the monthly cut-off date, but which the PACE provider submits to the Department after the payment processing date, may not be processed until the following month's payment cycle and shall be retroactive to the first day of that month.

(6) When the participant completes the disenrollment form by the monthly cut-off date, but the PACE provider does not receive the form until after the cut-off date, the disenrollment may not be processed until the following month, and the PACE provider shall promptly notify the participant in writing that the disenrollment will not be processed until the end of the next month and that the participant shall continue to receive all services from the PACE provider.

(7) A participant who moves out of the service area shall be processed as a voluntary disenrollment.

E. Disenrollment Initiated by the PACE Provider.

(1) The PACE provider shall have a written policy regarding termination of a participant's enrollment by the PACE provider which shall address, at a minimum:

(a) Under what conditions a participant is to be disenrolled by the PACE provider; and

(b) The time elements involved in processing terminations.

(2) A disenrollment initiated by the PACE provider shall require prior approval by the Department.

(3) A disenrollment may not occur because of an adverse change in the participant's health status.

(4) The participant's complete medical and utilization history shall be provided by the PACE provider to the Department, upon request, in order to determine an appropriate disenrollment date.

(5) The PACE provider shall notify the participant within 14 days of when the disenrollment is approved, and the participant may appeal the decision under the terms of COMAR 10.01.04.

(6) Disenrollment may be requested by the PACE provider by providing to the Department acceptable documentation that the:

(a) Participant's domicile was relocated outside the PACE provider's service area;

(b) Participant is no longer eligible in accordance with Regulation .05 of this chapter;

(c) Participant is discovered to be an individual for whom there existed legal documentation at the time of enrollment that the individual was mentally incompetent, but the participant signed the enrollment form;

(d) Participant commits fraudulent or illegal acts, such as permitting use of the participant's medical identification card by others, altering a prescription, theft or other criminal acts committed in any provider's or PACE provider's premises;

(e) Participant fails to complete and submit consents, releases, or assignments and other documents reasonably requested by the PACE provider in order to obtain or assure payment by Medicare, Medicaid, or other third party payers; or

(f) Participant has died.

(7) A PACE provider requesting disenrollment based on documentation under §E(6)(d) of this regulation shall report any illegal acts to law enforcement authorities or to the Medicaid Fraud Control Unit of the Department's Recipient Fraud Unit as appropriate.

(8) If a request for disenrollment is approved, the PACE provider shall facilitate a PACE participant's enrollment into other programs by:

(a) Making appropriate referrals; and

(b) Ensuring clinical records are made available to new providers within 10 days of disenrollment.

F. Disenrollment by the Department. The Department shall disenroll a participant if the:

(1) PACE Provider Agreement between the PACE provider and the Department is terminated;

(2) Participant dies;

(3) Participant becomes ineligible for enrollment in accordance with Regulation .05 of this chapter; or

(4) Participant loses eligibility for Medical Assistance Program benefits or changes to a category of assistance not eligible for enrollment in PACE.

G. Effective Date of Termination.

(1) Except as specified in §H of this regulation or unless the Department specifically authorizes an earlier effective date, a disenrollment initiated by the participant or the PACE provider before the monthly cut-off date established by the Department, if approved, shall be effective on the first day of the month following the respective cut-off date.

(2) The Department shall approve or disapprove requests for voluntary disenrollment within 5 working days of the date the request is received.

(3) A disenrollment initiated by either the Department or the PACE provider because the participant died or became ineligible for enrollment for one of the other reasons specified in this regulation is effective the day after the event causing the ineligibility.

(4) For disenrollments initiated by the Department, the Department shall provide the PACE provider with written notice.

(5) A disenrollment resulting from the participant's loss of Program eligibility shall be effective on the day following the participant's last date of eligibility.

(6) The Department may recover any capitation payments made on behalf of the participant for periods following the effective date of the participant's termination of enrollment or loss of eligibility, but not for a retroactive period greater than 3 months except in the case of:

(a) The participant's death; or

(b) The participant's relocation of domicile outside the PACE provider's service area.

(7) The Department may determine a retroactive disenrollment date based on the conditions present when the disenrollment is requested or indicated.