DSH Alert 1
Client Alert
CMS Releases Updates to PACE Enrollment Guidance

Medicaid Disproportionate Share Hospital (DSH)

January 2019

On December 5, 2023, the Centers for Medicare & Medicaid Services (CMS) released updates to the enrollment and disenrollment guidance detailed in the Programs of All-Inclusive Care for the Elderly (PACE) Manual. Most of the updates are revisions necessary to reflect the final June 2019 PACE regulations, published in CMS-4168-F. The regulatory updates cover PACE organization enrollment and disenrollment procedures, timing of the initial comprehensive participant assessment, and timing for both voluntary and involuntary disenrollments. The updates also permit the electronic signature option for PACE enrollment agreements and make minor technical updates, such as making pronouns gender neutral. The guidance is effective immediately and available at PACE Chapter 4-12-05-23.

Revisions to the PACE Manual chapter 4 – Enrollment and Disenrollment:

  • Pronouns made gender neutral.
  • State Administering Agency abbreviated – SAA.
  • Eligibility Determination: The State will provide oversight of the PACE organization’s administration of the criteria, and of any associated enrollment denials based on the application of the criteria.
  • Initial IDT Assessment: Within 30 days of the date of enrollment, the interdisciplinary team must consolidate the discipline-specific assessments into a single plan of care for each participant through discussion in team meetings and consensus of the entire IDT.
  • Enrollment Agreement:
    • Must include the following notifications:
      • When a Medicaid-only or a private pay PACE participant becomes eligible for Medicare, they will be disenrolled from PACE if they elect to obtain Medicare coverage other than from their PACE organization.
      • The participant Bill of Rights (CMS Participant Rights template can be found at PACE Participants Rights (cms.gov)).
    • A PACE membership card that must indicate the member is a participant of a PACE program and must include the phone number of the PACE organization.
    • Electronic signature is now an option for PACE enrollment regulations.
  • Disenrollment: Enrollment in the PACE program continues until the participant’s death regardless of changes in health status unless the participant voluntarily disenrolls or the PACE organization involuntarily disenrolls the participant for strictly defined reasons.
  • Voluntary Disenrollment:
    • The PACE organization must ensure that its employees or contractors do not engage in any practice that would reasonably be expected to have the effect of steering or encouraging disenrollment of participants due to a change in health status.
    • A participant’s voluntary disenrollment is effective on the first day of the month following the date the PACE organization receives the participant’s notice of voluntary disenrollment.
  • Involuntary Disenrollment:
    • The PACE organization may involuntarily disenroll a participant only for the following reasons:
      • Failure to Pay/Satisfactory Payment Arrangements: After a thirty-day grace period, the participant fails to pay, or make satisfactory arrangements to pay, any applicable Medicaid spend down liability or any amount due under the post-eligibility treatment of income process.
      • Disruptive or Threatening Behavior: A participant and/or a participant’s caregiver, which includes any family member involved in the participant’s care engages in disruptive or threatening behavior.
    • The PACE organization must provide the participant at least 30 days advance notice of an involuntary disenrollment. A participant’s involuntary disenrollment is effective on the first day of the next month that begins 30 days following the date the PACE organization sends notice of the disenrollment.
    • The PACE organization must take the following actions upon involuntary disenrollment of a Participant:
      • Complete the disenrollment as expediently as allowed under Medicare and Medicaid;
      • Coordinate the disenrollment date between Medicare and Medicaid as applicable;
      • Give reasonable advance notice to the participant about disenrollment;
      • Submit the disenrollment transaction to CMS systems in a timely and accurate manner.
    • The PACE organization must continue to provide all needed services, and the PACE participant must continue to use the PACE organization’s services and pay any premiums, until the date the enrollment is actually terminated.
  • Role of State Administering Agency: SAA may deem a participant who no longer meets the State Medicaid nursing facility level of care requirements to continue to be eligible for the PACE program until the next annual reevaluation.
  • Access to MA, PDP and Medigap Coverage Following Disenrollment: Individuals who disenroll from PACE have a Special Election Period (SEP) to elect an MA plan or a standalone PDP.

All updates are effective immediately and available at PACE Chapter 4-12-05-23.

Jared Duzan, CFE

Rose Anne Howland, RN, MS, CFE, CHC, CPHQ, LFACHE
Senior Manager

Vicki Bartlett, RN, BSHA, CCM, COC
Senior Manager