Common use of Involuntary Disenrollment Clause in Contracts

Involuntary Disenrollment. All involuntary disenrollment actions must be reviewed and approved by the SAA2. The review process includes reviewing documentation from the PACE organization and from the State case to ensure the reasons for the involuntary disenrollment meet the criteria as set forth in 42 CFR §460.164(e). The SAA representative may discuss the reasons for the involuntary disenrollment with the participant and/or his/her authorized representative to ensure the participant’s health and safety are not compromised due to the disenrollment. The PACE organization must provide the participant with a 30- day notice of intent to disenroll from PACE services. This notification must include the reasons for the disenrollment and the participant's appeal rights. A copy of the notice provided to the participant and/or the representative will be sent to the APD/AAA case manager, the APD PACE Coordinator and CMS Region 10 representative. The PACE organization and the APD/AAA case manager will coordinate efforts to transition the participant from PACE services. Involuntary disenrollment may occur in the following cases and must follow state required procedures. • The participant's behavior is disruptive, unruly, or abusive to the point that his/her enrollment seriously impairs the provider's ability to furnish services to the participant or other participants. The participant does not pay or make satisfactory arrangements to pay the PACE monthly premium after a 30-day grace period. • The participant no longer meets the nursing home level of care eligibility criteria as assessed by the APD/AAA case manager. The case manager and local office leadership do not believe that disenrollment from PACE • services will result in deterioration of the participant's condition to the point that he/she will meet eligibility criteria within six months of losing eligibility. • The participant moves out of the PACE service area or is out of the service area for more than 30 consecutive days and the move or extended absence was not facilitated or approved by the PACE organization. • The PACE program agreement between CMS, the State of Oregon, and the PACE organization is not renewed. • The local PACE organization decides not to continue to participate in PACE. • The local PACE organization loses the contracts and/or licenses which enable it to offer health care services.

Involuntary Disenrollment. All involuntary disenrollment actions must be reviewed and approved Providence ElderPlace/PACE can terminate your benefits by the SAA2. The review process includes reviewing documentation from the PACE organization and from the State case to ensure the reasons for the involuntary disenrollment meet the criteria as set forth notifying you in 42 CFR §460.164(e). The SAA representative may discuss the reasons for the involuntary disenrollment with the participant and/or his/her authorized representative to ensure the participant’s health and safety are not compromised due to the disenrollment. The PACE organization must provide the participant with a 30- day notice writing of our intent to disenroll from PACE services. This notification must include the reasons for the disenrollment and the participant's appeal rights. A copy you, if: • You move out of the notice provided to the participant and/or the representative will be sent to the APD/AAA case manager, the APD PACE Coordinator and CMS Region 10 representative. The PACE organization and the APD/AAA case manager will coordinate efforts to transition the participant from PACE services. Involuntary disenrollment may occur in the following cases and must follow state required proceduresour designated service areas. • The participant's behavior is disruptive, unruly, or abusive to the point that his/her enrollment seriously impairs the provider's ability to furnish services to the participant or other participants. The participant does not pay or make satisfactory arrangements to pay the PACE monthly premium after a 30-day grace period. • The participant no longer meets the nursing home level of care eligibility criteria as assessed by the APD/AAA case manager. The case manager and local office leadership do not believe that disenrollment from PACE • services will result in deterioration of the participant's condition to the point that he/she will meet eligibility criteria within six months of losing eligibility. • The participant moves out of the PACE service area or is If you are out of the service area for more than 30 consecutive days and days, an involuntary disenrollment process will be initiated. Any medical care that occurs after the move or extended absence was effective date of disenrollment will not facilitated or approved be covered by the PACE organization. • The PACE program agreement between CMS, the State of Oregon, and the PACE organization is not renewed. • The local PACE organization decides not to continue to participate in Providence ElderPlace/PACE. • The local You are not in contact with ElderPlace/PACE organization and your whereabouts are unknown for at least 30 days despite our attempts to contact you. • You fail to pay your monthly private pay premiums within a 30- day grace period or fail to make satisfactory arrangements to pay your premiums. • You fail to pay, after a 30-day grace period, or fail to make satisfactory arrangements to pay any applicable