New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 280 - MEDICAID ELIGIBILITY - PROGRAM OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE) › Part 600 - BENEFIT DESCRIPTION › Section 8.280.600.14 - CHANGES IN ELIGIBILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If the recipient ceases to meet any of the eligibility
				  criteria, the case is closed following provision of advance notice as
				  appropriate. See 8.200.430 NMAC for information about notices and hearing
				  rights.
A.
Non-provision of PACE
				services:
To be eligible for PACE, an applicant/recipient must receive
				PACE services. If PACE services are no longer being provided and are not
				expected to be provided for at least a full calendar month, the recipient is
				ineligible for the program and the case must be closed after appropriate notice
				is provided, unless an exception has been prior authorized by MAD.
B.
Admission to an acute care or
				nursing facility:
If a PACE recipient enters an acute care or nursing
				facility, he still remains eligible. A PACE recipient may be disenrolled from
				the program either voluntarily or involuntarily. If disenrollment occurs, a new
				application for institutional care medicaid is not required in the following
				circumstances: the former PACE recipient is in an acute care or nursing
				facility; he continues to meet all eligibility criteria for institutional care
				medicaid; or the periodic review on the PACE case is not due in either the
				month of disenrollment or the following month.
C.
Reporting changes in
				circumstances:
The primary responsibility for reporting changes in the
				recipient's circumstances rests with the recipient or representative. At the
				initial eligibility determination and all on-going eligibility
				redeterminations, the income support division (ISD) must explain the reporting
				responsibilities requirement to the applicant/recipient or representative and
				document that such explanation was given. In the event that PACE services
				should cease, the PACE provider must immediately notify the income support
				division office by telephone of that fact. The telephone call is to be followed
				by a written notice to the ISD.
D.
Disenrollment:
A PACE recipient loses medicaid eligibility under
				this program when he is either voluntarily or involuntarily disenrolled. The
				PACE provider must inform the ISD office when disenrollment occurs. A
one
				time only
reinstatement will be allowed if the individual continues to
				meet all financial, non-financial and medical eligibility criteria.
				Reinstatement is subject to availability of positions and redetermination of
				medicaid eligibility. A PACE recipient may voluntarily disenroll at any time.
				Involuntary disenrollment occurs when any of the following situations exist:
(1) recipient moves out of PACE service
				area;
(2) recipient 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) recipient experiences a
				breakdown in the physician or team relationship such that the PACE provider
				ability to furnish services to either the recipients or other recipients is
				seriously impaired;
(4) recipient
				refuses services or is unwilling to meet conditions of participation as they
				appear in the enrollment agreement;
(5) recipient refuses to provide accurate
				financial information, provides false information or illegally transfers
				assets;
(6) recipient is out of the
				PACE service area for more than one calendar month (unless other arrangements
				have been made);
(7) recipient is
				enrolled in PACE that loses its contract or licenses which enables it to cover
				health care services;
(8) recipient
				fails to meet the financial or non-financial criteria; or
(9) recipient ceases to meet the level of
				care at any time.