Enrollment in a Medicaid Managed Long Term Care (MLTC) plan is mandatory for most adult Dual Eligibles (people who have Medicare or Medicaid), who need Medicaid personal care (PCS) or Consumer Directed Personal Assistance Program (CDPAP) services, with some exceptions - See also DOH list of exclusions and exemptions here.
However, an MLTC plan may -- and in some cases must -- involuntarily disenroll a member from the plan for certain reasons NOTE: New guidance issued Sept. 3, 2024 DOH MLTC Policy 24.02: replaces the 2023 guidance MLTC Policy 23.03, discussed in this article. The 2023 and 2024 versions are identical except for adding a new ground for involuntary disenrollment - non-cooperation with the assesment. Plans may start the process of disenrollment by submitting an Involuntary Disenrollment Request Form to NY Medicaid Choice starting Oct. 3, 2024, which, after the various notices are sent, could result in disenrollment on Nov. 1, 2024.
NOTICES TO MEMBER BEFORE DISENROLLMENT - The plan -- and then NY Medicaid Choice -- each send the member a notice prior to the disenrollment. The second notice from NY Medicaid Choice has Fair Hearing and AId Continuing rights. See more about the notices and procedures below.
A. Nov. 2024: New State Guidance will be effective, revising guidance from 2023 expanding Grounds for Disenrollment Takes Effect
B. Alert re TRANSITION RIGHTS if INVOLUNTARILY DISENROLLED
C. Reasons the plan MUST disenroll a member (mandatory grounds) (the paragraph numbering tracks the numbering in Policy 24.02)
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Moved to a County Outside the Plan's Service Area
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Absent from the service area for more than 30 consecutive days
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- iv. Enrollee is Hospitalized or in a Residential Program of OMH, OPWDD or OASAS for 45 consecutive days.
v. - vi. No longer enrolled in Aligned D-SNP Plan (MAP plans only)
vii. For PACE or MAP, an Enrollee no longer meets the Nursing Home Level of Care standard and cannot be deemed eligible.
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For MLTC plans only, Enrollee is age 18-21 and Does Not Meet the Nursing Home Level of Care Standard so is Not Eligible for MLTC.
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No longer in need of a Community Based Long Term Services and Supports (CBLTSS) for more than 120 days.
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Did not receive any of seven MLTC Community-Based Long Term Services & Supports (CB-LTSS) services in the prior calendar month
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Enrollee refused to cooperate or was unable to be reached to complete assessment - NEW GROUND in DOH MLTC Policy 24.02 - not in prior guidance
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Member in a Nursing Nome for 3+ months, was determined eligible for Institutional Medicaid AND Has No Active Discharge Plan (not in this guidance but exists elsewhere)
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Medicaid eligibility stops (not in this guidance but exists elsewhere)
D. Reasons that the plan MAY disenroll a member (optional grounds for disenrollment).
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You or your family's behavior interferes with provision of services.
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You have not paid the spend-down bill for 30 days - THIS GROUND IS STILL ON HOLD
E. Steps and Notices Required in the Disenrollment Process.
F. DOH will require plans to repay premium where Enrollee should have been disenrolled
G. Previous DOH Guidance on Disenrollments that is Superseded by MLTC Policy 23.03:
Involuntary disenrollments were suspended during the COVID pandemic, except for those based on a long-term nursing home stay. NYS DOH reinstated some involuntarily disenrollments with various directives in 2022.
On Sept. 3, 2024, DOH Issued DOH MLTC Policy 24.02: Updated Resumption of MLTC Involuntary Disenrollment Guidance that updates the previous policy MLTC Policy 23.03, which reinstated most grounds for disenrollment effective Nov. 1, 2023 (posted in DOH MLTC Policy library here). This guidance specifically "supersedes" the previous involuntary disenrollment guidance. However, the only change made by MLTC Policy 24.02 conmpared to Policy 23.03 is the addition of a new ground for involuntary disenrollment - non-cooperation with the assesment.
The earlier directives that are now superseded by MLTC Policy 24.02 are listed here.
Appendix 3 of MLTC Policy 24.02 has a SUMMARY TABLE of all of the disenrollment grounds described in detail below.
Most of the mandatory and optional disenrollment reasons are in the Model MLTC contract (2022 version) Article V, Part D, sec. 3-4 pp. 21-22)(Find most recent contracts here under dropdown for MODEL CONTRACTS). Medicaid Advantage Plus (MAP) and PACE plans have a unique additional mandatory reason for disenrollment involving the aligned Medicare coverage - see here.
Plan members should have Transition Rights if involuntarily disenrolled from a plan for most of the reasons discussed below. Section G of the policy describes Transition of Care Responsibilities of the plans. For each of the involuntarily disenrollment grounds, the member is either transitioned to another MLTC plan or to Fee for Service (FFS), which means to the local county Dept. of Social Services to authorize PCS/CDPAP. MLTC Policy 24.02: Section G provides:
"Prior to the effective date of the disenrollment, plans must make any necessary referrals to another plan or the HRA/LDSS for covered and non-covered services. The plan must make arrangements to transfer the Person Centered Service Plan (PCSP) to the receiving plan or HRA/LDSS. If the member is auto- assigned to a MLTCP plan, the receiving plan should continue the current PCSP until a new PCSP is completed. within fifteen (15) calendar days of the enrollment. This new PCSP should be based on the existing New York Independent Assessor Program CHA, if current. If the Enrollee is due for reassessment, a new CHA should be conducted." (emphasis added).