Medicaid spenddown liability or any share of cost. • Your behavior threatens your health and safety or the health and safety of others and cannot be managed even with the support of Providence ElderPlace/PACE. • Your caregiver (including any family members involved in your care) engages in disruptive or threatening behavior such that this behavior jeopardizes your health and safety, or the safety of caregivers or others. • You are accepted for admission to a state psychiatric hospital. • You are admitted to an Enhanced Care Facility (ECF). • You are incarcerated. • You no longer meet Medicaid eligibility criteria and do not want to or cannot pay privately. • You attempt to buy or sell methadone or other controlled substances, resulting in discharge from a contracted methadone maintenance or substance abuse treatment program. • Providence ElderPlace/PACE loses the contracts and/or licenses which enable enabling it to offer health care services. • Providence ElderPlace/PACE’s agreement with Medicare or Medicaid is not renewed or is terminated. • Providence Health and Services decides not to continue the ElderPlace/PACE program. Providence ElderPlace/PACE must receive approval from Oregon Department of Human Services, Aging and People with Disabilities (ODHS-APD) to disenroll any participant. If you are involuntarily disenrolled, the effective date of disenrollment and termination of Providence ElderPlace/PACE benefits is the first day of the month following the 30-day notice. Participants who have been involuntarily disenrolled may choose to use the Participant Appeals Procedure to appeal their involuntary disenrollment. (See Section 14) Providence ElderPlace/PACE has an agreement with the Center for Medicare and Medicaid Services (CMS) and the State Administering Agency (ODHS-APD) that is subject to renewal on a periodic basis. Although unlikely, if this agreement is not renewed, the program will be terminated, and we will assist in connecting you to another plan.

Involuntary Disenrollment. All involuntary disenrollment actions must be reviewed and approved by the SAA2. The review process includes reviewing documentation from the PACE organization and from the State case CNY can terminate your benefits through written notification to ensure the reasons for the involuntary disenrollment meet the criteria as set forth in 42 CFR §460.164(e). The SAA representative may discuss the reasons for the involuntary disenrollment with the participant and/or his/her authorized representative you if: You fail to ensure the participant’s health and safety are not compromised due to the disenrollment. The PACE organization must provide the participant with a 30- day notice of intent to disenroll from PACE services. This notification must include the reasons for the disenrollment and the participant's appeal rights. A copy of the notice provided to the participant and/or the representative will be sent to the APD/AAA case manager, the APD PACE Coordinator and CMS Region 10 representative. The PACE organization and the APD/AAA case manager will coordinate efforts to transition the participant from PACE services. Involuntary disenrollment may occur in the following cases and must follow state required procedures. • The participant's behavior is disruptive, unruly, or abusive to the point that his/her enrollment seriously impairs the provider's ability to furnish services to the participant or other participants. The participant does not pay or fail to make satisfactory arrangements to pay any amount you owe PACE CNY after the PACE monthly premium after a 30-day grace period. • The participant no longer meets the nursing home level of care eligibility criteria as assessed by the APD/AAA case manager. The case manager and local office leadership do not believe that disenrollment from PACE • services will result in deterioration of the participant's condition to the point that he/she will meet eligibility criteria within six months of losing eligibility. • The participant moves ; You move out of the PACE CNY service area or is you are out of the service area for more than 30 consecutive days and unless PACE CNY agrees to a longer absence due to extenuating circumstances; You are a person whose behavior is jeopardizing your health or safety or that of others or you are a person with decision-making capacity who consistently does not comply with his/her individual plan of care or the move terms of the Enrollment Agreement; You have a family member or extended absence was caregiver whose behavior is jeopardizing your health or safety or that of others or your family member or caregiver is consistently not facilitated complying with your individual plan of care or approved by the terms of the Enrollment Agreement; During annual recertification it is determined you no longer require nursing facility level of care; PACE organization. • The PACE program agreement between CMS, the State of Oregon, and the PACE organization is not renewed. • The local PACE organization decides not to continue to participate in PACE. • The local PACE organization CNY loses the contracts contract and/or licenses which enable enabling it to offer health care care, or PACE CNY loses its contracts with necessary outside providers, or PACE CNY ceases operations. PACE CNY has a contract with the Centers for Medicare and Medicaid Services (CMS) and the NYS Medicaid Agency which is subject to renewal on a periodic basis