Rule 173-50-05 | PACE: involuntary disenrollment.
(A) A participant is subject to involuntary disenrollment from PACE for an reason outlined in 42 C.F.R. 460.164(b).
(B) Process to involuntarily disenroll a PACE participant:
(1) If a PACE organization requests permission to disenroll a participant under this rule, it shall submit the request to ODA along with documentation reflecting grounds for involuntary disenrollment and the PACE organization's efforts to remedy the situation.
(2) ODA shall approve or deny the request based upon the requirements in paragraph (A) of this rule and notify the PACE organization of the decision.
(3) If ODA does not approve the request, the PACE organization shall continue to provide necessary services to the participant.
(4) If ODA approves the request, the PACE organization is subject to the involuntary disenrollment process in 42 C.F.R. 460.164, 460.166, and 460.172.
(5) A participant's involuntary disenrollment is effective on the first day of the next month that begins thirty days after the day the PACE organization sends notice of the disenrollment to the participant.
(6) After ODA approves an involuntary disenrollment, ODA sends the participant a notice of denial and hearing rights under division 5101:6 of the Administrative Code.
(a) If the participant requests a hearing within fifteen days after ODA approves the involuntary disenrollment, ODA places the disenrollment on hold until a state hearing has been conducted.
(b) If the decision of the state hearing is that ODA made a correct decision to disenroll, then ODA enters the decision into the ODA- and ODM-approved eligibility systems.
(c) If the decision of the state hearing is that ODA made an incorrect decision to disenroll, the participant remains enrolled in PACE.
Last updated July 1, 2024 at 4:25 PM
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