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Medicaid Recipients to be "Default Enrolled" into Medicare Special Needs Plans when they Enroll in Medicare-- April 1, 2021

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Views: 14619
Posted: 20 Jan, 2021
by Valerie Bogart (New York Legal Assistance Group)
Updated: 14 Jul, 2023
by Anna Arellano (New York Legal Assistance Group)

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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:

  • they reach age 65, or
  • after they collect Social Security Disability Insurance (SSDI)  for 24 months.  

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 (MMC) Plans Before They are Enrolled In Medicare

  2. UNTIL NOWWhat happens when Medicaid recipients become enrolled in Medicare

    1. The  rules until now

    2. Special COVID-19 Rules in the Public Health Emergency

  3. NEW - April 2021 - Default Enrollment of New Duals in Dual-SNP or MAP Plans

    1. Two types of Medicare Plans for Default Enrollment - Dual-SNPs and Medicaid Advantage Plus  (MAP)

    2. 60-Day Notice Sent by Medicaid Plan of Default Enrollment and the Right to Opt Out

    3. How you Access MEDICAID Services After default enrollment

    4. Which  Plans Are  Approved for Default Enrollment as of March 2021 

    5. Member Right to Continuity of Care After Default Enrollment - and Changing Plans 

    6. 2023 Update - Issues  in the Unwinding of the Pandemic 

    7. LAW, REGULATIONS and GUIDANCE AUTHORIZING DEFAULT ENROLLMENT 

    8. Fact Sheets and for More Info  -- and Getting Help

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:  

  • For Medicaid -- they are disenrolled from their Medicaid managed care plan and then have "regular" or "fee-for-service" Medicaid. 

  • Those Medicaid recipients who received Medicaid home care (personal care or Consumer-Directed Personal Assistance (CDPAP))  from their Medicaid managed care plan are transitioned to a Managed Long Term Care (MLTC) plan for their Medicaid home care services.   See NYS DOH MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC.  They have fee for service or regular Medicaid for services not covered by MLTC.  

  • Normally, before the pandemic, once they became enrolled in Medicare their Medicaid was transferred from NYSOH to the local Medicaid agency to  redetermine  Medicaid eligibility under the stricter non-MAGI rules.  These transfers to the local Medicaid agency and redeterminations were not done during the COVID-19 Public Health Emergency.   

  • For Medicare, they may choose between Original Medicare or a Medicare Advantage Plan.  If they choose Original Medicare, they must also enroll in a Medicare Part D plan.  See this Toolkit produced by the Medicare RIghts Center, Coverage Options for Dually Eligible New Yorkers.

  • During the COVID-19 pandemic, Medicaid managed care members have remained in their Medicaid managed care plan once they became enrolled in Medicare.  This is an unusual departure from the past, described above.  See NYS Dept. of Health - April 2, 2020  GIS 20 MA/04 – Coronavirus (COVID-19) – Medicaid Eligibility Processes During Emergency Period (page 2).  These individuals use their Medicare card as their new "primary" insurance and their Medicaid managed care plan as secondary coverage, which includes Medicaid home care services like personal care or CDPAP.  So they are not transitioned to MLTC at this time. 

3.  April 2021 - NEW DEFAULT ENROLLMENT 

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.  


A.  TWO TYPES OF  "default enrollment"  - 

  • Default enrollment is always into a Medicare "Dual Special Needs Plan"  (Dual-SNP or D-SNP).  But which plan the consumer is assigned to  depends on whether individual receives Medicaid Long Term Services & Supports (LTSS) such as Personal Care or CDPAP from their mainstream managed care (MMC) plan.  

  1.  Not receiving Long Term Services & Supports (LTSS - Medicaid home care services such as personal care or CDPAP) from their MMC plan.

 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.

  1. If receiving Long Term Services & Supports (LTSS) such as Medicaid personal care or CDPAP services from their MMC plan

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 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.  

D.    WHICH PLANS HAVE BEEN APPROVED in NYS FOR DEFAULT ENROLLMENT? 

  • List as of February 2023 is posted on the NYS Dual Eligibles webpage under the IB-Dual dropdown.  Additional plans can be approved by CMS on a rolling basis. These plans and any newly approved plans will continue using default enrollment for each following month as their MMC and HARP members become Medicare eligible.

  • The column labeled "Product Type" indicates either:

    • "MMC/HARP" -- the IB-Dual Plans that do not provide personal care, CDPAP, or other Medicaid community-based long term care services.   

    • "MAP"  - Those who do receive these communitybased long term care services are default enrolled in a "MAP" plan.

