WHAT CHANGE IS HAPPENING APRIL 1, 2021
Beginning April 1, 2021, a change is coming for New York Medicaid recipients who newly become enrolled in Medicare and become "Dual Eligibles" - someone who has both Medicare and Medicaid. Every month about 3,000 - 4,000 Medicaid recipients in New York State become enrolled in Medicare. They become eligible for Medicare either because:
There are about 800,000 Dual Eligibles in New York State. The change beginning in April 2021 affects how Medicare and Medicaid services will be accessed by new Dual Eligibles. Members in the Medicaid managed care (MMC) and HARP plans listed here will be "default enrolled" into a Medicare Advantage plan for Dual Eligibles ("Dual-Special Needs Plan" or "Dual-SNP") unless they opt out, and will remain in their Mainstream Medicaid 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 and their 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.
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:
Members in certain designated Medicaid Managed Care (MMC) and HARP plans will be "default enrolled" in a certain type of Medicare Advantage plan 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 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 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.
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:
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.
See MRC Flier Default Enrollment in New York State.
Enrollees 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.
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. 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, in 2023 MAGI and non-MAGI Medicaid have the same income limits at 138% FPL. However, Workers Comp and Veterans' benefits 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.
May 2023 Update -- Now that the Public Health Emergency is unwinding, these challenges will emerge. DOH has said that those mainstream members who are new to Medicare will have their Medicaid renewed on NYSOH rather than transferred to the local Medicaid office. However, unless the member is already in an IB-Dual or MAP plan, or eligible to enroll in such plans, they will be disenrolled from the mainstream plan once they have Medicare. Once disenrolled from the mainstream plan, they can no longer be "default enrolled" into a Dual-SNP, IB-Dual plan. Only those receiving Medicaid home care services from their mainstream plans will likely be default enrolled in either a MAP or MLTC plan. Neither the federal or state government have explained how default enrollment can possibly work under the ordered time frames.
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.
See also CMS Medicare Managed Care Manual- Chapter 2 § 40.1.4
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
Medicare Rights Center provided much of the information in this article. You can register for newsletters here. See Medicare RIghts Center fact sheets:
If you have any questions, please email Beth Shyken-Rothbart at firstname.lastname@example.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 email@example.com