Programs of All-Inclusive Care for the 
Elderly (PACE) 
 
Chapter 4  Enrollment and Disenrollment 
Table of Contents 
(Rev. 2, Issued: 06-09-11) 
 
Transmittals for Chapter 4 
 
10 - Introduction 
 
10.1 - Eligibility for Enrollment 
 
10.2 - Eligibility Criteria 
 
10.3 - End Stage Renal Disease (ESRD) 
 
10.4 - Hospice 
 
20 - Discrimination against Beneficiaries Prohibited 
 
30 - Enrollment 
 
30.1 - Eligibility Determination 
 
30.2 - Denial of Enrollment 
 
30.3 - Enrollment of Individuals Pending Medicare or Medicaid Eligibility 
 
30.4 - Initial IDT Assessment 
 
30.5 - Enrollment Agreement 
 
40 - Disenrollments 
 
40.1 - Documentation of Disenrollment 
 
40.2 - Disenrollment Process 
 
40.3 - Voluntary Disenrollment 
 
40.4 - Involuntary Disenrollment 
  40.5 - Additional Written Evidence of Involuntary Disenrollment for Disruptive 
or Threatening Behavior 
 
40.6 - Role of State Administering Agency 
 
50 - Enrollment in other Medicare and Medicaid Programs Following Disenrollment 
from PACE 
 
50.1 - General Requirements 
 
50.2 - Access to MA, PDP, and Medigap Coverage Following Disenrollment 
 
50.3 - Enrollment/Disenrollment of Hospitalized Beneficiaries 
 
60 - Reinstatement in PACE 
 
70 - Retroactive Enrollment for Medicare Payment 
 
80 - Retroactive Disenrollment for Medicare Entitled Participants  10 - Introduction 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
This chapter discusses eligibility criteria and the enrollment process for the PACE 
program as provided in 42 CFR  460.150. The eligibility criterion includes a 
requirement that a PACE eligible individual meet a specific level of care which is 
determined by the State Administering Agency and varies from state to state. State 
enrollment processes are separate from the processes identified below. PACE 
organizations should consult their State Administering Agency for instruction in State 
enrollment processes. 
 
10.1 - Eligibility for Enrollment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
10.2 - Eligibility Criteria 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
To enroll in a PACE program, an individual must meet the following eligibility 
requirements listed in the Program Agreement: 
 
  Be 55 years of age or older; 
 
  Be determined by the State Administering Agency to need the level of care 
required under the State Medicaid plan for coverage of nursing facility services; 
 
  Reside in the PACE organizations service area; 
 
  Be able to live in a community setting at the time of enrollment without 
jeopardizing his/her health or safety based on criteria set forth in the program 
agreement; 
 
  Meet any additional program-specific eligibility conditions imposed under its 
respective PACE Program Agreement; 
 
A PACE participant may not be concurrently enrolled in any other Medicare Advantage, 
Medicare Prescription Drug, or Medicaid prepayment plan, or optional benefit, such as a 
1915c Home and Community Based Services waiver or the Medicare Hospice benefit. 
 
A potential participant is not required to be a Medicare beneficiary or Medicaid recipient. 
A PACE enrollee may be, but is not required to be, any or all of the following: (1) 
entitled to Medicare Part A; (2) enrolled under Medicare Part B; (3) eligible for 
Medicaid. 
 
PACE enrollees who become entitled to Medicare Part A and/or enrolled in Medicare 
Part B on a retroactive basis will be eligible for Medicare Part D beginning the month in 
which the individual received notification of the retroactive Medicare entitlement  decision, resulting in some cases in which the individuals Medicare Part A and Part B 
dates will precede the Part D date. For instance, an individual has Medicaid coverage 
throughout 2009. In May 2009, the individual is notified that s/he is entitled to Medicare 
Part A and/or B retroactive to November, 2008. The last day of eligibility for Medicaid 
prescription drug coverage is April 30, 2009; the first day of Part D eligibility is May 1, 
2009. 
 
