Can My MLTC Plan Kick Me Out? "Involuntary Disenrollment" from MLTC plans

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 or Consumer Directed Personal Assistance Program (CDPAP) services,  with some exceptions.  See also DOH list of exclusions and exemptions here. 

However,  an MLTC plan can involuntarily disenroll a member from the plan for certain reasons.    This article explains:

1. Reasons the plan MUST disenroll a member (mandatory grounds), and
2. Reasons that the plan MAY disenroll a member (discretionary grounds for disenrollment). 
3. Steps and Notices Required in thh Disenrollment Process.

Most of the mandatory and discretionary 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) plans have a unique mandatory reason for disenrollment -- the first one listed in the first group below -- which is not in the MLTC model contract. 

Involuntary disenrollments were suspended during the COVID pandemic, but NYS DOH reinstated involuntarily disernollments with various directives in 2022.   Others may resume later in 2023.  The descriptions below explain the current status of each ground for disenrollment. 

WARNING:  Plan members have Transition Rights if disenrolled from a plan for most of the reasons discussed below.  See more about Transition rights in this article.   if you VOLUNTARILY disenroll from one plan and switch to another plan,  however, you do not have Transition rights.  See more here about when you do NOT have transition rights. 

State directives include:

• GIS 21 MA/17 - Managed Long Term Care’s Involuntary Disenrollment Resumption (August 18, 2021)(No longer in D-SNP aligned with MAP plan; Moved to a different county not in plan's service area)

  • Undated Memo to Health Plan Administrators. 
• GIS 21 MA/24  - Managed Long Term Care Involuntary Disenrollment Resumption – Additional Reasons - Absent from service area for more than 30 days
• GIS 22 MA/03 - Managed Long Term Care Involuntary Disenrollment Resumption - Additional Reason - did not receive any of seven community-based long term care services in prior calendar month
  • Attachment I  (amended list of MAP plans that may initiate disenrollment because absent  from service area for 30 days per (GIS 21 MA/24  (May 16, 2022)
  • Attachment II  -schedule of disenrollment dates 

I.   Mandatory Grounds for Involuntary Disenrollment from an MLTC or MAP plan

1.  You are a Medicaid Advantage Plus (MAP) plan member, but you enroll in a new Medicare Part D drug plan or Medicare Advantage plan that is not "aligned" with your MAP plan.

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.  MAP plans cover all Medicare, Medicaid, home care, and pharmacy benefits in one insurance plan. If you are a MAP member you must be enrolled in the Medicare D-SNP plan that is "aligned" with your MAP plan.  That means it is operated by the same insurance company that operates your MAP plan. Even that is not enough - the D-SNP must be the particular one that is aligned with the MAP plan.  See here.

How do people enroll in a MAP or a D-SNP?   Some people choose to enroll in a MAP plan initially - instead of an MLTC plan.  Similalry, some dual eligibles chose to enroll in a D-SNP because it can reduce some  out of pocket costs. 

• Default Enrollment -- However, since April 2021, some Medicaid recipients who had Medicaid on the NYSofHealth, then became enrolled in Medicare, have been "default enrolled" into D-SNP plans when they first became enrolled in Medicare. 

• Those who had received personal care or CDPAP from their mainstream Medicaid Managed care plan were default enrolled into D-SNP plan AND the MAP plan "aligned" with their mainstream plan, meaning operated by the same insurance company.  They might not realize they are in a MAP plan. 

• Others who did not receive home care from their mainstream plan have been default enrolled into a Dual-SNP and remained in their mainstream plan for wrap-around secondary coverage.  The mainstream plan is then called an IB-Dual plan (Integrated Benefits-Dual) plan.  

• See more about default enrollment in this article. 

Which Medicare D-SNP is aligned with a MAP Plan or IB-Dual Plan in your county?

• this Excel list ("MAP" in Column L means the plan is aligned with and part of a MAP plan in that county) OR

• in the 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. 

If you are in a MAP and you enroll in a Part D drug plan or switch to a different D-SNP or Medicare Advantage plan, you will be disenrolled from the D-SNP plan that is aligned with your MAP plan.  This will then result in your being disenrolled from your MAP plan.  

What happens after disenrollment from MAP plan - Referred to local Medicaid office (Dept. of Social Services or "LDSS") that should continue the same Plan of Care until the next reassessment. GIS 21 MA/17 - Managed Long Term Care’s Involuntary Disenrollment Resumption (August 18, 2021)

2. You move to a different county in NYS that is out of the MLTC plan's service area. 

Most MLTC plans only serve certain counties.  If you move to a county that is not served by your plan, and notify your local Medicaid office (HRA in NYC) of the change of address, you will be disenrolled from your old MLTC plan. 

