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BackgroundEvery month about 3,000 - 4,000 Medicaid recipients in New York State become enrolled in Medicare, either because they reach age 65 or after they collect Social Security Disability Insurance (SSDI) for 24 months. They become "Dual Eligibles" when they have both Medicare and Medicaid. Most Medicaid recipients who do not have Medicare are enrolled in "mainstream" Medicaid managed care (MMC) plans. Those with behavioral health needs are in HARP plans. See plans listed here. As described more below, before COVID, people could not remain in mainstream Medicaid managed care plans once they became Dual Eligibles with Medicare. They were transferred out of those plans and had "regular" or "fee for service" Medicaid and/or MLTC. During COVID, they were allowed to remain in these plans, with or without home care. Now, many will be able to remain in these Medicaid plans indefinitely IF they enroll in an "aligned" Medicare Dual-SNP plan. Coverage under the Medicaid plan will be secondary to their Medicare coverage.
Since April 1, 2021, members of some mainstream Medicaid managed care or HARP plans who newly become enrolled in Medicare are being assigned to "integrated" all-in-one plans that cover both Medicare and Medicaid. They are "default enrolled" into a Medicare Advantage Special Needs Plan for Dual Eligibles ("Dual-SNP") that is operated by the same insurance company that operates their Medicaid mainstream plan (called an "aligned" plan). They will remain in their Mainstream Medicaid or HARP plan to provide secondary coverage. For these new dual eligibles, the Mainstream plan is now called an "IB-DUAL" plan for "Integrated benefits - Dual Eligible." This article explains what notices they will receive, their right to OPT OUT of default enrollment and other rights, and what will happen going forward.
COVERED IN THIS ARTICLE:
1. Background - Most Medicaid Recipients are in "Mainstream" Medicaid Managed Care Plans Before They are Enrolled In Medicare.Nearly 5 million Medicaid recipients who do not have Medicare are enrolled in Medicaid Managed Care (MMC) health insurance plans, sometimes called "mainstream" plans.
What happens when Medicaid recipients become enrolled in Medicare is changing.2. Until now, except for special rules during the pandemic, when a Medicaid recipient becomes enrolled in Medicare (at age 65 or based on disability), here is what happens:
NOTE - these transfers to MLTC plans were SUSPENDED since COVID started, and have still not been reinstated as of 10/29/24. Mainstream members receiving home care from their mainstream plans should remain in those plans and continue receiving home care from those plans. Sometime in 2025 this is expected to revert to the pre--COVID rules.
3. April 2021 - NEW DEFAULT ENROLLMENT Members in certain designated Medicaid Managed Care (MMC) and HARP plans are "default enrolled" in a certain type of Medicare Advantage plan "Dual-Special Needs Plan" or Dual-SNP operated by the same insurance company that operates their Medicaid managed care plan. The date of the enrollment in this "aligned" Medicare plan is the 1st day of the month in which their Medicare enrollment becomes effective. The individual will receive advance written notice of the right to opt out of this auto-enrollment and select alternate coverage. This right is described more below.
Consumer is assigned to an "aligned" Dual-SNP, meaning that it is operated by the same insurance company that operates their Medicaid managed care plan. The consumer remains in their original mainstream managed care plan, which is now considered an "IB-DUAL" plan or "Integrated Benefit-DUAL plan," providing secondary coverage to the primary Medicare D-SNP.
