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:
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:
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.
Which Medicare D-SNP is aligned with a MAP Plan or IB-Dual Plan in your county?
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.
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)
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.
6. Medicaid eligibility stops
7. Other Mandatory reasons for involuntary disenrollment have not yet resumed after being halted because of COVID.
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).
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.
III. STEPS AND NOTICES BEFORE MLTC or MAP MEMBER IS DISENROLLED INVOLUNTARILY
Plans may not unilaterally or directly disenroll a member.