• What happens after disenrollment - Referred to local Medicaid office (Dept. of Social Services or "LDSS") that should continue the same Plan of Care until the next reassessment. See  GIS 21 MA/17 - Managed Long Term Care’s Involuntary Disenrollment Resumption (August 18, 2021) and undated Memo to Health Plan Administrators.  Alternately, call NY Medicaid Choice  at 1-888-401-6582 about transferring to an MLTC plan in the new county. 

• 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.  See 2008 LCM-01 - Continued Medicaid Eligibility for Recipients Who Change Residency (Luberto v. Daines).  

• 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. 

3.  You were absent from the service area for more than 30 consecutive days (90 days for Wellcare Fidelis Dual Plus MAP only). 

Disenrollments begin 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)

• Plan must submit form to NY Medicaid Choice stating last date of contact with enrollee.  Member notified that they may transfer to a different MLTC plan.  If no response from member, member disenrolled to local district which must continue same plan of care until they reassess.

• What happens after disenrollment -  if member does not respond to contact from  NY Medicaid Choice asking them to select a plan in their new service area, they are refered to the local Medicaid office (LDSS) which must continue same plan of care until they reassess.  GIS 21 MA/24. 

• 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. 

4.   Member in a Nursing Nome for 3+ months AND was determined eligible for Institutional Medicaid. 

See this article for info on notices member and their representative should receive before disenrollment and appeal rights.  Members should NOT be disenrolled if they have an active discharge plan to return home, and need to appeal if disenrollment is threatened. 

Members have the right to re-enroll within 6 months of the disenrollment.  

See more in  this article. 

5.  Did not receive any of seven MLTC Community-Based Long Term Care (CB-LTC) services in the prior calendar month

 On May 16, 2022,  DOH Issued  GIS 22 MA/03 - Managed Long Term Care Involuntary Disenrollment Resumption - Additional Reason to authorize enrollments on this ground  effective July 1, 2022, with disenrollment notices to be sent by plan 30 days before.  The GIS lists the seven services considered CB-LTC. This ground 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.   

• Attachment II  -of GIS 22 MA/03 schedule of disenrollment dates 

• PLAN MUST attach to referral to NY Medicaid Choice "a written statement on plan letterhead that includes the reason why the enrollee has not received services. If no contact was made with the enrollee or authorized representative, the specific dates and times of a combination of at least five phone and mail attempts within the last 30 days should be included."

• WHAT HAPPENS AFTER DISENROLLMENT?   Disenrolled to "Fee for service" through the local district.

6.  Medicaid eligibility stops 

• 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 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 with the right to request a Fair Hearing. 

• See more about the "unwinding" here.  

• MLTC plans should help members respond the renewal requests.  

• See tips about responding to renewals here. 

• 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. 

7.  Other Mandatory reasons for involuntary disenrollment have not yet resumed after being halted because of COVID. 

• Hospitalized or in a residential program of OMH or OASAS for 45 consecutive days - not yet resumed as of March 6, 2023, after being halted during the pandemic

II.  Reasons Plans MAY Disenroll a Member - Discretionary grounds for Involuntarily Disenrollment

1.  You or your family member's behavior impairs plan's ability to provide services.

Status:  Disenrollments were rreinstated on Jan. 1, 2022 after being paused in COVID.  Aplplies to  MAP, PACE & MLTC. See GIS 21 MA/24 (plan must submit names of home care agencies used and results of service attempts).

• What happens after disenrollment -- member reassigned to new MLTC plan if disenrolled.  GIS 21 MA/24 

• 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.  

2.  Member Not Paying the Spend-down to the plan -- 

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, 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.

• STATUS:  This ground has NOT yet been reinstated as a ground for disenrolllment as of 3/6/23.

III.  STEPS AND NOTICES BEFORE MLTC or MAP MEMBER IS DISENROLLED INVOLUNTARILY 

Plans may not unilaterally or directly disenroll a member. 

1. The plan must make a referral to New York Medicaid Choice, operated by Maximus, to request that NYMC  approve disenrollment.  To do this, NY Medicaid Choice must agree that one of the above grounds for involuntary disenrollment is met.    The plan's referral to New York Medicaid Choice uses a form.  Each of the different grounds for disenrollment requires different documentation by the plan.  For example, to disenroll member becasue their or a family member's behavior impairs the plan's ability to provide services, the plan must document its reasonable efforts to resolvethe problem.  See above. 

2. NY Medicaid Choice issues Notice of involuntary disenrollment to the member.   This notice must be sent 10 days in advance of the proposed date of disenrollment, with the right of 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.  

3. What happens after disenrollment?  NYS policy is inconsistent, setting different ways for a member who was disenrolled to access home care services after disenrollment. See the individual ground for disenrollment above to see what happens in a particular situation.  Advocates are concerned that some of these policies cause unnecessary disruption for continuity of care, where a better transition would be possible.