However, here are two warnings:
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If you VOLUNTARILY disenroll from one plan and switch to another plan, you do not have Transition rights in the new plan. WARNING: for some involuntary grounds for disenrollment, the enrollee will be asked if they want to VOLUNTARILY disenroll - if they say YES they will have no transition rights. See, e.g. being absent from county for 30 days and See more here about when you do NOT have transition rights. The FAQs for MLTC Policy 23.03 state, "The Plan cannot ask nor encourage the member to voluntarily disenroll." However, watch out for pressure to "voluntarily" disenroll.
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MLTC Policy 24.02 Section G fails to require the new plan or LDSS to continue the same plan of care for a certain amount of time -- it is only required until they complete a new assessment.
Also, the policy fails to require that if the new plan of care REDUCES PCS/CDPAP services, they must provide advance written notice with appeal rights, and may do so only for reasons consistent with MLTC Policy 16.06, such as a change in medical condition or if a mistake was made in the prior authorization. Under a change in a state regulation effective Nov. 8, 2021, MLTC plans may try to reduce your hours after the Transition Period if the Plan determines that the previous plan gave you “more services than are medically necessary,” based on "a clinical rationale that shows review of the client’s specific clinical data and medical condition." 18 NYCRR Sec. 505.14(b)(4)(viii)(c)(3)(vii), 505.28(i)(4)(iii)(h).
When a consumer is transfered to the Local DSS, transition procedures are especially weak. NYC HRA, for example, has no procedure for how an MLTC plan that disenrolls a member can convey the PCSP and for HRA to implement it. Also, if the plan of care includes services outside the purview of the LDSS, such as adult day care, private duty nursing, or medical supplies, the LDSS cannot implement those. The guidance is silent on how the consumer can continue receiving those services.
Most MLTC plans only serve certain counties. If you move to a county that is not served by your MLTC, MAP, or PACE plan, and notify your local Medicaid office (HRA in NYC) of the change of address, you will be disenrolled from your old MLTC, MAP or PACE plan. If you move to a county covered by your MLTC or MAP plan, your enrollment should be transferred to the new county (re-linked). See Policy 23.02 FAQs - which state that the plan should contact the local Medicaid office if the enrollment did not transfer.
Disenrollment procedures- under MLTC Policy 24.02 (same as MLTC Policy 23.03 but replacing prior guidance)
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The plan must immediately notify the HRA/LDSS of the new residential address when the plan has verified that an Enrollee has moved out the plan's service area.
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Within five (5) business days of notification that the Enrollee no longer resides in the plan's service area, the plan must submit the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC with the new address, and include dates of when the plan notified HRA/LDSS of the new address.
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Note: The enrollee's residential address must be updated by the HRA/LDSS in order for the disenrollment/ transfer to be processed by NYMC. If the address has not been updated, the plan must resubmit the involuntary disenrollment to NYMC after the address is updated.
What Happens after Disenrollment - How Does Person Continue Receiving Home Care?
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MANDATORY MLTC ENROLLEES (adults age 21+ who have Medicaid and Medicare and who are not in the OPWDD waiver and are not in home hospice) --
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will be notified by NYMC that they may transfer to another MLTC plan.
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Eligible enrollees who do not choose a plan will be auto-assigned to a MLTC plan in their service area.
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NYLAG COMMENT: This policy is an improvement over the now superseded GIS-21-MA/17 that merely referred them to their local medicaid office and did not auto-assign them to an MLTC plan.
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Those not eligible for MLTC -- are disenrolled to local Medicaid office (Dept. of Social Services or "LDSS").
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NYLAG comment: This provision would seem to apply only to those MLTC members who became enrolled in a home hospice program while they were enrolled in MLTC. They are excluded from enrolling in an MLTC plan. Unfortunately, MLTC Policy 24.02 and Policy 23.03, unlike previous guidance that they supersede (GIS 21 MA/17) do not say that the local Medicaid office (Dept. of Social Services or "LDSS") must continue the same Plan of Care that the plan provided until the next reassessment.
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TIP: Transferring Medicaid and MLTC services to a different county can be a complicated process. The procedure in this guidance should avoid disruption in coverage -- 2008 LCM-01 - Continued Medicaid Eligibility for Recipients Who Change Residency (Luberto v. Daines). It is helpful that MLTC Policy 24.02 (like MLTC Policy 23.03) requires the plan to notify the local district of the change in address.
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In NYC, to notify HRA of a move to a different county, fax a signed MAP- 751k form (3/15/21) to 1-917-639-0837 or email by encrypted email to undercareproviderrelations@hra.nyc.gov. The form is posted in multiple languages on HRA site here. Be sure to mention on the form that requesting LUBERTO transfer for individual enrolled in an MLTC, MAP or PACE plan, and the name of the plan. Also call NY Medicaid Choice at 1-888-401-6582 about transferring to an MLTC plan in the new county.