[42 CFR  460.150, 423.30(a)(3)] 
 
10.3 - End Stage Renal Disease (ESRD) 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Individuals with End Stage Renal Disease (ESRD) are among the most frail and complex 
persons to care for. 
 
In January 2005, a risk-adjusted capitation model was implemented exclusively for 
ESRD. The ESRD CMS-HCC (Health Condition Code) model accounts for the additional 
costs of providing ESRD patients with the costly and highly specialized care needed. This 
model is exclusively for ESRD patients and has three categories of ESRD acuity: those 
that are on dialysis; that that have kidney or kidney and pancreas transplant(s); and those 
that have had kidney grafts. 
 
The PACE care delivery model is well-suited to meeting the needs of this population and 
it is not appropriate to deny enrollment to these individuals solely based on their ESRD 
status. 
 
[71 FR 71310 (Dec. 8, 2006)] 
 
10.4 - Hospice 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Since comprehensive care is provided to PACE participants, those participants who need 
end-of-life care will receive the appropriate medical, pharmaceutical, and psychosocial 
services through the PACE organization. If a participant specifically wants to elect the 
hospice benefit from a certified hospice organization, the participant must voluntarily 
disenroll from the PACE program. The PACE organization will work with the State 
Administering Agency and CMS to facilitate the election of the hospice benefit and will 
work with the elected hospice organization to coordinate the transition of care. 
 
[42 CFR  460.154(i)] 
 
20 - Discrimination against Beneficiaries Prohibited 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE organization must not discriminate against any participant in the delivery of 
required PACE services based on race, ethnicity, national origin, religion, sex, age,  mental or physical disability, sexual orientation or source of payment. Each PACE 
organization must agree to meet all applicable requirements under Federal, State and 
local laws and regulations including provisions of the Civil Rights Act, the Age 
Discrimination Act and the Americans with Disabilities Act. These requirements include, 
but are not limited to, all requirements contained in the regulations implementing those 
Acts. 
 
[42 CFR  460.32(a)(2), 460.98(b)(3)] 
 
30 - Enrollment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
30.1 - Eligibility Determination 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Intake is an intensive process during which PACE staff members make one or more visits 
to a potential participants place of residence and the potential participant may make one 
or more visits to the PACE center. At a minimum, the intake process must include the 
following activities: 
 
  The PACE staff must explain to the potential participant and his or her 
representative or caregiver the following information: 
 
  The PACE program, using a copy of the enrollment agreement, 
specifically references the elements of the agreement, including but not 
limited to 42 CFR  460.154(e), (i) through (m), and (r); 
 
  The requirement that the PACE organization would be the participants 
sole service provider and clarification that the PACE organization 
guarantees access to services, but not to a specific provider; 
 
  A list of the employees of the PACE organization who furnish care and 
the most current list of contracted health care providers; 
 
  Monthly premiums, if any; 
 
  Any Medicaid spenddown obligations; 
 
  Post-eligibility treatment of income; 
 
  The potential participant must sign a release to allow the PACE organization 
to obtain his or her medical and financial information and eligibility status for 
Medicare and Medicaid; 
 
  The State Administering Agency must assess the potential participant, 
including any individual who is not eligible for Medicaid, to ensure that he or  she needs the level of care required under the State Medicaid plan for 
coverage of nursing facility services. 
 
The PACE staff must assess the potential participant to ensure that he or she can be cared 
for appropriately in a community setting and that he or she meets all requirements for 
PACE eligibility. This involves an assessment of the individuals care support network as 
well as the individuals health condition to determine whether or not his or her health or 
safety would be jeopardized by living in a community setting. The criterion for 
determining if an individual is able to live safely in the community is established, and 
must be approved, by the State. If it is determined that the prospective PACE enrollees 
health or safety would be jeopardized by remaining in a community setting, the PACE 
organization should deny enrollment. Refer to Chapter 8 of the PACE Manual for the 
IDT Assessment requirements. 
 
