Enrollment & Disenrollment

Section 1: Intake and Screening

The Enrollment Representative is responsible for the coordination of all events leading up to admission into the program.

Procedure:

1. Upon receipt of a phone call requesting a referral to the respective Franciscan PACE Center, information will be obtained from the potential participant as outlined in the telephone inquiry form. Anyone recording information concerning a referral will be asked to obtain as much identifying data as possible, especially information on how to re-contact the interested party if the Enrollment Representative is not available.
2. Once a telephone screening is complete, the referral is considered an official referral and results of the application are processed for data purposes.
3. The Enrollment Representative is responsible for fully explaining the program, its services, eligibility requirements, and other program information as described below.
   1. Using a copy of the Enrollment Agreement, the Enrollment Representative will explain to the potential participant and his or her representative information including, but not limited to:
      • Conditions for enrollment and disenrollment in PACE
      • Notification that enrollment in PACE results in disenrollment from any other Medicare or Medicaid prepayment plan or optional benefit. Electing enrollment in any other Medicare or Medicaid prepayment plan or optional benefit, including the hospice benefit, after enrolling as a PACE participant is considered a voluntary disenrollment from PACE. If a Medicaid-only or private pay participant becomes eligible for Medicare after enrollment in PACE, the participant will be disenrolled from PACE if he or she elects to obtain Medicare coverage other than from Franciscan PACE.
      • Information on the consequences of subsequent enrollment in other optional Medicare or Medicaid programs following disenrollment from PACE.
      • Description of PACE services available, including all Medicare and Medicaid covered services, and how services are obtained from Franciscan PACE.
      • Description of the procedures for obtaining emergency and urgently needed out-of-network services.
      • The participant bill of rights.
      • The applicant's authorization for disclosure and exchange of personal information between CMS, its agents, the Louisiana Department of Health/Office of Aging and Adult Services (OAAS), and Franciscan PACE.
   2. The requirement that Franciscan PACE would be the participant's sole service provider and clarification that Franciscan PACE guarantees access to services, but not to a specific provider.
   3. A list of the employees of Franciscan PACE who furnish care and the most current list of contracted health care providers.
   4. Monthly premiums, if any.
   5. Any Medicaid spenddown obligations.
   6. Post-eligibility treatment of income.
4. If initial screening indicates a potential admission, a pre-enrollment assessment is scheduled. The Pre-Enrollment team consists of a Primary Care Provider, MDS Coordinator, Home Care Coordinator, and any team member deemed necessary by the Pre-Enrollment Team to complete an assessment.
5. After the pre-enrollment assessment is completed, a home visit will be scheduled to ensure the potential participant can be cared for appropriately in a community setting and that the potential participant meets all requirements for PACE eligibility. A release of information consent will be obtained to allow Franciscan PACE to obtain the individual’s medical and financial information and eligibility status for Medicare and Medicaid. While no time frames are established for this process, it is essential for community relations that some contact occur as soon as possible. The delay for Medicaid financial eligibility and scheduling for center assessments are such that contact at this phase of enrollment should take place as soon as possible.

Section 2: Denial of Enrollment

Per the State of Louisiana, individuals may not be able to be cared for in a community setting without jeopardizing his or her health or safety if any of the following conditions exist:

1. Potential participant does not have the capability to call for emergency assistance or does not have the capability to determine when emergency assistance is needed.
2. A physician, familiar with the potential participant’s health and social history, has documented a condition that requires 24-hour/7-days per week skilled care.
3. The potential participant’s residence:
   1. Has been condemned; or
   2. Has been determined unsafe for habitation by the PACE provider (detailed documentation of specifics required); or
   3. Poses a threat to PACE program staff due to:
      • Physical condition and integrity of dwelling, or
      • Evidence of abuse and/or neglect from other household members, or
      • Criminal activities or behavior, or
      • Illegal drug use, or
      • Brandishing of weapons, or
      • Dangerous pets/animals.
4. The potential participant exhibits health concerns that involve dangerous behavior(s) which would pose a threat to the individual, other PACE participants, or PACE program staff.
5. Individual whose current medical treatment or regimen requires 24-hour supervision and whose care is more appropriately provided in an institutional setting (hospital or skilled nursing facility).

