powered by LeadingAge New York

DOH Issues Information to MLTC Plans on Resuming Additional Disenrollments

On Nov. 29th, the Department of Health (DOH) provided Managed Long Term Care (MLTC) plans guidance via email regarding the resumption of two additional involuntary disenrollment categories. Previously, involuntary disenrollments had resumed for certain enrollees who were no longer members of the plan’s Medicare Advantage program and for members no longer living in the plan’s service area. DOH will begin resuming two additional processes prospectively, effective for a disenrollment date of Jan. 1, 2022 and monthly thereafter. MLTC plans may begin submitting disenrollments on Dec. 1, 2021 for the following two additional disenrollment reasons:

  1. Enrollee or family member engages in behavior that seriously impairs the Contractor's ability to furnish services for reasons other than those resulting from the enrollee’s special needs.
  • Applicable to all MLTC plan types (Partially Capitated MLTC (MLTCP), Medicaid Advantage Plus (MAP), and Program of All-Inclusive Care for the Elderly (PACE)).
  • Requires a written statement from the health plan (on plan letterhead) describing the situation, including the names of different home care agencies utilized and results of service attempts.
  • Adult Protective Services (APS) reference is needed for safety issues.
  • The plan must submit supporting documentation along with the Involuntary Disenrollment Request Form.
  • DOH expects that the member will be enrolled or transferred to another MLTC plan.
  1. Enrollee has been absent from the plan's service area for more than 30 (or 90, based on the plan’s model contract with the State) consecutive days.
  • Applicable to all MLTC plan types.
  • Requires 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.
  • The plan must submit supporting documentation along with the Involuntary Disenrollment Request Form.
  • The member will be notified that they may transfer to another MLTC plan. If no selection is made by the member, the member will be disenrolled to Medicaid fee-for-service (FFS) or be auto-assigned if an MLTCP member.
  • Some enrollees who are absent from the service area may have also voluntarily and temporarily requested a modification to their approved care plan (see April 23, 2020 COVID-19 Guidance: Voluntary Plan of Care Schedule Change). As part of the next reconfirmation of the enrollee’s continued agreement with the voluntary care plan (occurring at least every 90 days), plans must inform the enrollee that continued absence from the service area will result in initiation of disenrollment. Therefore, a plan should not initiate disenrollment until it reconfirms the voluntary service plan with the enrollee.

As part of the resumption of involuntary disenrollments, the plan must send its Notice of Intention to Disenroll to all enrollees and their authorized representatives for whom it requests disenrollment. Plans send this notice 30 days prior to the requested disenrollment effective date (e.g., Dec. 1, 2021 mailing date for a Jan. 1, 2022 effective date). Plans will be notified of disenrollments via the 834 process.

The date of disenrollment depends on the date the disenrollment request is received and accepted per the 2022 MLTC Plan Processing Schedule for Involuntary Disenrollments available here. Individuals will be notified of their disenrollment by New York Medicaid Choice (NYMC) due to the above reasons. Fair hearing rights apply to this notice, including Aid to Continue. The disenrollment notice has contact information if the individual disputes the disenrollment (NYMC at 888-401-6582).

Individuals who are disenrolled from their MLTC plan will continue to receive their Medicaid coverage through another managed care plan or the Medicaid FFS program. Prior to the effective date of disenrollment, plans must make all necessary referrals to another plan or to the Local Department of Social Services (LDSS) for all covered and non-covered services. Plans must make arrangements to transfer the Plan of Care (POC) to the receiving plan or LDSS. If the member is auto-assigned to an MLTCP plan, the receiving plan should continue the current POC until a new Community Health Assessment (CHA) is completed and the POC is updated, which should be completed as soon as feasible, but no later than the next scheduled reassessment date.

Questions about this process should be addressed to mltcinfo@health.ny.gov.

LeadingAge NY Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-461-5993