[42 CFR  460.70, 460.152(a); 71 FR 71309 (Dec. 8, 2006)] 
 
30.2 - Denial of Enrollment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
When an enrollment is denied because his or her health or safety would be jeopardized by 
living in a community setting, the PACE organization is required to complete the 
following steps: 
 
  Notify the individual in writing of the reason for enrollment denial and their 
appeal rights; 
 
  Refer the individual to alternative services as appropriate; 
 
  Maintain supporting documentation of the reason for the denial; and, 
 
  Notify CMS and the State Administering Agency and make the 
documentation available for review. Notification to CMS can be accomplished 
through reporting the Data Elements for monitoring in HPMS. 
 
[42 CFR  460.152(b)] 
 
30.3 - Enrollment of Individuals Pending Medicare or Medicaid 
Eligibility 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Eligibility to enroll in a PACE program is not restricted to an individual who is either a 
Medicare beneficiary or Medicaid recipient. During the enrollment process the applicant 
must sign a release to allow the PACE organization to obtain his or her medical and 
financial information and eligibility status for Medicare and Medicaid. The PACE 
organization is required to include any Medicaid spenddown obligations in the 
enrollment agreement. CMS requires that that information regarding post eligibility  treatment of income is also included in the enrollment agreement. As an additional 
participant protection, PACE organizations are required to review post-eligibility 
treatment of income with prospective enrollees as determined and calculated by the state. 
 
[42 CFR  460.152(a)(2) and (g)] 
 
30.4 - Initial IDT Assessment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
An initial comprehensive assessment is performed by the Interdisciplinary Team (IDT) 
on each participant independent of any pre-enrollment screening by the IDT. This 
assessment must be completed promptly following enrollment. The eight IDT members 
who conduct the initial assessment in person are the primary care physician, registered 
nurse, masters level social worker, dietitian, physical therapist, occupational therapist, 
recreational therapist or activities coordinator, and home care coordinator. The IDT may 
identify other healthcare specialists that are required to conduct additional assessments 
outside the IDT members expertise or scope of practice. On completion of the 
assessments, the IDT promptly consolidates the discipline-specific assessments into a 
single plan of care for each participant through discussion in team meetings and 
consensus of the entire IDT. In developing the plan of care, female participants must be 
informed that they are entitled to choose a qualified specialist for womens health 
services from the PACE organizations network to furnish routine or preventive womens 
health services. 
 
[42 CFR  460.104(a) and (b)] 
 
30.5 - Enrollment Agreement 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE-eligible prospective enrollee (or legal representative) must agree to several 
enrollment conditions including, but not limited to: having the PACE organization and its 
provider network as the sole provider of services; giving signed consent for the PACE 
organization to obtain medical and financial information to verify eligibility; and, 
agreeing to any applicable monthly premiums or Medicaid spenddown obligations. If the 
prospective PACE enrollee meets the eligibility requirements and signs the PACE 
enrollment agreement, the effective date of enrollment in the PACE program is on the 
first day of the calendar month following the date the PACE organization receives the 
participants signed enrollment agreement. The PACE organization must submit a timely 
and accurate enrollment transaction to complete the enrollment in CMS systems. The 
enrollment agreement must, at a minimum, contain the following information: 
 
  Applicants name, sex, and date of birth; 
 
  Medicare beneficiary status (Part A, Part B, or both) and number, if 
applicable; 
    Medicaid recipient status and number, if applicable; 
 
  Information on other health insurance, if applicable; 
 
  Conditions for enrollment and disenrollment in PACE; 
 
  Description of participant premiums, if any, and procedures for payment of 
premiums; 
 
  Notification that a Medicaid participant and a participant who is eligible for 
both Medicare and Medicaid are not liable for any premiums, but may be 
liable for any applicable spenddown liability and any amounts due under the 
post-eligibility treatment of income process; 
 
