may disenroll from the program for any reason upon written notification to the
program. If the participant is
unable or unwilling to provide written notification, he/she may provide verbal
notice, and Total Senior Care, Inc. will confirm the request in writing.
A participant may be involuntarily disenrolled from the program only
if certain restrictive criteria are met (see
All participants who disenroll from Total Senior Care, Inc. will be
linked to appropriate services for their care after enrollment in the PACE
For individuals with Medicaid, all disenrollment requests are reviewed by
the Cattaraugus County Department of Social Services and are effective on the
first day of the month following the month in which the request is made (or the
subsequent month if the request is submitted later than the deadline for
For individuals with Medicare only, the disenrollment will be processed
as quickly as possible through the Medicare system.
Any involuntary disenrollment requested by Total Senior Care, Inc. must
be approved by Cattaraugus County Department of social Services before the
disenrollment can take effect, regardless of the participantís insurance
participant notifies the program that he/she wishes to disenroll.
staff will contact the participant/caregiver to determine the reason for
participant is not required to provide a reason, but the program will
request the information for quality improvement purposes.
disenrollment is a result of program dissatisfaction, a member of the IDT will
contact the participant/caregiver within 24 hours to discuss concerns or issues
that could be addressed and resolved so that the participant could decide to
remain in the program. If the
participant still wishes to disenroll, the program will follow through with the
disenrollment process. He/she will
be asked to sign a disenrollment request form.
participant will be informed by the program that their PACE services will
continue to be provided by the Total Senior Care, Inc. program until the end
of the month or until the end of the following month if the decision is made
after the cut-off date for notification of Cattaraugus County Department of
Social Services. (For an
individual with Medicare only, the disenrollment will be completed through
the Medicare system.)
IDT (generally the Social Worker or Intake Coordinator) will compile the
required information for submission to Cattaraugus County Department of
Social Services. The following
information will be included (based on direction of Cattaraugus County
Department of Social Services):
Disenrollment request form (signed by the participant if a
voluntary disenrollment; by a member of the IDT on the second page of the form
if an involuntary disenrollment). If
the participant refuses to sign the disenrollment request form, the program
staff will document this in the participantís record.
A copy of the letter that is sent to the participant confirming his/her
request for disenrollment is also forwarded to Cattaraugus County Department of
Brief summary of the participantís health status, service needs,
and plan for providing services upon disenrollment.
Disenrollment requests are submitted on a timely basis in
accordance with working procedures with Cattaraugus County Department of Social
Program will notify the participant of the disenrollment process,
including the anticipated effective date.
Cattaraugus County Department of Social Services will disenroll
the participant to be effective the first day of the next month.
(The disenrollment will be effective on the first day of the subsequent
month if the request is submitted later than the deadline for processing it.)
Cattaraugus County Department of Social Services will notify Total
Senior Care, Inc. (Usually within
three to five days of the end of the month) in writing that disenrollment has
been entered into the Medicaid system, and the effective date of the change.
Services from Total Senior
Care, Inc. to the participant will remain in place until the effective date of
At this point:
CMS is notified of the disenrollment so that traditional Medicare
benefits can be restored.
The participant will be given written notice that the
disenrollment has been completed.
All services will remain in place until the end of the month
unless participant chooses to terminate services.
During this time period, Total Senior Care, Inc. staff links the
participant to services that would be provided once the disenrollment is
Alternative long term supportive services in the community or in a
facility-based program, as appropriate, to ensure that the participantís
health and long term care needs continue to be met after his/her enrollment in
Total Senior Care, Inc. ends.
A physician, for the provision of medical care.
(If a referral is needed, Total Senior Care, Inc. staff will provide
Medicare prescription drug coverage, through a Medicare PDP or
Medicare MA/PD plan.
The home care nurse completes discharge SAAM assessment.
The IDT (generally the social worker) writes summary in progress
notes that includes: service at point of termination, participantís reason for
termination, and arrangements made with the participant for continuation of
services under other arrangements if indicated.
situations, Total Senior Care, Inc. must disenroll a participant, even if the
participant wishes to remain enrolled in the program.
In these circumstances, the program will submit the required
documentation needed to process the disenrollment to Cattaraugus County
Department of Social Services within five days of the time that the program
determines that involuntary disenrollment is required.
reasons shall require an involuntary disenrollment, unless the participant
agrees to voluntarily terminate his/her enrollment and signs a disenrollment
The participant moves out of the area or leaves the area for at
least 30 consecutive days, unless Total Senior Care, Inc. has agreed to a longer
period of absence. In such
instances, NYSDOH must be notified and agree to the programís decision.