Disenrollments on this ground began Jan. 1, 2022,. See GIS 21 MA/24 and amended list of MAP plans that may initiate disenrollment on this ground -- Attachment I of GIS 22 MA/03 (May 16, 2022) and Letter to Health Plan administrators 11/29/21 Resumption of Two Additional MLTC Involuntary Disenrollment Reasons - (Web) (PDF) - 11.29.2021.
Effective Nov. 1, 2023, the procedures have changed. MLTC Policy 23.03 (and continuing under MLTC Policy 24.02, which replaces Policy 23.03.
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After the the Enrollee has been absent from the plan's service area for 30 consecutive days, the plan is required to make five (5) reasonable attempts to contact the Enrollee. The plan must document the status of each attempt in the monthly Care Management record. The record should reflect any services received during this period.
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Upon a successful contact with the Enrollee and/or their designee, the plan must inform the Enrollee and/or their designee of the requirement to be in the service area to maintain their membership with the plan. If the Enrollee discloses that they will be out of the service area for more than thirty (30) consecutive days, the plan should discuss with the Enrollee the option of a voluntary disenrollment or a voluntary transfer to another plan. See this warning about "voluntary" transfers to another plan.
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After making the 5 contact attempts, and within five (5) business days of notification that the Enrollee has been absent from the plan's service area (i.e., visiting family in another state) for more than thirty (30) consecutive days, if the plan is unable to reach the enrollee or representative, or if the Enrollee does not request to voluntarily disenroll, the plan must initiate the involuntary disenrollment process with NYMC. The referral to NYMC must include the Managed Long Term Care Involuntary Disenrollment Request Form along with:
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document at least five (5) attempts to contact the Enrollee or their Medicaid authorized representative (see above);
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a written statement from the Enrollee's Home Care Agency, or other pertinent evidence, that an effort was made to contact the Enrollee including the date of the last contact with the Enrollee.
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Consumer may remain in the plan if they return to the service area, and call NYMC or the plan prior to the disenrollment effective date. The plan must document the continued enrollment request as an occurrence in the monthly Care Management record including any changes to the existing PCSP. MLTC Policy 23.03 Section D.
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What happens after disenrollment - NYMC wwill send a disenrollment confirmation notice that will tell Enrollee to contact NYMC to discuss enrollment options and will disenroll them to FFS through the local DSS. NYLAG COMMENT - the 2023 and 2024 guidance do not say the DSS must continue the same plan of care, unlike prior guidance GIS 21 MA/24.
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WARNING: Consumers were allowed to pause home care during COVID, if they went to stay with family or wanted to limit exposure to home care aides. See COVID-19 Guidance for Voluntary Plan of Care Schedule Change issued April 23, 2020 (Web) (PDF). Those consumers should be given a chance to reinstate services before they are disenrolled on this ground. See NYLAG Know Your Rights Fact Sheet for MLTC Members about this guidance allowing voluntary pause of services.
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MLTC plans only - if Enrollee has been hospitalized for forty-five consecutive (45) days or longer and does not have an active discharge plan - MLTC plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days from the date the plan knows 45 days has elapsed. The MLTC plans must have up-to-date case management notes while the Enrollee is hospitalized and ongoing status of the Enrollee during the hospitalization.
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MLTCP plans must submit the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC and include the name of the hospital, the date of the admission, and that Enrollee does not have a discharge plan
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What happens after disenrolled - NYMC will send a disenrollment confirmation notice that indicates that the Enrollee should contact NYMC to discuss enrollment options that may be available upon discharge from the hospital.
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For all MLTC plan types including MAP and PACE - 45 days in a residential program -- Per MLTC Policy 24.02, like MLTC Policy 23.03, the plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days from the date the plan knows the Enrollee enters a residential program with the Office of Mental Health (OMH), Office for People with Developmental Disabilities - see here.(OPWDD), Office of Addiction Services and Supports (OASAS) or an OMH state operated psychiatric center that is not a MLTC plan covered benefit for forty-five (45) consecutive days or longer.
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MAP PLANS INCLUDE SOME RESIDENTIAL SERVICES -- The FAQs for Policy 23.03 caution that starting Jan. 1, 2023, MAP plans include some residential services, receipt of which are NOT grounds for involuntary disenrollment. See MLTC Policy 22.03 - Behavioral Health Benefits Carve into Medicaid Advantage Plus (MAP) and Policy 23.03 supplement listing residential services covered by MAP. Details on the OMH/OASAS residential program are provided in the New York State MAP Plans Behavioral Health Billing and Coding Manual.
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Plans must submit the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC and include the type and name of the program and date of admission
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Member will receive Notice with fair hearing and Aid Continuing rights from NY Medicaid Choice,
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What happens after disenrolled - NYMC will send a disenrollment confirmation notice that indicates that the Enrollee should contact NYMC to discuss enrollment options that may be available upon discharge from the residential program.