  Notification that a Medicare participant may not enroll or disenroll at a Social 
Security office; 
 
  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 or Medicare Part D plan, after enrolling 
as a PACE participant, is considered a voluntary disenrollment from PACE; 
 
  Information on the consequences of subsequent enrollment in other optional 
Medicare or Medicaid programs following disenrollment from PACE (i.e., 
conditions that might apply when enrolling in another managed care plan); 
 
  Description of PACE services available, including all Medicare and Medicaid 
covered services, and how services are obtained from the PACE organization; 
 
  Description of the procedures for obtaining emergency and urgently needed 
out-of-network services; 
 
  The participant Bill of Rights; 
 
  Information on the process for grievances and appeals and Medicare/Medicaid 
phone numbers for use in appeals; 
 
  Notification of a participants obligation to inform the PACE organization of a 
move or lengthy absence from the organizations service area; 
 
  An acknowledgment by the applicant or representative that he or she 
understands the requirement that the PACE organization must be the 
applicants sole service provider; 
    A statement that the PACE organization has an agreement with CMS and the 
State Administering Agency that is subject to renewal on a periodic basis and, 
if the agreement is not renewed, the program will be terminated; 
 
  The applicants authorization for disclosure and exchange of personal 
information between CMS, its agents, the State Administering Agency, and 
the PACE organization; 
 
  The effective date of enrollment; 
 
  The signature of the applicant or his or her designated representative and the 
date. 
 
After the participant signs the enrollment agreement, the PACE organization must give 
the participant the following: 
 
  A copy of the enrollment agreement; 
 
  A PACE membership card; 
 
  Emergency information to be posted in his or her home identifying the 
individual as a PACE participant and explaining how to access emergency 
services; 
 
  Stickers for the participants Medicare and Medicaid cards, as applicable, 
which indicate that he or she is a PACE participant and which include the 
phone number of the PACE organization. 
 
If there are changes in the enrollment agreement information at any time during the 
participants enrollment, the PACE organization must meet the following requirements: 
 
  Give an updated copy of the information to the participant; 
 
  Explain the changes to the participant and his or her representative or 
caregiver in a manner they understand. 
 
[42 CFR  460.152(a)(1) and (2), 460.154, 460.156, 460.158] 
 
40 - Disenrollments 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
There are only three reasons a participant can be disenrolled from a PACE program: 
 
  Death; 
    Voluntary disenrollment, (which would include enrollment by a participant into 
another Medicare Plan); or, 
 
  Involuntary disenrollment by the PACE organization due to cause. 
 
[42 CFR  460.160(a)] 
 
40.1 - Documentation of Disenrollment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
A PACE organization must meet the following requirements: 
 
  Have a procedure in place to document the reasons for all voluntary and 
involuntary disenrollments; 
 
  Make documentation available for review by CMS and the State 
Administering Agency; 
 
  Use the information on voluntary disenrollments in the PACE organizations 
internal Quality Assessment and Performance Improvement (QAPI) program. 
 
[42 CFR  460.172] 
 
40.2 - Disenrollment Process 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE organization must take the following actions upon voluntary or involuntary 
disenrollment or death 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 organizations services and pay any 
premiums, until the date the enrollment is actually terminated. The disenrollment date 
will be coordinated between Medicare and Medicaid for a participant who is dually 
eligible. No disenrollment will become effective until the participant is appropriately 
reinstated into other Medicare and Medicaid programs and alternative services are 
arranged.   
[42 CFR  460.166(a) and (b)] 
 
40.3 - Voluntary Disenrollment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Enrollment in the PACE program continues until the participants death regardless of 
changes in health status unless the participant voluntarily disenrolls or the PACE 
organization involuntarily disenrolls the participant for strictly defined reasons. A PACE 
participant may voluntarily disenroll from the program without cause at any time [42 
CFR  460.160 and 42 CFR  460.162]. The disenrollment date will be coordinated 
between Medicare and Medicaid for a participant who is dually eligible. No 
disenrollment will become effective until the participant is appropriately reinstated into 
other Medicare and Medicaid programs and alternative services are arranged. 
 