Consumer is assigned to a Dual-SNP "aligned" with their Mainstream plan, but also to an aligned Medicaid Advantage Plus (MAP) plan -- all operated by the same insurance company. The MAP plans are a combo of a Medicare D-SNP (HMO) and an MLTC plan, plus they cover all Medicaid services not covered by MLTC plans. In other words, they cover ALL Medicare and Medicaid services. The member must only use providers in the plan's provider network for all Medicare and Medicaid services. SEE ICAN info on types of MLTC plans including MAP. This is a big change from before, as Medicaid managed care members who first became enrolled in Medicare and had received home care from their mainstream plan were default enrolled into an MLTC plan, allowing them to keep their preferred Medicare coverage separately. MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC. Now default enrollment is to a MAP plan that is a type of Medicare Advantage plan. See lists of New York City - All long term care plans - look for the Medicaid Advantage Plus plans. For other regions click here - scroll down to HEALTH PLAN LISTS for "Long Term Plans" by region See Medicare RIghts Center fact sheets about MAP plans: WARNING about Appeal rights in Medicaid Advantage Plus (MAP) Plans - All MAP plans must use the new "FIDE" integrated appeal process, described here. This is a new appeal system, which was used in the now-closed FIDA program. FIDA had very few enrollees compared to MAP plans (6,000 in FIDA in its last year 2019 compared to 25,000 in MAP). So the integrated appeals system has had growing pains -- Advocates have seen long delays in scheduling these hearings and other problems. See more here. One concern about MAP hearings is the State's position that appellants are not entitled to rights under the Varshavsky v. Perales class action. See this article about these important protections, including the right to a home hearing if an initial phone hearing is not decided fully favorably. B. 60-Day Notice From Managed Care Plan Before Default Enrollment Individuals subject to default enrollment should receive a notice from their Medicaid managed care or HARP plan at least 60 days before being default enrolled into the aligned D-SNP or Medicaid Advantage Plus plan (MAP). The Notice states that unless the member "opts out," they will be automatically enrolled in the aligned D-SNP on the first of the month of their initial Medicare enrollment. Plan notices should provide clear information comparing the new D-SNP and the beneficiary’s current MMC or HARP, including differences in benefits, premium costs, and cost-sharing.
Notices also include instructions to "opt out" of D-SNP enrollment and instead choose Original Medicare or a different Medicare Advantage Plan. A person can opt out of being default enrolled up until the calendar day prior to the enrollment effective date, which is also the individual’s Medicare effective date. The NYS-approved templates for the 60-DAY DEFAULT ENROLLMENT NOTICES are modeled after the CMS model notices. The NYS notices can be downloaded from the NYS Dual Eligibles webpage under the IB-Dual dropdown:
C. HOW WILL THOSE DEFAULT ENROLLED in a DUAL-SNP ACCESS MEDICAID SERVICES?Once default enrolled, the individual will be enrolled in the aligned Medicare D-SNP for primary coverage and prescription drug coverage, AND will remain enrolled in the Medicaid managed care (MMC) or HARP plan for secondary coverage. If the individual received Medicaid home care or other LTSS from the MMC plan, they are default enrolled into a MAP plan. These plans provide ALL Medicaid services, not just those covered by MLTC plans These members must make sure to use only providers in the plan's network, whether the provider is providing a Medicare or Medicaid service. The MAP plan covers their prescription drugsm so the member does NOT join a separate Part D plan. D. WHICH PLANS HAVE BEEN APPROVED in NYS FOR DEFAULT ENROLLMENT?
See MRC Flier Default Enrollment in New York State. E. Member Right to Continuity of Care After Default Enrollment into D-SNP or MAP PlanEnrollees are entitled to 60 days of continuity of care to continue receiving services under an existing plan of care from their previous plans, including services from any providers with whom they are under an episode of care if the provider is not in the D-SNP network. This information should be included in the MMC or HARP member materials for duals remaining in the plan. For those MMC members who are default enrolled into a Medicare Advantage Plus plan, the MAP plan must continue the the same type and amount of home care or other Long Term Services and Supports they individual received from the MMC plan previously. See MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC.
May a consumer change plans after being default enrolled?