- The enrollment in the plan can continue if the Enrollee has returned to a community setting or has an active discharge plan with an expected discharge date, prior to or near the disenrollment effective date. The plan must document the active discharge plan or the return to the community setting as an occurrence in the monthly Care Management record. MLTC Policy 23.03 Part D. The enrollee may contact the plan or NYMC with this information. If the disenrollment was already processed, the plan must submit the enrollment to NYMC for the next effective date. However, if the request to continue enrollment is received after the disenrollmenet effective date, "a new enrollment application must be completed."
An active discharge plan from a residential program or hospital "requires that the individual has a plan to leave the residential program or hospital and return to the community. In other words, the discharge plan has current goals to make specific arrangements for a return to the community and/or staff are taking active steps to accomplish discharge." MLTC Policy 24.02 (same as MLTC Policy 23.03 Part D).
BACKGROUND: MAP plans combine in one all-in-one plan a D-SNP (DUAL-SNP) Medicare Advantage Special Needs Plan for Dual Eligibles, plus an MLTC plan. See more about MAP plans here. PACE plans like MAP plans cover all Medicare and Medicaid services in one insurance plan, including home care and all other MLTC services and pharmacy benefits.
To be enrolled in a MAP plan, you must be enrolled in the specific Medicare D-SNP plan that is "aligned" with your MAP plan. PACE members must be enrolled in the aligned PACE Medicare plan. The Medicare plan must be operated by the same insurance company that operates your MAP plan, and must be the specific plan that is aligned with the MAP or PACE plan. See 2024 list here (see Column R for Affiliated MAP plan in each county).
- See also DOH article about Integrated Plans for Dual Eligible New Yorkers - click on Dropdown for IB-DUAL and then scroll down to the table of plans. Plans with "MAP" in the third column labeled PRODUCT TYPE are the aligned D-SNPs for MAP plans. Beware to look at the plan ID numbers because plan names sound alike.
How do people enroll in a MAP with a D-SNP -- or a PACE plan?
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Voluntary enrollment -- Some people choose to enroll in a MAP or PACE plan instead of an MLTC plan. Similarly, some dual eligibles chose to enroll in a Medicare D-SNP because it can reduce some out of pocket costs, even if they do not need home care so do not join a MAP plan.
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Default Enrollment (with right to opt out)-- Since April 2021, some Medicaid recipients who had Medicaid on the NYSofHealth, have been "default enrolled" into Medicare Advantage Dual D-SNP plans when they first became enrolled in Medicare, at age 65 or based on disability. If they received personal care or CDPAP from their mainstream Medicaid Managed care plan, and if they were default enrolled into a D-SNP plan that was "aligned" with a MAP plan, they they were also default enrolled into the MAP plan. "Aligned" plans are specific plans operated by the same insurance company that operate as a component of a MAP plan.
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See more about default enrollment in this article - which also explains default enrollment into an IB-Dual plan (Integrated Benefits-Dual) plan for people who do not receive personal care or CDPAP from their mainstream health plan.
WARNING: Just switching to a Medicare Part D plan or switching to a different D-SNP or Medicare Advantage Plan would lead someone who n eeds home care to be disenrolled from their MAP or PACE plan -- and cause their home care to STOP!!
Many MAP and PACE members do not realize that if they enroll in a Part D drug plan, or switch to a different D-SNP or Medicare Advantage plan, they will be disenrolled from the D-SNP or PACE Medicare plan that is aligned with their MAP or PACE plan. This will then result in being disenrolled from their MAP or PACE plan. Many MAP or PACE members don't realize that just joining a Part D plan or switching Medicare Advantage plans could cause them to lose their home care! They don't realize that their home care is provided by the MAP or PACE plan, which requires enrollment in the "aligned" D-SNP or Medicare PACE plan.
- BEWARE OF MEDICARE PLAN MARKETING!! Unfortunately, many Part D and Medicare Advantage plans do heavy marketing to attract new members. A promise of an Over the Counter card can lure a MAP or PACE member to switch plans -- not realizing this will lead to LOSS OF THEIR HOME CARE.
Steps of disenrollment from MAP or PACE plan - under MLTC Policy 24.02 (same as MLTC Policy 23.03 that it replaces)
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"The plan is required to make three (3) reasonable attempts (as described in Section B. Reason ii.) over five (5) business days to contact the Enrollee to inform them that the plan received notification that the Enrollee was no longer enrolled in the aligned Medicare Advantage Dual Eligible Special Needs Plan [MA D-SNP]. Upon a successful contact with the Enrollee and/or their designee, the plan must inform the Enrollee of their disenrollment from the aligned MA D-SNP.
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If the Enrollee would like to remain enrolled in the MAP plan, the plan would assist the Enrollee in reinstating the enrollment in the aligned MA D-SNP to remain aligned in ..." the MAP plan. The MAP plan would not submit an involuntary disenrollment to NYMC in this instance.
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If the Enrollee acknowledges that the Medicare and Medicaid enrollment is not aligned and the Enrollee requests to voluntary disenroll from the MAP plan, the plan is required to ...submit a completed voluntary disenrollment form to NYMC. This situation would not be considered an involuntary disenrollment reason.
