Procedures and Policies

Eligibility/Enrollment

If you meet eligibility requirements and want to enroll, you must sign and agree to abide by the conditions of LIFE, as explained in this agreement. You will be expected to actively participate and comply with your care plan.

Your effective date of enrollment will be the first day of the calendar month following the date you sign the Enrollment Agreement.

Note: Individuals currently enrolled in a Medical Assistance HMO, Home and Community Based Waiver Program, or other Medical Assistance Program must be disenrolled from that program before they can enroll with LIFE. You will be required to disenroll from a Medicare HMO, so we can effectively coordinate your care. Potential enrollees may not enroll in LIFE at a Social Security Office.

Enrolling in LIFE includes four steps: Intake, Assessment, Determination of Medical and Financial Eligibility and Enrollment.

Your benefit coverage officially begins on your effective date of enrollment.

Intake

Intake begins when you or someone on your behalf makes a call to LIFE. If it appears from this first conversation that you are potentially eligible, a program representative will visit you to explain our program and obtain further information about you. During this visit:

  • You will learn how the LIFE program works, the kinds of services LIFE offers, and answers to any questions you may have about LIFE.
  • We will explain that if you enroll, you must agree that all of your healthcare services will be provided and/or coordinated by LIFE, including primary care and specialist physician services (other than emergency services). Members of your health team will approve these services. LIFE participants may be fully and personally liable for the costs of unauthorized services (other than emergency services).
  • We will have you sign a release allowing us to obtain your past medical records so our health team can fully assess your health conditions.
  • You will be encouraged to visit the LIFE Center to see what it is like. If you are interested in enrolling, our program representative will assist you with the enrollment process.

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Assessment

The health team will meet with you to evaluate your needs and goals. After the assessment has been completed, the health team will meet to specifically discuss your evaluation and determine if your needs can be appropriately met by our program. If so, the health team will develop an individual plan for services and schedule time with you to explain how it will best meet your needs and preferences. However, LIFE cannot guarantee or offer enrollment before a formal eligibility determination has been made.

Determination of Medical and Financial Eligibility

Because LIFE is committed to serving only frail older adults who need long-term care and are eligible for nursing home care, an outside opinion must confirm that your situation qualifies you for our services. The local Area Agency on Aging will determine your medical eligibility for the program after making an assessment of your needs. The local County Assistance Office will determine your financial eligibility for the program, if applicable.

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Important Notice

If you are eligible for Medicare or Medicaid, the services or benefits you get once you become a participant in PACE are made possible through an agreement that we have with The Centers for Medicare and Medicaid Services (CMS) of the United States Department of Health and Human Services regarding Medicare and Medicaid benefit coordination. When you become a Participant, you are agreeing to accept benefits only from Mercy LIFE in place of your usual Medicare and Medicaid benefits.

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Participants Without Medicare Coverage at the Time of Enrollment

A participant who becomes eligible for Medicare after enrollment must obtain all Medicare coverage (Parts A and/or B, and Part D) through Mercy LIFE in order to remain in the PACE program.

Mercy LIFE will track your Medicare benefits to ensure that you are enrolled in the CMS Medicare systems as soon as possible. You will be notified by letter and/or a phone call and apprised of eligibility status and your options. You will be provided with a 60-day advance notice of your ability to opt out of PACE if you do not wish your Medicare services to be administered by the PACE program.

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Enrollment

You, and if you wish, your family or caregiver, will meet with the program representative to review and come to an agreement about your participation in the LIFE program before you sign the Enrollment Agreement. At this meeting you have an opportunity to discuss:

  • The plan of care recommended for you by the health team, which incorporates plans for family and caregiver involvement.
  • That when you are enrolled in LIFE, all of your Medical Assistance and Medicare services must be authorized or coordinated by the health team. (Remember, approval is not required for emergency care.)
  • What to do if you are unhappy with the LIFE program. (See Participant Grievance Procedure.)

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Final Approval and Enrollment

If you decide to join LIFE, we will ask you to sign the Enrollment Agreement. Upon signing this agreement, you will receive:

  • A copy of the Enrollment Agreement.
  • A sticker with LIFE’s emergency telephone numbers and an instruction sheet to put on or by your telephone telling you what to do in an emergency.
  • An identification card or sticker that must be placed with your Medical Assistance and Medicare card indicating that you are enrolled in LIFE.

Since LIFE provides comprehensive care for its participants, enrollment in LIFE results in disenrollment from any other Medicare or Medical Assistance prepayment plan.

All LIFE services are provided and admissions and referrals are made without regard to race, sex, color, national origin, ancestry, religious creed, sexual orientation, or handicap. Complaints of discrimination may be filed with the following state agencies:

Office for Civil Rights Pennsylvania Human Relations Commission

U.S. Department of Health & Human Services go to www.phrc.state.pa.us for your local office

150 South Independence Mall West
Suite 372, Public Ledger Building
Philadelphia, PA 19106-9111
Main Line: 215.861.4441
Hotline: 800.368.1019

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Termination of Benefits

Your benefits under LIFE can be stopped if you choose to disenroll from the program voluntarily or if you no longer meet the conditions of enrollment and are involuntarily disenrolled. This program is available through an agreement LIFE has with the state and federal government. If this agreement is not renewed by those agencies, this program will be terminated. The effective date of termination of benefits will be midnight of the last day of the month in which the notice was given.

You are required to continue to use LIFE’s service and to pay any applicable fee until termination becomes effective.

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Voluntary Disenrollment

If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative at your center. You will need to sign a Disenrollment Form, which will indicate that you will no longer be entitled to services through LIFE after midnight on the last day of the month. You may not disenroll from LIFE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance prepayment plan or optional benefit, including the hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE.