[42 CFR  460.162, 460.166] 
 
40.4 - Involuntary Disenrollment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE organization may involuntarily disenroll a participant only for any of the 
following reasons: 
 
  Failure to Pay: Any participant who fails to pay, or make satisfactory 
arrangements to pay any premiums due, to the PACE organization after a 
thirty-day grace period; 
 
  Disruptive or Threatening Behavior: A participant engages in disruptive or 
threatening behavior. Such behavior is defined as the following: 
 
  Behavior that jeopardizes the participants own health or safety, or the 
safety of others; or 
 
  Consistent refusal to comply with an individual plan of care or the terms 
of the PACE enrollment agreement by a participant with decision-making 
capacity. Note that a PACE organization may not involuntarily disenroll a 
PACE participant on the grounds that the participant has engaged in 
noncompliant behavior related to an existing mental or physical condition 
unless the participants behavior is jeopardizing his or her health or safety 
or that of others. Noncompliant behavior includes repeated noncompliance 
with medical advice and repeated failure to keep appointments; 
 
  Relocation Outside of the Service Area: The participant moves out of the 
PACE program service area or is out of the service area for more than 30 
consecutive days without PACE organization concurrence; 
    Non-renewal or Termination of Program Agreement: The PACE 
organizations program agreement with CMS and the State Administering 
Agency is not renewed or terminated; 
 
  Inability to Provide Services: The PACE organization is unable to offer 
healthcare services due to the loss of state licenses or contracts with outside 
providers; 
 
  Ineligibility: It is determined that the participant no longer meets the State 
Medicaid nursing facility level of care requirements and is not deemed 
eligible, the participant must be disenrolled. 
 
Before an involuntary disenrollment is effective, the State Administering Agency must 
review it and determine in a timely manner that the PACE organization has adequately 
documented acceptable grounds for disenrollment. Once it has been deemed appropriate 
to involuntarily disenroll the participant, the PACE organization must follow the 
disenrollment process as defined in 42 CFR  460.166 and discussed in 40.2 of this 
manual. 
 
NOTE: A PACE organization may have a waiver allowing for involuntary disenrollment 
for additional reasons such as, disruptive or threatening behavior by a family member or 
failure of Medicaid participants to pay share of cost. 
 
[42 CFR  460.164(a), (b), (d), and (e); 71 FR 71315 (Dec. 8, 2006)] 
 
40.5 - Additional Written Evidence of Involuntary Disenrollment for 
Disruptive or Threatening Behavior 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
In addition to the documentation of disenrollment discussed in 40.1, if a PACE 
organization proposed to involuntarily disenroll a participant who is disruptive or 
threatening, the PACE organization must document the following information in the 
participants medical records: 
 
  The reasons for proposing to disenroll the participant; and  
 
  All efforts to remedy the situation. 
 
[42 CFR  460.164(c)] 
 
40.6 - Role of State Administering Agency 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
At least annually, the State Administering Agency must re-evaluate whether or not a 
participant needs the level of care required under the State Medicaid plan for coverage of  nursing facility services by using the eligibility criteria specified in the program 
agreement and by reviewing the participants medical record or plan of care. 
 
The State may permanently waive the annual recertification requirement if it determines 
there is no reasonable expectation of improvement or significant change in the 
participants condition because of the severity of a chronic condition or the degree of 
impairment of functional capacity (NOTE: State authorized waiver of annual 
recertification, which includes the reason for waiving the annual recertification 
requirement, must be documented in the medical record). 
 
Furthermore, the State Administering Agency 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 if, in the absence of continued coverage under the 
program, the State Administering Agency determines the participant reasonably would be 
expected to meet the nursing facility level of care requirement in the next six months. 
 