This can be obtained verbally by calling the Bureau of Continuing care
initiatives at 518-474-6965.
Program staff will attempt to assist participant in securing necessary
services in the new location.
The participant fails to pay for or make arrangements to pay Total
Senior Care, Inc. the amount due within thirty days (30 days) after the amount
There are other
situations where if unresolved, an involuntary disenrollment action can become
necessary. These include:
The participant loses his/her right to receive benefits from the
Medicaid program and is unwilling and/or
unable to pay privately for the services. Total
Senior Care, Inc. staff will attempt to
assist participant in regaining benefits.
All participants who have a Medicaid surplus receive a monthly
invoice from Total Senior Care, Inc., advising them of their current obligation
to pay. Prior to initiating a
disenrollment for non-payment of surplus, the program will provide to the
participant, in writing, a summary of the charges owed and a timeframe for
paying this amount to Total Senior Care, Inc.
A member of the IDT
(usually the social worker) will discuss the notice with the participant and
his/her family (if appropriate) to ensure that they understand the consequences
If the participant
continues to fail to make payments, Total Senior Care, Inc. will request
You, a member of your household, or a caregiver jeopardize your
health and safety, or the health and safety of others, including members of the
Total Senior Care, Inc. team and network.
You, a family member or a caregiver jeopardizes your health and
safety by consistently not complying with or interfering in your care plan or
the requirements of your enrollment agreement.
safety of Total Senior Care, Inc. personnel is considered grounds for
developing alternate service arrangements for the participant.
For example, if appropriate, Total Senior Care, Inc. personnel may
continue to provide services at the PACE center during the investigation of
the unsafe situation. Staff will
inform the Executive Director of the threat for investigation.
If threat is validated, participant will be disenrolled from the
program. In the event that an investigation is initiated, and the situation
is progressing in such a way that involuntary enrollment may be considered,
the PACE Center Manager will advise the DSS via an email to the Cattaraugus
County Health Administrator.
Program will notify the participant of results of validated investigation
and notify family and the local DSS of involuntary disenrollment within one
day of validated investigation.
Upon annual re-assessment, the participant is no longer clinically
eligible for nursing home level of care.
such instances, The IDT discusses the assessment to evaluate the
participantís risk for decompensating and requiring nursing home level of
care within the next six months in the absence of Total Senior Care, Inc.
The results of this assessment are documented in the participantís
in the professional opinion of the IDT, a return to nursing home level of
care will not be needed in the subsequent six-month period, the program will
Total Senior Care, Inc. is no longer able to provide PACE services
due to the termination of its agreement with NYSDOH/CMS, of the loss of licenses
that are needed to provide PACE services, or the loss of contractors which
results in the programís inability to provide services.
staff will attempt to assist participant in securing necessary services in
the new location.
To ensure that all
participantsí rights are protected, the following procedures apply for any
Each involuntary disenrollment request must be reviewed and
approved by the Cattaraugus County Department of social Services.
If, the local DSS does not approve the disenrollment, Total Senior Care,
Inc. may appeal this decision using the dispute resolution process.
In addition, a participant who is involuntarily disenrolled from
Total Senior Care, Inc. has the right to appeal this decision externally.
For an individual with Medicaid, he/she will be notified of the right to
file a fair hearing by the Cattaraugus County Department of Social Services.
For an individual with Medicare-only, the participant will be notified of
his/her appeal rights to the New York
State Department of Health, Office of Continuing Care Initiatives.
If the participant requests a fair hearing or other
appeal, his/her enrollment and service may continue while this appeal is being
Cattaraugus County Department of Social Services does not agree with the
recommendation to disenroll the participant, Total Senior Care, Inc. will notify
the participant of this decision in writing and a member of the IDT (usually the
social worker) will confirm this by telephone.
In this situation, PACE services from Total Senior Care, Inc. will
Senior Care, Inc. will monitor and track all involuntary and voluntary
disenrollments to detect trends and patterns.
Information about all disenrollments will be reported at the Quality
Management Committee meetings, and will be reported to the State Department of
Health or other regulatory authorities, consistent with contractual obligations.