and failure of PACE CNY to renew the contract will result in termination of enrollment in the program; You knowingly fail to complete and submit any necessary consent or release; You provide false information or otherwise engage in fraudulent conduct; You are homeless living in the streets or in a shelter and the Program is unable to provide services; or You do not require and receive at least one Community Based Long Term Care Service. PACE CNY will make every effort to work with you to resolve any issues that potentially could lead to involuntary disenrollment. Involuntary Disenrollment will not be processed without approval by NY Medicaid Choice. Medicaid beneficiaries will be offered Fair Hearing Rights. If you are a Medicare Participant and NYMC approves your involuntary disenrollment, you can request an external review through Medicare.

Involuntary Disenrollment. A participant’s involuntary disenrollment occurs after the GMWP organization meets the requirements set forth in this section and is effective on the first day of the next month that begins 30 days after the day GMWP organization sends notice of the disenrollment to the participant. All involuntary disenrollment actions must be disenrollments are reviewed and approved by the SAA2DHCS. The review process includes reviewing documentation from the PACE organization and from the State case to ensure the reasons for the involuntary disenrollment meet the criteria as set forth in 42 CFR §460.164(e). The SAA representative We may discuss the reasons for the involuntary disenrollment terminate your enrollment with the participant and/or his/her authorized representative to ensure the participant’s health and safety are not compromised due to the disenrollment. The PACE organization must provide the participant with a 30- day notice of intent to disenroll from PACE services. This notification must include the reasons for the disenrollment and the participant's appeal rights. A copy of the notice provided to the participant and/or the representative will be sent to the APD/AAA case manager, the APD PACE Coordinator and CMS Region 10 representative. The PACE organization and the APD/AAA case manager will coordinate efforts to transition the participant from PACE services. Involuntary disenrollment may occur in the following cases and must follow state required procedures. • The participant's behavior is disruptive, unruly, or abusive to the point that his/her enrollment seriously impairs the provider's ability to furnish services to the participant or other participants. The participant does not pay or make satisfactory arrangements to pay the PACE monthly premium after a 30-day grace period. • The participant no longer meets the nursing home level of care eligibility criteria as assessed by the APD/AAA case manager. The case manager and local office leadership do not believe that disenrollment from PACE • services will result in deterioration of the participant's condition to the point that he/she will meet eligibility criteria within six months of losing eligibility. • The participant moves GMWP if: You move out of the PACE GMWP service area and no longer live in the service area zip codes or is are out of the service area for more than 30 consecutive days without prior approval (see CHAPTER 6). You (or your caregiver) engages in disruptive or threatening behavior, i.e. your behavior jeopardizes the health or safety of yourself or others or you consistently refuse to comply with the terms of your Plan of Care or Enrollment Agreement, when you have decision-making capacity. Disenrollment under these circumstances is subject to prior approval by the DHCS and will be sought in the event that you display disruptive interference with care planning or threatening behavior which interferes with the quality of PACE services provided to you and other PACE participants. You are determined to no longer meet the Medi-Cal nursing home level of care criteria and are not deemed eligible. You fail to pay or fail to make satisfactory arrangements to pay any premium due to GMWP within the 30-day period specified in any cancellation notice (see CHAPTER 9). The agreement between GMWP, the Centers for Medicare and Medicaid Services and the move or extended absence was not facilitated or approved by the PACE organization. • The PACE program agreement between CMS, the State of Oregon, and the PACE organization DHCS is not renewedrenewed or is terminated. • The local PACE organization decides not to continue to participate in PACE. • The local PACE organization loses the contracts and/or licenses which enable it GMWP is unable to offer health care servicesservices due to the loss of our state licenses or contracts with outside providers. All rights to benefits will stop at midnight on the last day of the month following a voluntary or involuntary disenrollment (except in the case of termination due to failure to pay fees owed, see CHAPTER 9). We will coordinate the disenrollment date between Medicare and Medi-Cal, if you are eligible for both programs. You are required to use GMWP services (except for Emergency Services and Urgent Care provided outside our service area) until termination becomes effective. If you are hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, GMWP has the responsibility for service provision until you are reinstated with Medicare and Medi-Cal benefits (according to your entitlement and eligibility).