The State Administering Agency must establish the criteria to use in making the 
determination of deemed continued eligibility and the criteria used to make the 
determination of continued eligibility must be specified in the program agreement. These 
criteria must be applied in reviewing the participants medical record and plan of care. 
The State Administering Agency, in consultation with the PACE organization, may make 
a determination of deemed continued eligibility based on review of the participants 
medical record and plan of care. 
 
Finally, the State Administering Agency is responsible for reviewing medical record 
documentation and information about the involuntary disenrollment from a PACE 
organization that plans to involuntary disenroll a participant. As discussed above, in 
doing so, the State Administering Agency is required to determine in a timely manner 
that the PACE organization has adequately documented acceptable grounds for 
disenrollment. 
 
[42 CFR  460.160(b)] 
 
50 - Enrollment in other Medicare and Medicaid Programs Following Disenrollment 
from PACE 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
50.1 - General Requirements 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
To facilitate a participants reinstatement in other Medicare and Medicaid programs after 
disenrollment, the PACE organization must do the following: 
 
  Make appropriate referrals and ensure medical records are made available to 
new providers in a timely manner. 
    Work with CMS and the State Administering Agency to reinstate the 
participant in other Medicare and Medicaid programs for which the participant 
is eligible. 
 
[42 CFR  460.168; 1894(a)(2)(C) and 1934(a)(2)(C) of the Act] 
 
50.2 - Access to MA, PDP and Medigap Coverage Following 
Disenrollment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
Individuals who disenroll from PACE have a Special Election Period for 2 months after 
the effective date of PACE disenrollment to elect an MA plan or a standalone PDP. If the 
individual decides to return to original Medicare, the individual may purchase a Medigap 
(Medicare supplemental) policy that is offered in their state within 63 days of the last 
date of coverage. Under a Guaranteed Issue Period, the issuer of a Medicare 
Supplemental Policy may not deny or condition the issuance or effectiveness of the 
policy; may not discriminate in the pricing of such policy, because of health status, 
claims experience, receipt of health care, or medical condition, and, may not impose an 
exclusion of benefits based on a preexisting condition. The agent or insurer may request 
evidence of the date of disenrollment along with the application for the policy. The 
effective date of enrollment in the MA plan or standalone PDP would be the first of the 
month following the plans receipt of the enrollment request.  
 
[42 CFR  422.62(b)(4); 71 FR 71246 (Dec. 8, 2006)] 
 
50.3 - Enrollment/Disenrollment of Hospitalized Beneficiaries 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
The PACE organization must provide for the prompt transfer of copies of appropriate 
medical record information between treatment facilities to ensure continuity of care 
whenever a participant is temporarily or permanently transferred to another facility. 
Examples of appropriate medical record information include, but are not limited to: 
 
  The reason for the transfer; 
 
  The name and number of the attending physician; 
 
  Participants demographics; 
 
  Active diagnoses and treatment plan including current medications and 
activities of daily living status; 
 
  Special dietary considerations, etc. 
 
It is essential that the medical history and plan of care follow the participant. This 
requirement is intended to ensure communication between providers.   
More information regarding medical records documentation can be found in Chapter 12 
of this manual. 
 
[71 FR 71326 (Dec. 8, 2006)] 
 
60 - Reinstatement in PACE 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
A previously disenrolled participant may be reinstated in the PACE program. If the 
reason for disenrollment is failure to pay the premium and the participant pays the 
premium before the effective date of disenrollment, the participant is reinstated in the 
PACE program with no break in coverage. 
 
[42 CFR  460.170] 
 
70 - Retroactive Enrollment for Medicare Payment 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
CMS expects that PACE plans will follow the procedures described in the Medicare 
Advantage & Prescription Drug Plan Communications User Guide (PCUG) to 
successfully submit accurate enrollment and disenrollment transactions to CMS within 
the current operating month cycle (http://www.reedassociates.org/). A calendar of the 
cycle for data submission is provided in the PCUG as Appendix C. Following the timely 
submission of enrollment and disenrollment actions, PACE plans must review the reports 
and replies provided by CMS to ensure each action has been successfully processed, as 
well as to obtain other important information that CMS provides via these interchanges. 
Descriptions and file lay-outs are provided in detail in the PCUG. 
 