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If the plan is unable to contact the Enrollee or if the Enrollee does not want to reinstate their Medicare enrollment in the aligned MA D-SNP plan, the plan is required to submit the Involuntary Disenrollment Request Form to NYMC within five (5) business days of the plan receiving notification that the Enrollee was no longer enrolled in the aligned MA D-SNP.
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The enrollment in xurrrent MAP or PACE plan can continue if, prior to the disenrollment effective date, the Enrollee reenrolls in the aligned Medicare plan. MLTC Policy 23.03 Part D.
What Happens after Disenrollment from the MAP or PACE Plan - How Does Person Continue Receiving Home Care? Under MLTC Policy 24.02 (same as MLTC Policy 23.03 it replaces) --
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MANDATORY MLTC ENROLLEES (adults age 21+ who have Medicaid and Medicare and who are not in the OPWDD waiver and are not in home hospice) --
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If disenrollment is involuntary under the policy described above, mandatory enrollees will be notified by NYMC that they may transfer to another MLTC plan.
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Eligible enrollees who do not choose a plan will be auto-assigned to a MLTC plan in their service area.
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NYLAG COMMENT: This policy is an improvement over the now superseded (GIS 21 MA/17) that merely referred them to their local medicaid office and did not auto-assign them to an MLTC plan.
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VOLUNTARY OR EXEMPT ENROLLEES (Adults age 21+ who do not have Medicare, persons age 18-21) -
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If they do not select a new MLTC plan, they will receive a disenrollment confirmation notice that will tell them to contact NYMC to discuss enrollment options that may be available to them.
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NYLAG COMMENT: They will not be auto-assigned to an MLTC plan, unlike mandatory MLTC enrollees. Unfortunately, MLTC Policy 24.02, identifical on this point to MLTC Policy 23.03, unlike previous guidance that they supersede (GIS 21 MA/17) does not say that the local Medicaid office (Dept. of Social Services or "LDSS") should continue the same Plan of Care that the MAP plan provided until the next reassessment. See more on Transition Rights here.
This reason is applicable to PACE and MAP plan types only, not MLTC. Per MLTC Policy 24.02, as in MLTC Policy 23.03 that it replaced, the plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of a Community Health Assessment (CHA) that assessed the Enrollee as no longer meeting nursing home level of care.
A nursing home leve of care is indicated by a "score" of 5 or more on the CHA.
Note: Nursing home level of care may be identified at any reassessment. As of now )Sept. 2024) and indefinitely, reassessment CHA's are conducted by plan nurses, unlike initial CHA's conducted prior to enrollment, which are conducted by the NY Independent Assessor Program.
Prior to initiating the involuntary disenrollment request, within five (5) business days of the CHA determination. the plan must submit supporting documentation to the Department at MLTCMDReview@health.ny.gov should the plan believe that:
- the absence of continued coverage under the plan would negatively impact the Enrollee's condition and
- the Enrollee would be reasonably expected to meet the nursing home level of care requirement within the next six months,
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The supporting documentation must include the CHA and a statement from the plan's Medical Director or clinical staff clearly stating the rationale for "deemed eligibility" based on the member's chronic condition. Supporting documentation may include but is not limited to medical records, relevant tests, an assessment by specialists, formal and informal supports that may impact the stability of the member's condition in the next six months. The Department reserves the right to request additional supporting documentation including an attestation from the Enrollee's primary care provider.
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If NY Medicaid Choice agrees that the member has deemed eligibility, the Enrollee's enrollment would continue uninterrupted.
- If the deemed eligibility review request is not approved, the plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of the deemed eligibility review determination. The plan must submit the deemed eligibility review outcome with the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC. See further procedures here.
What Happens After Involuntary Disenrollment --
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MANDATORY MLTC ENROLLEES (adults age 21+ who have Medicaid and Medicare and who are not in the OPWDD waiver and are not in home hospice) -- will be notified by NYMC that they may transfer to another MLTC plan.
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VOLUNTARY OR EXEMPT ENROLLEES (Adults age 21+ who do not have Medicare, persons age 18-21) -
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If they do not select a new MLTC plan, they will receive a disenrollment confirmation notice that will disenroll them to the Local District for FFS, and tell them to contact NYMC to discuss enrollment options that may be available to them.
- NYLAG comment - MLTC Policy 24.02, like MLTC Policy 23.03 that it replaces, does not specify transition rights for these enrollees. See more about Transition Rights here.
The plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of the comprehensive reassessment that finds member does not meet Nursing home level of care.
Documentation: The plan must submit the CHA with the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC.
What Happens After Involuntary Disenrollment -The disenrollment confirmation notice will indicate that the Enrollee should contact NYMC to discuss enrollment options that may be available to them. Appendix 3 table says the enrollee is transferred to FFS (Local DSS) but this is not made clear in the body of the guidance.
NYLAG Comment - Member should have transition rights with care transferred to a mainstream plan or FFS through the local DSS.
This reason is applicable to all MLTC plan types (MLTC, MAP and PACE). The plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of the comprehensive reassessment.
The plan must submit the CHA with the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC. See notice to member and other procedures here.