  • The column labeled "H/PB" shows the aligned MEDICARE Dual-SNP plan's ID number.  Caution:  The name of the MEDICARE  plans is not always the same as the name of the aligned MEDICAID  IB-DUAL or MAP plan.  For example, the listed Fidelis plans are aligned with these Wellcare Medicare DUAL-SNP plans:

    • Wellcare Fidelis Dual Plus (HMO D-SNP)(Plan ID H5599/003) - aligned with Fidelis MAP plan

    • Wellcare Fidelis Dual Access (HMO D-SNP)(Plan ID H5599/001) - aligned with Fidelis IB-Dual plan (MMC/HARP)

    • The Medicare Dual-SNP Plan IDs are on charts issued each year by CMS and posted here. (See SNP Landscape Source File for most recent year).   NYLAG sometimes posts an extract of these national lists for New York State - see 2023 lists here .  The 2023 Dual-SNP list is here

  • How many have been default enrolled into a Dual-SNP or MAP Plan?  When default enrollment began, DOH shared these figures:
  • April 1, 2021 - 700 members  
  • MAY  1, 2021 - 1300 members  
  • JUNE 1, 2021 - 1500 members  
  • 2022 - 2023 - No figures available, but as of April 2023 27,000 people are in IB- Dual plans.  Source:  DOH Monthly Medicaid Managed Care Enrollment Report - which show many members are in each  plans by county, see the NYS managed care enrollment reports).   

See MRC Flier Default Enrollment in New York State.   

E.  Member Right to Continuity of Care After Default Enrollment into D-SNP or MAP Plan 

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.

 

May a consumer change plans  after being default enrolled?

  • Individuals eligible for both Medicare and Medicaid have access to special enrollment periods (SEP) to change their Medicare coverage. (See Medicare Rights Center SEP Chart).  Therefore, if someone wants to switch the plan in which they were default enrolled, they can use a SEP to switch to Original Medicare with a Part D plan or to switch to a different Medicare Advantage plan.

  • If an individual enrolled into a D-SNP through default enrollment, if they voluntarily disenroll from the D-SNP, they will no longer be allowed  to remain enrolled in the IB-Dual plan (their MMC or HARP plan) for their Medicaid coverage.  They will be disenrolled from the IB-Dual plan and will have fee-for-service Medicaid. 

  • Individuals enrolled in a MAP plan may change plans to a different MAP or PACE plan or to an MLTC plan.  The new "lock-in" rules that prohibit MLTC members from changing plans after three months of enrollment, except for good cause, do not apply to MAP plans.  However, even though they MAY change plans does not mean they should.  When a consumer voluntarily changes between MLTC, PACE, or MAP plans, they do not have transition rights, meaning the right to continue the same hours of home care and other services in the new plan.   See more about transition rights here

F.   SOME PRACTICAL CONCERNS FOR AFTER THE PANDEMIC - Once Medicaid Eligibility Must be Redetermined for New Medicare beneficiaries

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.

 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. 

  • The rule was published in the Federal Register, Vol. 83, No. 73 (April 16, 2018)  (pages 16440 et seq)  and then  amended in the Federal Register, Vol. 84, No. 73  (April 16, 2019) (pages 16495-16502)

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 INFORMATION

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 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 

Tags
Medicaid managed care mainstream managed care D-SNP Dual-SNP default enrollment Dual-Special Needs Plan MAP
Attached files
item 2023 New York State Special Needs Plans updated 3-6-23.xlsx (74 kb) Download
item 2022-08-04 MAPDR-05 Medicaid Managed Care Plans NYC.pdf (129 kb) Download
item 2023-6-30 unwinding of medicaid continuous coverage.pdf (161 kb) Download

Also read
item Medicaid Personal Care or Home Attendant Services
item Income and Resource Limits for New York State Public Health Insurance Programs
item Medicaid Consumer Directed Personal Assistance Program (CDPAP) in New York State
item New "HARP" Plans Roll out for Managed Care Members who need Behavioral Health Services - Services Start January 2016 in NYC
item Transition Rights in Managed Care Plans - Rights of New Enrollees to Continue Receiving Services
item Managed Long Term Care
item Medicaid Managed Care
item Medicaid Advantage Plus "MAP" - New "FIDE" Appeals & Hearing Process began 2020 - Healthfirst Mistake March 2021
item Right to a "Home Hearing" under Varshavsky Case - Special Rights in Fair Hearings Seeking Increases in Medicaid Home Care
item Transition Rights after Enrolling in or Switching MLTC plans - 2022 Changes
item 2024 Medicare Part D Plans in New York State - with 2023 plans

Also listed in
folder Medicaid -> Home Care

External links
http://health.wnylc.com/health/client/images/icons/article_out.svg https://www.health.ny.gov/health_care/medicaid/redesign/mrt2/policy/index.htm
http://health.wnylc.com/health/client/images/icons/article_out.svg www.medicareinteractive.org/resources/toolkits/coverage-options-dually-eligible-new-yorkers
http://health.wnylc.com/health/client/images/icons/article_out.svg https://nymedicaidchoice.com/ask/about-health-plans
http://health.wnylc.com/health/client/images/icons/article_out.svg https://nymedicaidchoice.com/program-materials?language=en
http://health.wnylc.com/health/client/images/icons/article_out.svg www.medicareinteractive.org/pdf/MAP-consumer-factsheet.pdf
http://health.wnylc.com/health/client/images/icons/article_out.svg https://medicareinteractive.org/pdf/default-enrollment-NYS.pdf

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