Involuntary Disenrollment. All involuntary disenrollment actions must be reviewed and approved by the SAA2. The review process includes reviewing documentation from the PACE organization and from the State case CNY can terminate your benefits through written notification to ensure the reasons for the involuntary disenrollment meet the criteria as set forth in 42 CFR §460.164(e). The SAA representative may discuss the reasons for the involuntary disenrollment with the participant and/or his/her authorized representative you if:  You fail to ensure the participant’s health and safety are not compromised due to the disenrollment. The PACE organization must provide the participant with a 30- day notice of intent to disenroll from PACE services. This notification must include the reasons for the disenrollment and the participant's appeal rights. A copy of the notice provided to the participant and/or the representative will be sent to the APD/AAA case manager, the APD PACE Coordinator and CMS Region 10 representative. The PACE organization and the APD/AAA case manager will coordinate efforts to transition the participant from PACE services. Involuntary disenrollment may occur in the following cases and must follow state required procedures. • The participant's behavior is disruptive, unruly, or abusive to the point that his/her enrollment seriously impairs the provider's ability to furnish services to the participant or other participants. The participant does not pay or fail to make satisfactory arrangements to pay any amount you owe PACE CNY after the PACE monthly premium after a 30-day grace period. • The participant no longer meets the nursing home level of care eligibility criteria as assessed by the APD/AAA case manager. The case manager and local office leadership do not believe that disenrollment from PACE • services will result in deterioration of the participant's condition to the point that he/she will meet eligibility criteria within six months of losing eligibility. • The participant moves ;  You move out of the PACE CNY service area or is you are out of the service area for more than 30 consecutive days and unless PACE CNY agrees to a longer absence due to extenuating circumstances;  You are a person whose behavior is jeopardizing your health or safety or that of others or you are a person with decision-making capacity who consistently does not comply with his/her individual plan of care or the move terms of the Enrollment Agreement;  You have a family member or extended absence was caregiver whose behavior is jeopardizing your health or safety or that of others or your family member or caregiver is consistently not facilitated complying with your individual plan of care or approved by the terms of the Enrollment Agreement;  During annual recertification it is determined you no longer require nursing facility level of care;  PACE organization. • The PACE program agreement between CMS, the State of Oregon, and the PACE organization is not renewed. • The local PACE organization decides not to continue to participate in PACE. • The local PACE organization CNY loses the contracts contract and/or licenses which enable enabling it to offer health care care, or PACE CNY loses its contracts with necessary outside providers, or PACE CNY ceases operations. PACE CNY has a contract with the Centers for Medicare and Medicaid Services (CMS) and the NYS Medicaid Agency which is subject to renewal on a periodic basis and failure of PACE CNY to renew the contract will result in termination of enrollment in the program;  You knowingly fail to complete and submit any necessary consent or release;  You provide false information or otherwise engage in fraudulent conduct;  You are homeless living in the streets or in a shelter and the Program is unable to provide services; or  You do not require and receive at least one Community Based Long Term Care Service. PACE CNY will make every effort to work with you to resolve any issues that potentially could lead to involuntary disenrollment. Involuntary Disenrollment will not be processed without approval by NY Medicaid Choice. Medicaid beneficiaries will be offered Fair Hearing Rights. If you are a Medicare Participant and NYMC approves your involuntary disenrollment, you can request an external review through Medicare.