What happens after disenrollment -- the Enrollee will be disenrolled to FFS. The disenrollment confirmation notice will indicate that the Enrollee should contact NYMC to discuss enrollment options that may be available to them.
Note: New York Independent Assessor Program (NYIAP) CHA Determinations -- Once the reassessments are transferred to NYIAP, there may be circumstances where a plan disagrees with the clinical determination impacting the Enrollee's CBLTSS eligibility. Should the plan disagree with the CBLTSS determination, the plan must initiate the CHA Variance request process by completing the NYIAP CHA Variance Form with supporting documentation as described in MLTC Policy 22.01.
This reason is applicable to all MLTC plan types. - MAP, PACE and MLTC. The plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of confirming that the Enrollee has not received CBLTSS within the previous calendar month. The seven services are:
- Nursing services in the home
- Physical, Speech or Occupational Therapies in the home
- Home health aide services
- Personal care services in the home (Level 2)
- Adult day health care
- Private duty nursing
- Consumer Directed Personal Assistance Services (CDPAP)
The plan must first make three (3) outreach attempts to the enrollee on different days of the week and different times of day.The plan must submit the Managed Long Term Care Involuntary Disenrollment Request Form along with
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The Intent to Disenroll letter (template is Appendix 1 of MLTC Policy 24.02)
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A statement indicating that the Enrollee that has not received at least one of the CBLTSS identified in the Person-Centered Service Plan (PCSP) in a specified month,
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The authorized schedule of services and the name of the authorized provider of the services, if available.
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If no contact was made with the Enrollee or their authorized representative, state the reason the Enrollee has not received the services, the specific dates, time, and type of three contact attempts made by the plan.
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The safe discharge plan including information about any referrals to other providers of applicable services or supports made on behalf of the Enrollee and the status of such referral(s).
What happens after disenrollment -- the Enrollee will be disenrolled to FFS. The disenrollment confirmation notice will indicate that the Enrollee should contact NYMC to discuss enrollment options that may be available to them.
Examples from MLTC Policy 24.02 (same as MLTC Policy 23.03) of When to and When Not to Initiate Involuntary Disenrollment when the Enrollee Does Not Receive CBLTSS
- A plan must initiate involuntary disenrollment due to lack of Enrollee receiving CBLTSS within previous calendar month: in these examples:
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An Enrollee chooses not to receive plan services because family or other natural supports are providing the needed assistance, and the Enrollee does not agree to voluntarily disenroll.
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The plan identifies that the Enrollee is not receiving services, and the plan has been unable to communicate with the Enrollee despite three (3) reasonable attempts (as described in Section B. Reason ii.) over five (5) business days.
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Per MLTC Policy No. 13.03, 13.05, and 13.11, the Enrollee has been identified as only receiving Social Adult Daycare (SADC) services, which is not one of the 7 MLTC services. MLTC enrollees who are disenrolled to FFS will not be able to access the SADC service.
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Per MLTC Policy No. 13.15, the Enrollee has been assessed as needing only level 1 housekeeping services.
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A plan would not initiate involuntary disenrollment due to the Enrollee not receiving CBLTSS within previous calendar month in these examples:
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Nursing services in the home is the only service in the Enrollee's plan of care, and the scheduled frequency results in no scheduled nursing service within previous calendar month.
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An Enrollee has been assessed to need personal care, but the plan is unable to locate an in-network provider to furnish the service and is working to find an out-of-network provider to furnish services.
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Enrollee is hospitalized during the calendar month that the Enrollee was identified as not receiving CBLTSS.
Members who are unhoused or living in a shelter -- FAQ for MLTC Policy 23.03 states how plan should handle this if Plan cannot provide CBLTSS in these settings -
- "The Care Manager should assist the enrollee in transferring to another residential location that would allow the Enrollee to receive needed services. In the event the member is unwilling or unable to transfer to a facility where they are able to receive services and more than 30 days have passed, the Plan should follow the Enrollee Has Not Received CBLTSS in the Previous Month disenrollment reason."
After receiving an Intent to Disenroll letter or an involuntary disenrollment notice, an Enrollee may contact the plan or NYMC to request reinstatement of their Plan of Care and continue enrollment in the plan. The plan must document the continued enrollment request as an occurrence in the monthly Care Management record including any changes to the existing PCSP. This should cancel the disenrollment. MLTC Policy 24.02 Part D.
NYLAG COMMENT: This ground of disenrollment is not listed in the Model MLTC Contract (pages 22-23 of the PDF), which might be a basis to challenge disenrollment. Also, if the consumer did not receive services because of the aide shortage, this should be raised as a defense. Also, see here for those who voluntarily paused services because of COVID.
xi. NEW STARTING NOV. 2024 - Enrollee refused to cooperate or was unable to be reached to complete the required assessment. NEW disenrollment ground in DOH MLTC Policy 24.02
Plans may submit an Involuntary Disenrollment Request Form to NY Medicaid Choice starting Oct. 3, 2024, which, after the various notices are sent, could result in disenrollment on Nov. 1, 2024. The following is a direct quote from DOH MLTC POLICY 24.02:
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This reason is applicable to all MLTC plan types. The plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of exhausting all efforts to gain the Enrollee's cooperation with completing the required assessment (the mandatory annual assessment or significant change in condition assessment, if needed). Enrollees, whether auto-assigned, passively, or voluntarily enrolled, are subject to be involuntarily disenrolled if the Enrollee refuses an assessment after any applicable continuity of care period.
