N.M. Admin. Code § 8.315.2.17 - DISENROLLMENT OF PARTICIPANTS
All voluntary and involuntary disenrollments will be documented and available for review by the state medicaid agency. The provider will inform the ISD office when a participant is being disenrolled either voluntarily or involuntarily. Disenrollment is effective by the first day of the second calendar month following the date in which enrollment has changed.
A. Voluntary disenrollment: A
participant may begin the process of voluntary disenrollment at any time during
the month. The provider shall use the most expedient process allowed by
medicaid and medicare procedures while ensuring a coordinated disenrollment
date. Until enrollment is terminated, the participants are required to continue
using the PACE program services and remain liable for any premiums. The
provider shall continue to provide all needed services until the date of
termination.
B. Involuntary
disenrollment: A participant may be involuntarily disenrolled if the
participant:
(1) moves out of the PACE program
service area;
(2) is a person with
decision-making capacity who consistently does not comply with the individual
plan of care and poses a significant risk to self or others;
(3) experiences a breakdown in the physician
or team participant relationship such that the PACE program provider's ability
to furnish services to either the participant or other participant(s) is
seriously impaired;
(4) refuses
services or is unwilling to meet conditions of participation as they appear in
the enrollment agreement;
(5)
refuses to provide accurate financial information, provides false information
or illegally transfers assets;
(6)
is out of the PACE program provider service area for more than 30 days (unless
arrangements have been made with the PACE program provider);
(7) is enrolled in a PACE program that loses
its contracts or licenses which enable it to offer health care
services;
(8) ceases to meet the
financial or non-financial criteria; and
(9) ceases to meet the level of care (LOC) at
any time.
Notes
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