However, if an eligible individual has fulfilled all enrollment requirements, but the PACE 
organization or CMS has been unable to process the enrollment for the required effective 
date, CMS (or its designee) may process a retroactive enrollment. A retroactive 
enrollment is an action to enroll a beneficiary into a PACE program for an earlier time 
period. 
 
The request by a PACE organization for a retroactive enrollment must be made within 
ninety (90) days of the original effective date of enrollment (first day of the calendar 
month following the date the PACE organization receives the participants signed 
enrollment agreement). When an individual has fulfilled all enrollment requirements, but 
the PACE organization or CMS has been unable to process the enrollment in a timely 
manner, the PACE organization must submit to CMS via the CMS retroactive processing 
contractor (RPC) a copy of the signed completed enrollment agreement. Note that the 
document must have been signed by the participant (or authorized representative) prior to 
the requested effective date of coverage in order to effectuate the requested effective 
coverage date. Continued failure to accurately and timely process enrollment transactions 
via direct systems interchange with CMS is contrary to operational guidance and will be  considered a compliance issue by CMS. Issues older than 90 days from the original, valid 
effective date must be reviewed and approved by the CMS regional office account 
manager prior to submission to the RPC. PACE organizations must follow the standard 
operating procedure (SOP) in conjunction with these instructions, as provided on the 
RPC web site at: http://www.reedassociates.org/ to submit retroactive requests for 
consideration. 
 
80 - Retroactive Disenrollment for Medicare Entitled Participants 
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11) 
 
If an enrollment was never legally valid or if a valid request for disenrollment was 
properly made, but not processed or acted on (including system error or plan error), CMS 
(or its designee) may process a retroactive disenrollment. CMS (or its designee) may also 
process a retroactive disenrollment if the reason for the disenrollment is related to a 
permanent move out of the service area. 
 
A retroactive disenrollment can only be submitted to CMS by the PACE organization via 
submission of the request to the retroactive processing contractor. Requests from a PACE 
organization must include a copy of the disenrollment request or documentation that 
substantiates an allowable involuntary disenrollment as well as an explanation as to why 
the disenrollment was not processed and submitted to CMS correctly. PACE 
organizations must submit retroactive disenrollment requests to CMS (or its designee) 
within ninety (90) days of the effective disenrollment date. If CMS approves a request for 
retroactive disenrollment, the PACE organization must return any premium paid by the 
participant for any month for which CMS processed a retroactive disenrollment. In 
addition, CMS will retrieve any capitation payment for the retroactive period. 
 
A retroactive request must be submitted by the PACE organization to CMS (or its 
designee) in cases in which the PACE organization has not properly processed or acted 
on the participants request for disenrollment as required. A disenrollment request would 
be considered not properly acted on or processed if the effective date is a date other than 
as required. Continued failure to accurately and timely process enrollment transactions 
via direct systems interchange with CMS is contrary to operational guidance and will be 
considered a compliance issue by CMS. Issues older than 90 days from the original, valid 
effective date must be reviewed and approved by the CMS regional office account 
manager prior to submission to the RPC. PACE organizations must follow the Standard 
Operating Procedure (SOP) in conjunction with these instructions, as provided on the 
RPC web site at: http://www.reedassociates.org/ to submit retroactive requests for 
consideration. 
 
[Retroactive Enrollment/Disenrollment Implementation Guidance for PACE 
Organizations (Dec. 22, 2009)]  Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R2PACE 06/09/2011  Initial Publication of Manual  06/03/2011 NA 
06/03/2011  Initial Publication of Manual - Rescinded and  06/03/2011 NA 
R1_SO 
replaced by Transmittal 2 
 
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