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The plan must submit the following required documentation:
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A statement detailing all efforts used to gain the Enrollee's cooperation with scheduling and completing the required assessment.
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A statement detailing at least ten (10) outreach attempts over the course of thirty (30) calendar days to schedule and complete the required assessment. The outreach attempts must be conducted on different days of the week and different times of day. There must be at least two (2) visits to the Enrollee's home which may include the utilization of existing providers as outlined below.
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A statement demonstrating how the plan worked with the Enrollee's existing providers to educate the Enrollee and gain cooperation to schedule and complete the required assessment. Plans must document which providers were engaged including but not limited to the Enrollee's Personal Care Agency, the Fiscal Intermediary, primary care physician and other providers that render services to the Enrollee in the community.
Note: Member education must include an explanation that the assessment is required to continue plan eligibility and enrollment and that services could be discontinued. Enrollees who are involuntarily disenrolled for this reason must meet current MLTC program enrollment criteria upon re-enrollment, which may include a new NYIAP assessment.
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In the event that the member has an authorized or designated representative that assists in making decisions, the plan must include outreach to the authorized or designated representative in at least five (5) of the ten (10) outreach attempts.
Each of the attempts must have a documented outcome of the attempts to reach, schedule and complete the required assessment.
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For example: Contacted the member at (123) 456-7891 and the member is ill. Advised that we will attempt to reschedule once the member is well. The case record must be updated with the current status of when a follow up outreach attempt will be made.
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For example: Contacted the member at (123) 456-7891 and the member said that they do not want an assessment and their health has not changed since the last assessment. Member wants to continue the plan of care without having to complete the required assessment. Educated the member that the assessment is a requirement for continued enrollment. The member declined to schedule the assessment.
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The outcome of each outreach attempt must be documented in the case record. As a reminder, there must be ten (10) outreach attempts to the Enrollee including five (5) outreach attempts to the authorized or designated representative, if applicable.
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The plan must submit the following documents with the Managed Long Term Care Involuntary Disenrollment Request Form:
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if Enrollee schedules and completes required assessment prior to disenrollment effective date, enrollment in plan can continue.
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(See notice to consumer, fair hearing and aid continuing rights here)
xii. Member in a Nursing Nome for 3+ months AND was determined eligible for Institutional Medicaid and has No Active Discharge Plan
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This ground for disenrollment is not listed in MLTC Policy 24.02 because for the time being, plans may not initiate disenrollment on this ground. These disenrollments are still initiated by DOH in batches, after DOH identifies those enrollees in nursing homes for 3+ months who have been approved for Institutional Medicaid, and asks the plans to identify those who do not have an active discharge plan. Down the road, DOH will allow PLANS to initiate these disenrollments. DOH MLTC Policy 24.02: Part E.
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See this article for information on notices member and their representative should receive before disenrollment because of a Long Term Nursing Home Stay, and their appeal rights. Members should NOT be disenrolled if they have an active discharge plan to return home, and they need to appeal if disenrollment is threatened.
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Members have the right to re-enroll within 6 months of the disenrollment.
xiii. Medicaid Eligibility Stops
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MLTC Policy 24.02 nor MLTC Policy 23.03 that it replaces do not include the involuntary disenrollments that result from a Medicaid discontinuance. Local Department of Social Services (HRA/LDSS) initiated disenrollment reasons include instances where the Enrollee is no longer eligible for Medicaid, the Enrollee is deceased, the Enrollee is incarcerated, etc.
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Since the pandemic began in March 2020, most people retained Medicaid coverage automatically unless they died or moved out of state. With the "unwinding" of these continuous coverage protections, beginning in July 2023, MLTC members may begin to have Medicaid discontinued, if they do not timely respond to a renewal request from their local Medicaid agency. They should receive 10-day advance notice of any discontinuance of Medicaid from their local DSS, with the right to request a Fair Hearing.
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See more about the "unwinding" here.
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MLTC plans should help members respond to the renewal requests. See tips about responding to renewals here.
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WARNING: If Medicaid eligibility stops because of a problem with eligibility at the LDSS, the consumer will NOT receive notice from NYMC that they will be disenrolled from the plan. Plan enrollment lapses automatically upon discontinuance of Medicaid.
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Advocates have asked NYS DOH to tell plans to continue services for 90 days after Medicaid is discontinued to allow time to fix an error in the renewal process that caused the discontinuance. This is not yet required.
Status: Disenrollments were reinstated on Jan. 1, 2022 after being paused in COVID. Applies to MAP, PACE & MLTC. MLTC Policy 24.02 Part C which incorporates Policy 23.03, revises and supersedes the earlier guidance effective Nov. 1, 2023 (GIS 21 MA/24)
The plan must have made and documented reasonable efforts (as described in Section B. Reason ii. - summarized here) to resolve the problems presented.