Involuntary Disenrollment. All involuntary disenrollment actions must be reviewed and approved by the SAA2. The review process includes reviewing documentation from the Eddy SeniorCare may terminate PACE organization and from the State case to ensure the reasons for the involuntary disenrollment meet the criteria as set forth in 42 CFR §460.164(e). The SAA representative may discuss the reasons for the involuntary disenrollment with benefits after written notification when: • the participant and/or his/her authorized representative fails to ensure the participant’s health and safety are not compromised due to the disenrollment. The PACE organization must provide the participant with a 30- day notice of intent to disenroll from PACE services. This notification must include the reasons for the disenrollment and the participant's appeal rights. A copy of the notice provided to the participant and/or the representative will be sent to the APD/AAA case managerpay, the APD PACE Coordinator and CMS Region 10 representative. The PACE organization and the APD/AAA case manager will coordinate efforts to transition the participant from PACE services. Involuntary disenrollment may occur in the following cases and must follow state required procedures. • The participant's behavior is disruptive, unruly, or abusive to the point that his/her enrollment seriously impairs the provider's ability to furnish services to the participant or other participants. The participant does not pay or make satisfactory arrangements to pay any amount due to Eddy SeniorCare within 30 days after such amount becomes due; pro- vided that Eddy SeniorCare makes a reasonable effort to collect the PACE monthly premium after amount in- cluding a 30-day grace period. written demand for payment • The the participant no longer meets engages in disruptive or threatening behavior including behavior that jeopardizes his or her health or safety, or the nursing home level safety of others • the participant with decision making capacity who consistently refuses to com- ply with his or her individual plan of care eligibility criteria as assessed by or the APD/AAA case manager. The case manager and local office leadership do not believe that disenrollment from PACE • services will result in deterioration terms of the participant's condition to enrollment agree- ment • the point that he/she will meet eligibility criteria within six months of losing eligibility. • The participant moves out of the PACE Eddy SeniorCare service area or is out of the service area for more than 30 consecutive days days, unless Eddy SeniorCare agrees to a longer absence due to extenuating circumstances • at the time of the annual reassessment, it is determined that the participant no longer meet nursing home level of care requirements Uniform Assessment Sys- tem for New York (UAS-NY) (score of less than 5) and is not deemed eligible • Eddy SeniorCare's program agreement with the Centers for Medicare and Med- icaid Services and the move or extended absence was not facilitated or approved by the PACE organization. • The PACE program agreement between CMS, the New York State Department of Oregon, and the PACE organization Health is not renewed. renewed or is terminated • The local PACE organization decides not to continue to participate in PACE. • The local PACE organization loses the contracts and/or licenses which enable it Eddy SeniorCare is unable to offer health care servicesservices due to the loss of State licenses or contracts with outside providers • you have a family member or caregiver whose behavior is jeopardizing your health or safety or that of others • your family member or caregiver is consistently not complying with your indi- vidual plan of care or the terms of the enrollment agreement. All involuntary disenrollments go to New York Medicaid Choice for concurrence. If you have Medicaid you will be advised of your Fair Hearing Rights. If you have Med- icare you can request an external review through the CMS Independent review entity. If you have both Medicare and Medicaid, Eddy SeniorCare will help you choose which agency to review your involuntary disenrollment. Those who have neither Medicaid nor Medicare may complain to the Department of Health.