If Franciscan PACE determines that an applicant’s health and safety cannot be ensured with the services that PACE can provide, Franciscan PACE shall submit, within 5 working days, to OAAS:

• Justification for the determination that health and safety cannot be ensured.
• All assessments and medical records used to make the determination

OAAS staff will review the information for completeness and request the OAAS Service Review Panel “SRP” review the attached documentation. If the SRP disagrees with Franciscan PACE, SRP will provide suggestions for services that can be provided that would remedy the health and safety concern. (SRP is an internal OAAS panel that reviews requests made whenever there is a question about the appropriateness of a service. SRP is also used for 1915(c) Waiver participants, as well as Medicaid state plan personal assistance service recipients.)

If SRP agrees with PACE, SRP will provide documentation to Franciscan PACE in writing acknowledging the health and safety concern.

An individual may be denied enrollment in circumstances where it is determined the individual is unable to live safely in a community setting without jeopardizing his or her health or safety.

If such a decision occurs the following procedure will be followed:

1. The individual will be informed, in writing, as to why preliminary screening has found them ineligible for services. If applicable, the initial referral source will also be contacted.
2. Written notification will include any applicable appeal rights.
3. Franciscan PACE will refer the individual to alternative services, as appropriate.
4. Documentation of all interactions, reason for denial, and referrals to other resources will be maintained as part of the intake record.
5. Franciscan PACE will notify CMS and OAAS as specified and will make the documentation available for review.
6. Trends and patterns in denials will be reviewed by the Management Team for discussion and problem solving.

Policy: An individual may be ineligible for enrollment in circumstances where the individual does not meet the basic eligibility criteria.

Procedure: If such a decision occurs the following procedure will be followed:

1. The individual will be informed, in writing, as to why preliminary screening has found them ineligible for services. If applicable, the initial referral source will also be contacted.
2. If the individual is ineligible based on not meeting the established level of care guidelines, OAAS will send a letter informing them they are not eligible for the program, and will include a notification of appeal rights.
3. Documentation of all interactions, reason for ineligibility, and referrals to other resources will be maintained as part of the intake record.
4. Trends and patterns in denials will be reviewed by the Management Team for discussion and problem solving.

Eligibility for Medicaid-sponsored long-term care in Louisiana consists of meeting established criteria. In addition to meeting general, categorical, and financial eligibility criteria, an individual must also meet medical or psychobehavioral and functional requirements for nursing facility level of care. OAAS completes the screening to determine whether the applicant meets the nursing facility level of care requirements established by the the State and will notify Franciscan PACE of their determination.

A participant’s enrollment into Franciscan PACE is effective the first day of the calendar month following the date Franciscan PACE receives the signed Enrollment Agreement.

Upon enrollment, Franciscan PACE will give the participant the following:

1. A copy of the Enrollment Agreement.
2. A PACE membership card that indicates he or she is a Franciscan PACE participant and includes the phone number of the PACE organization.
3. Emergency information to be posted in his or her home identifying the individual as a Franciscan PACE participant and explaining how to access emergency services.

Franciscan PACE will submit participant information to CMS and the State Administering Agency, in accordance with established procedures.

If there are changes in the Enrollment Agreement information at any time during the participant's enrollment, Franciscan PACE must meet the following requirements:

1. Give an updated copy of the information to the participant.
2. Explain the changes to the participant and his or her representative or caregiver in a manner they understand.

A Franciscan PACE participant’s enrollment will continue regardless of changes in health status unless the participant voluntarily disenrolls, is involuntarily disenrolled, or passes away. Unless the PACE participant is granted a permanent waiver of the annual level of care assessment based on a determination there is no reasonable expectation of improvement or significant change in the participant’s condition because of the severity of a chronic condition or the degree of impairment of functional capacity, an assessment will be performed annually by OAAS to determine the PACE participant continues to meet the level of care established as necessary to receive nursing facility services.

If a PACE participant no longer meets requirements for nursing facility level of care, he or she may be deemed to continue to be eligible for the PACE program until the next annual reevaluation, if in the absence of continued coverage under this program, the participant reasonably would be expected to meet the nursing facility level of care requirements within the next six months. The Office of Aging and Adult Services (OAAS) in consultation with the PACE provider, will make a determination of continued eligibility based on a review of the participant’s medical record, plan of care, and Primary Care Provider’s evaluation. In these cases, Franciscan PACE will be required to submit specific documentation to OAAS to validate continued eligibility in PACE.