The default enrollment process started in 2021. During the COVID-19 Public Health Emergency. In the pandemic, new dual eligibles have remained on Medicaid even if normally they would no longer be eligible now that they have Medicare, because normally they are subject to an asset test under non-MAGI Medicaid rules. In normal times, many may lose Medicaid when their Medicaid case is transferred from the NYSofHealth Exchange to the local Medicaid districts, which are charged with redetermining their eligibility under "non-MAGI" rules that apply to most people who are age 65+ or who have Medicare. See Medicare Rights Center toolkit for Moving from the Marketplace to Medicare in NYS. (registration required) and See GIS 16 MA/004 -Referrals from NY State of Health to Local DSS for Individuals who Turn Age 65 and Instructions for Referrals for Essential Plan Consumers (PDF); 2014 LCM-02 - Medicaid Recipients Transferred at Renewal from New York State of Health to Local Departments of Social Services Under "MAGI" Medicaid used for those without Medicare, there is no resource limit. In Non-MAGI Medicaid, there are strict resource limits. Fortunately, beginning in 2023, MAGI and non-MAGI Medicaid have the same income limits at 138% FPL. This is from a change in state law for which NYLAG advocated passionately along with many other groups. However, Workers Comp, Veterans' benefits, and family support do not count as income for MAGI Medicaid, but do for non-MAGI Medicaid. For this reason, many new dual eligibles lose Medicaid, or if they keep Medicaid, are determined to have a high "spend-down" when they get Medicare and Medicaid transitions to non-MAGI Medicaid. It generally takes many months for these eligibility determinations to be made by the local Medicaid agencies. Yet the regulations about Default Enrollment require the mainstream Managed Care plan to send notice to its members 60 days before they become eligible for Medicare, telling them they will be default enrolled in a D-SNP plan. Those D-SNP plans may only enroll those with Full Medicaid, not those with a spend-down. But there hasn't been enough time in that short period to determine WHO is eligible for Full Medicaid. In the pandemic, none of these complex transitions are required; Congress has said that no state may cut off Medicaid for anyone who was eligible or becomes eligible during the pandemic. Therefore, the NYS Dept. of Health appropriately has said that all new dual eligibles will remain in their Medicaid managed care plans. GIS 20 MA/04. For NYC, see this HRA Alert 6/30/23 which provides for the Resumption of Medicare Requirements - Disenrollment from Mainstream Managed Care will resume for clients in receipt of Medicare. Individuals who became eligible to apply for Medicare during the Covid emergency will be required to comply with the Medicare application requirement. G. LAW, REGULATIONS and GUIDANCE AUTHORIZING DEFAULT ENROLLMENT 42 CFR §§ 422.66 (c) and 422.68 (d) (amended in 2018 to allow Default Enrollment of some dual eligibles into D-SNPs, with certain protections.
See also CMS Medicare Managed Care Manual- Chapter 2 § 40.1.4 CMS published Default Enrollment FAQ's in February 2019 and this Fact Sheet in 2019. This process is a more limited version of seamless conversion, which CMS placed a moratorium on in 2016. NYS DOH Stakeholder Meetings about Future of Integrated Care - Presentations H. FACT SHEETS AND FOR MORE INFORMATIONMedicare Rights Center provided much of the information in this article. You can register for newsletters here. See Medicare RIghts Center fact sheets: 4. New 2024 - Voluntary Enrollment into IB-DUAL plan as secondary coverage for Medicare, if enrolled in "aligned" D-SNP.The state has been conducting a pilot program that allows dual eligibles who are enrolled in certain Dual-Special Needs Plans (D-SNPs) to also enroll in the "aligned" IB-Dual plan. Together, these plans provide comprehensive integrated coverage of all Medicare and Medicaid services, except that the Medicaid IB-Dual plan does not provide personal care, CDPAP or other long term care. For those services, the individual must instead enroll in a MAP plan (for integrated all-in-one care) OR in an MLTC plan. Which plans allow VOLUNTARY enrollment into an IB-DUAL plan, if consumer is enrolled in the "aligned" D-SNP plan? On the DOH chart (go to dropdown for IB-DUAL) or on NYLAG's adaption of DOH's chart (Excel)(PDF) - look at the LAST COLUMN. If the cell in that column is blank, then voluntary enrollment in the IB-DUAL plan is NOT allowed for that plan. If the cell says YES, then voluntary enrollment is allowed. Some cells show the date when voluntary enrollment in the IB-DUAl is first allowed. CAUTION: Dual-SNPs are doing heavy marketing of dual eligibles to enroll in their plans - enticing them with Over-the-counter cards and other perks. But -- consumers must be sure that all of their preferred providers are in the plan's network - otherwise the D-SNP won't pay the bill, which means Medicare won't cover it. Just because the member's doctor or other provider is in their MEDICAID managed care plan does not mean that the doctor or other provider is in the MEDICARE D-SNP. In 2024, 80% of providers must be in both plans' networks. See State Medicaid Agency Contract (SMAC) between D-SNPS and NYS 2024. (at page 8). Also they need to make sure their drugs are covered by the plan's "formulary." QUESTIONS and HELPIf you have any questions, please email Beth Shyken-Rothbart at bshyken@medicarerights.org . Those who received Personal Care or CDPAP services from the Medicaid Managed Care or HARP plan and become enrolled in Medicare may call the Independent Consumer Advocacy Network (ICAN) for counseling on their rights and options. 1-844-614-8800 or ican@cssny.org
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