Can My MLTC Plan Kick Me Out? "Involuntary Disenrollment" from MLTC plans - Changes Nov. 2023

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   This article explains:

A.  Nov. 2023:  New State Guidance expanding Grounds for Disenrollment Takes Effect

B.  Alert re TRANSITION RIGHTS if INVOLUNTARILY DISENROLLED

C.  Reasons the plan MUST disenroll a member (mandatory grounds):

  1. Moved to a County Outside the Plan's Service Area 

  2. Absent from the service area for more than 30 consecutive days 

  3. No longer enrolled in Aligned D-SNP Plan (MAP plans only)

  4. Enrollee is Hospitalized or in a Residential Program of OMH, OPWDD or OASAS for 45 consecutive days. 

  5. For PACE or MAP, an Enrollee no longer meets the Nursing Home Level of Care  standard and cannot be deemed eligible.

  6. 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.

  7. No longer in need of a Community Based Long Term Services and Supports (CBLTSS) for more than 120 days.

  8. Did not receive any of seven MLTC Community-Based Long Term Services & Supports (CB-LTSS) services in the prior calendar month

  9. Member in a Nursing Nome for 3+ months,  was determined eligible for Institutional Medicaid AND Has No Active Discharge Plan

D.  Reasons that the plan MAY disenroll a member (optional grounds for disenrollment). 

  1. You or your family's behavior interferes with provision of services.

  2. 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F.  Previous DOH Guidance on Disenrollments that is  Superseded by MLTC Policy 23.03:

A.  Status:  November 1, 2023 - Updated Disenrollment Policy Takes Effect  

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

Effective Nov. 1, 2023 most grounds for disenrollment are reinstated with updated guidance issued Oct. 18, 2023 -- MLTC Policy 23.03: Resumption of MLTC Involuntary Disenrollment Guidance (posted in DOH MLTC Policy library here).    This guidance specifically "supersedes" the previous involuntary disenrollment guidance. This article now describes the updated guidance.

The earlier directives that are now superseded by MLTC Policy 23.03 are listed here.    

Appendix 3 of MLTC Policy 23.03 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.

B.  ALERT:  Members Usually Have Transition Rights if involuntarily Disenrolled! 

Plan members have Transition Rights if involuntarily disenrolled from a plan for most of the reasons discussed below. This means the right to have the same services continue in the same amount once they switch to a new plan or to services administered by the local county Medicaid agency.  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.  WARNING:  for some  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. 

MLTC Policy 23.03 Section G 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 "FFS," which means the local county Dept. of Social Services to authorize PCS/CDPAP.  MLTC Policy 23.03 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).

NYLAG comment:   The policy fails to require  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.  

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

1. You move to a different county in NYS outside 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 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. 

Disenrollment procedures- under MLTC Policy 23.03 (replacing prior guidance)

What Happens after Disenrollment - How Does Person Continue Receiving Home Care?

2.  You were absent from the service area for more than 30 consecutive days 

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.

3.  Medicaid Advantage Plus (MAP) or PACE plan member is no longer enrolled in the Medicare  Dual Special Needs Plan ("DUAL-SNP") "aligned" with your MAP plan or the PACE Medicare plan.  

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 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 2023 SNP list here ("MAP" in Column L)  and 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?   

What would lead a MAP  or PACE member to be disenrolled from their  plan based on being disenrolled from the aligned D-SNP plan or Medicare PACE plan?  

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. 

Steps of disenrollment from MAP or PACE plan -  under MLTC Policy 23.03 --

What Happens after Disenrollment from the MAP or PACE Plan - How Does Person Continue Receiving Home Care?  Under MLTC Policy 23.03 --

4.   Enrollee is Hospitalized or in a Residential program of OMH, OPWDD or OASAS for 45 consecutive days

5. For PACE or MAP, an Enrollee no longer meets the Nursing Home Level of Care standard and cannot be deemed eligible.

This reason is applicable to PACE and MAP plan types only, not MLTC.  Per MLTC Policy 23.03, the plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of a Community Health Assessment (CHA) where the Enrollee was assessed as no longer meeting nursing home level of care.  Note: Nursing home level of care may be identified at any reassessment.  

Prior to initiating the involuntary disenrollment request, within tive (5) business days of the CHA determination. hte plan must submit a deemed eligibility review request to the Department at MLTCMDReview@health.ny.gov should the plan believe that:

  1. the absence of continued coverage under the plan would negatively impact the Enrollee's condition and
  2. the Enrollee would be reasonably expected to meet the nursing home level of care requirement within the next six months, 

What Happens After Involuntary Disenrollment -- 

6.  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.

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.

7.  No longer in need of a Community Based Long Term Services and Supports (CBLTSS) for more than 120 days.

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.

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.

8.   Enrollee Did Not Receive Any of Seven (7) Community Based Long Term Services and Supports (CBLTSS) in the Previous Month

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:

  1. Nursing services in the home
  2. Physical, Speech or Occupational Therapies in the home
  3. Home health aide services
  4. Personal care services in the home (Level 2)
  5. Adult day health care
  6. Private duty nursing
  7. 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

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 23.03 of When to and When Not to Initiate Involuntary Disenrollment when the Enrollee Does Not Receive CBLTSS

  1. A plan must initiate involuntary disenrollment due to lack of Enrollee receiving CBLTSS within previous calendar month: in these examples
    • 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.

    • 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.

    • Per MLTC Policy No. 13.0313.05, 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.

    • Per MLTC Policy No. 13.15, the Enrollee has been assessed as needing only discreet level 1 housekeeping services.

  2.  A plan would not initiate involuntary disenrollment due to the Enrollee not receiving CBLTSS within previous calendar month in these examples:

    • 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.

    • 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.

    • Enrollee is hospitalized during the calendar month that the Enrollee was identified as not receiving CBLTSS.

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 23.03 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.   

9. Member in a Nursing Nome for 3+ months AND was determined eligible for Institutional Medicaid  and has No Active Discharge Plan 

10.  Medicaid Eligibility Stops  

D.  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 reinstated on Jan. 1, 2022 after being paused in COVID.  Applies to  MAP, PACE & MLTC. MLTC Policy 23.03 Part C 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:

What happens after disenrollment --  

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 -- THIS GROUND STILL ON HOLD as of 11/1/2023

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.

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

Plans may not unilaterally or directly disenroll a member.  New procedures in MLTC Policy 23.03 

  1. Plan sends the Enrollee an Intent to Disenroll letter (Template is Appendix 1 of MLTC Policy 23.03).  The new guidance requires a copy of the letter be sent to their authorized representatives.  See the template for language tailored to different groups of enrollees (mandatory vs. voluntary enrollees) or different grounds for disenrollment. 

  2. 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  -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.

  3. 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.   This step is NOT described in MLTC Policy 23.03.  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.  

  4. NY Medicaid Choice gives plan that disenrolled member notice that member was autoassigned or selected a different MLTC.    This is so the plan will transmit the PCSP to the new plan. The policy does not state that the plan is notified if the consumer is transferred to the LDSS,  also so that the plan can transmit the service plan.
  5. 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.   

State directives were issued as GIS directives and  as COVID guidance (under "Other Guidance" at this link but not as MLTC Policies 



Article ID: 238
Last updated: 02 Nov, 2023
Revision: 1
Medicaid -> Home Care -> Can My MLTC Plan Kick Me Out? "Involuntary Disenrollment" from MLTC plans - Changes Nov. 2023
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