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Disenrollment Policy

 A participant 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 Involuntary Disenrollment).

  All participants who disenroll from Total Senior Care, Inc. will be linked to appropriate services for their care after enrollment in the PACE program terminates.

  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 processing it). 

  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 coverage.

PROCEDURES

  A.      VOLUNTARY DISENROLLMENT

  1. The participant notifies the program that he/she wishes to disenroll.
  1. Program staff will contact the participant/caregiver to determine the reason for   disenrollment.  The participant is not required to provide a reason, but the program will request the information for quality improvement purposes.

If 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. 

  1. The 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.)
  1. The 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 Social Services.

   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 Services.

   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 disenrollment.

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 completed, including:

ß  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.

ß  A physician, for the provision of medical care.  (If a referral is needed, Total Senior Care, Inc. staff will provide several choices.)

ß  Medicare prescription drug coverage, through a Medicare PDP or Medicare MA/PD plan.

ß  The home care nurse completes discharge SAAM assessment.

ß  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. 

B.      INVOLUNTARY DISENROLLMENT

In certain 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.

The following reasons shall require an involuntary disenrollment, unless the participant agrees to voluntarily terminate his/her enrollment and signs a disenrollment request form: 

1.          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.

2.            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 becomes due.

There are other situations where if unresolved, an involuntary disenrollment action can become necessary.  These include:

1.          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. 

2.          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 of non-payment.  

       If the participant continues to fail to make payments, Total Senior Care, Inc. will request disenrollment. 

3.          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. 

4.          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.

  • Threatened 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.
  • The 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.

5.          Upon annual re-assessment, the participant is no longer clinically eligible for nursing home level of care.

  • In 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 record.
  • If, 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 request disenrollment.

6.    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. 

  • Program 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 involuntary disenrollment:

   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 processed. 

If 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 continue.

Total 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.

 
  Total Senior Care is a managed long-term care plan and is a not-for-profit organization.

PACE is a program of all-inclusive care for the elderly, funded by Medicare and Medicaid through a contract with the Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health.

 
 
  © Copyright 2008 Total Senior Care, Inc. All Rights Reserved. Pending CMS approval