DOCUMENTATION: Along with the Managed Long Term Care Involuntary Disenrollment Request Form , a MAP or MLTC plan must submit to NYMC the following. PACE plans send the request to DOH instead of NYMC:
- The plan's written statement describing the case situation and why the plan is unable to furnish services.
- The names of different home care agencies utilized, and the results of service attempts.
- Documentation of a referral to Adult Protective Services (APS) must be included when there is a report of safety issues.
What happens after disenrollment --
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MANDATORY MLTC ENROLLEES (adults age 21+ who have Medicaid and Medicare and who are not in the OPWDD waiver and are not in home hospice) -- will be notified by NYMC that they may transfer to another MLTC plan.
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If NOT ELIGIBLE FOR MLTC -- will be disenrolled to the Local District for FFS, and told to contact NYMC to discuss enrollment options that may be available to them.
Possible defenses -- Under the model contract Article V section (D)(1)(c) and as required by 42 CFR 438.56(b) -- Disenrollment may not be based in whole or in part on an adverse change in the Enrollee’s health or on the capitation rate payable to the plan. Disenrollment may not be initiated because of the Enrollee’s high utilization of covered medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his/her special needs except as may be established under the contract Article V section D(5)(a). That section states the plan must have made and documented reasonable efforts to resolve the problems presented by the individual.
The model contract says that if an Enrollee fails to pay for or make arrangements satisfactory to the plan to pay the spenddown/surplus within thirty (30) days after such amount first becomes due, they may be disenrolled. This is provided that during that thirty (30) day period ,the plan first makes a reasonable effort to collect such amount, including making a written demand for payment and advising the Enrollee in writing of his/her prospective disenrollment.
Plans may not unilaterally or directly disenroll a member. New procedures in MLTC Policy 24.02 (unchanged from MLTC Policy 23.03)
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Plan sends the Enrollee an Intent to Disenroll letter (Template is Appendix 1 of MLTC Policy 24.02, unchanged from MLTC Policy 23.03).
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The plan must send a copy of the letter to enrollee's authorized representatives.
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See the template for language tailored to different groups of enrollees (mandatory vs. voluntary enrollees) or different grounds for disenrollment.
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The plan must send a disenrollment request to NY Medicaid Choice. This includes the Managed Long Term Care Involuntary Disenrollment Request Form, (Appendix 2 of the policy) along with the required supporting documentation for the selected disenrollment reason, and a copy of the Intent to Disenroll letter, and the transmittal form requested from NYMC. TIMING -
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The Policy gives plans a deadline to submit the disenrollment request by the 7th - 9th of the current month to secure enrollment by the 1st of the next month. This allows time for NY Medicaid Choice to send the 10-day notice of involuntary disenrollment to the member, with the opportunity for the member to requesta a Fair Hearing. See below.
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Also, plan must "initiate an involuntary disenrollment within five (5) business days of the date the plan is notified of the triggering event." MLTC Policy 24.02 (under A. Mandatory vs. Optional Involuntary Disenrollment heading). The failure to comply with this deadline is penalized by having to repay capitation premiums for this period. See here.
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If NY Medicaid Choice agrees that one of the above grounds for involuntary disenrollment is met, it sends a Notice of Involuntary Disenrollment to the member. Per MLTC Policy 24.02, "Fair Hearing rights apply to this notice from NYMC including Aid to Continue. The involuntary disenrollment notice has contact information if the individual has questions regarding the disenrollment." While Policy 24.02 does not so state, presumably this notice must be sent 10 days in advance of the proposed date of disenrollment, to allow time for the member to request a Fair Hearing with the NYS Office of Temporary & Disability Assistance (OTDA). If the hearing is requested before the effective date of disenrollment, the member is entitled to remain in the plan until the hearing is held and decided. This is Aid Continuing.
The guidance does not specify that the NY Medicaid Choice notice must also be sent to the designated representative.
- NY Medicaid Choice notifies plan that disenrolled member that member was autoassigned or selected a different MLTC. This is so the plan will transmit the Person Centered Service Plan (PCSP) to the new plan. The policy does not state that the plan is notified if the consumer is transferred to the LDSS so that the plan can transmit the service plan.
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What happens to enrollee after disenrollment? See above and Appendix 3 table for which disenrollments result in auto-assignment to another plan, which to LDSS, and which are just told to call NY Medicaid Choice. Advocates are concerned that some of these policies cause unnecessary disruption for continuity of care, where a better transition would be possible.
DOH MLTC Policy 24.02 in Section H. reinstates the State's right to recover premiums paid to plans for months in which the Enrollee should have been disenrolled. This recovery was onhold during the COVID public health emergency, and was reinstated for several disenrollment grounds earlier, but is reinstated for all grounds in the guidance eff. Nov. 1, 2024. Consumers should be aware that the threat of this recovery will be an incentive for plans to initiate disenrollment on the MANDATORY grounds listed above. There should be no recovery where a plan chose not to pursue an OPTIONAL disenrollment.
State directives were issued as GIS directives and as COVID guidance (under "Other Guidance" at this link but not as MLTC Policies