Your social worker will assist you in returning to the appropriate Medicare/Medical Assistance Program. The Medicare or Medical Assistance program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE.

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Involuntary Disenrollment

LIFE can terminate your benefits, if:

  • You move out of the LIFE service area.
  • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself.
  • You engage in disruptive or threatening behavior.
  • You fail to pay or fail to make satisfactory arrangements to pay any premium due to LIFE after a 30-day grace period.
  • You are out of the service area for more than 30 days without prior approved arrangements.
  • You no longer meet the eligibility requirements for the program.
  • Our agreement with the federal and state government is terminated.
  • LIFE loses the contracts and/or licenses enabling it to offer health care services.

Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligible. Therefore, any individual who relocates to a personal care boarding home will be involuntarily disenrolled from the LIFE program.

Before you are involuntarily disenrolled from LIFE, we will provide you with 30 days written notice. Your disenrollment will be effective the last day of the month after 30 days’ notice.

Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangement to pay, or are out of the service area for more than 30 days without prior approved arrangements. An impartial party will review the involuntary disenrollment.

If you are disenrolled due to failure to pay the monthly fee, you can re-enroll simply by paying the monthly fee in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverage.

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Premiums

  • What you pay for PACE depends on your eligibility under Medicare and Medicaid.
  • If you are eligible for Medicaid, or dually eligible for both Medicare and Medicaid, you won’t pay a monthly premium for PACE.
  • If you don’t qualify for Medicaid, but you have Medicare, you’ll be charged a monthly premium for PACE.
  • There’s no deductible or copayment for any drug, service, or care approved by your health care team.
  • If you don’t have Medicare or Medicaid, you can pay for PACE privately.
  • PACE participants may be fully and personally liable for the costs of unauthorized or out-of-PACE program agreement services.

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Participant Grievance/Appeal Procedure

All of us at LIFE share the responsibility for assuring that you are satisfied with the care you receive. We encourage you to express any complaints you have at the time and place any dissatisfaction occurs. To be consistent with federal regulations for the program, your complaints or dissatisfaction with our program or decisions are identified as either grievances or appeals. Those processes are described below.

Grievance Procedure

The definition of a grievance is a complaint, either oral or written, expressing dissatisfaction with service delivery or the quality of care furnished.

  • Discuss your grievance with any staff member. Give complete information so that appropriate staff can help to resolve your concern in a timely manner.
  • The staff that receives your grievance will discuss with you and provide in writing the specific steps including time-frames for response that will be taken to resolve your grievance. The grievance will be reported to the health team within 5 working days.
  • If a solution is found by the staff and agreed to by you and/or your family/caregiver within 5 working days of making the grievance, the grievance is resolved.
  • If you are not satisfied with the solution, the staff will send a written report to the Executive Director (clinical complaints will be reviewed by qualified clinical personnel) for review, to be completed within 5 working days.
  • Immediately after review (but within 5 working days), a copy of a written report will be sent to you and/or your family/caregiver.
  • If you are still dissatisfied with the results, you may submit a request in writing within 30 days to ask for a review by LIFE’s Plan Advisory Committee.
  • The Plan Advisory Committee will send written acknowledgment of receipt of the grievance within 5 working days to you, investigate, find a solution and take appropriate actions.
  • The committee will send you a copy of a report containing a description of the grievance, the actions taken to resolve the grievance and the basis for such action. The committee has 30 working days from the day the grievance is filed with the committee to complete its report and send it to you.
  • If the decision is not in your favor, a copy of the report will be forwarded immediately to the federal government, the Pennsylvania Department of Human Services and the local Area Agency on Aging.

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Appeal Procedure

The definition of an appeal is action taken by you with respect to your disagreement with our non-coverage of or non-payment for a service, denial of enrollment, or your involuntary disenrollment from the program.

You will be notified in writing if we:

  • will not cover or pay for a service that you are receiving or requesting;
  • are denying enrollment into LIFE; or
  • are initiating an involuntary disenrollment from LIFE.
  • The notice will instruct you how to appeal our decision if you do not agree with it. You must request an appeal within 30 days of our notice to you. An involuntary disenrollment for non-compliance with your care plan or conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or being out of the service area for more than 30 days without prior approved arrangements, will automatically be considered an appeal.
  • Confirmation of receipt of your request for appeal will be sent to you within 24 hours of receipt of your request.
  • We will continue to furnish disputed services until a final determination is made if you appeal within 30 days of our notice to you; if we are proposing to terminate or reduce services you are currently receiving; and if you agree that you will be liable for the costs of the disputed services if the appeal is not resolved in your favor.
  • An impartial party will review your appeal and you will be notified in writing of the date and time of that review to have an opportunity to present evidence related to your dispute.
  • You will receive a written report of the third party review within 30 days of receipt of your appeal. That report will describe the appeal, actions taken, and outcome of the review.
  • If your appeal is resolved in your favor, we will provide or pay for the disputed service right away.
  • If the decision is not in your favor, a copy of the written report from the third party review will be forwarded immediately to the federal government, the Pennsylvania Department of Human Services and the Local Area Agency on Aging. You will also be notified in writing of your additional appeal rights under Medicare, or Medical Assistance through the State Fair Hearing Process. We will assist you in choosing which to pursue and forward the appeal to the appropriate entity.
  • If you believe that your life, health, or ability to regain function would be seriously jeopardized if you do not receive the service in question, you can request in writing that we speed up the appeal process. In that case you will receive the outcome of the appeal within 72 hours of receipt of your appeal.

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