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DOH Proposes Default Enrollment in Medicare Advantage Plans for Medicaid Managed Care Enrollees

The Department of Health (DOH) has proposed implementing "default enrollment" of mainstream Medicaid managed care enrollees in Medicare Advantage plans when they reach age 65 and become eligible for Medicare. The proposal was unveiled at a stakeholder meeting convened by the Department to discuss plans for integrated managed care for dually-eligible beneficiaries upon the expiration of the Fully Integrated Duals Advantage (FIDA) program in December 2019. In addition to the default enrollment proposal for new duals, the Department discussed its proposal for transitioning FIDA enrollees to the associated Medicaid Advantage Plus (MAP) products of their FIDA plans. The meeting presentation is available here.

The Department is working to secure the approval of the Centers for Medicare and Medicaid Services (CMS) for both the FIDA transition proposal and the default enrollment proposal. In order to transition FIDA enrollees to an affiliated MAP plan, three tests must be satisfied:

  • Financial – Medicare costs for the MAP product cannot be more than Medicare fee-for-service in the same county;
  • Network – The Medicare network of the FIDA and MAP products must be comparable; and
  • Benefits – The benefits of the FIDA and MAP products must be substantially similar.

The FIDA product has more expansive behavioral health and “waiver-type” social support benefits than the MAP product. Accordingly, the Department is working with CMS to ensure that comparable benefits are available either through fee-for-service Medicaid or through the managed care benefit package.

Under the default enrollment proposal, upon reaching age 65, mainstream managed care enrollees would be enrolled in the associated Medicare Advantage D-SNP product of their mainstream plan. If the enrollee does not require long term care services, he or she would also be enrolled in the plan’s Medicaid Advantage product for Medicaid benefits. If the enrollee requires long term care services, he or she would be enrolled in the plan’s D-SNP and MAP products for coverage of both Medicare and Medicaid long term care benefits. Enrollees would be given the option of opting out and enrolling in fee-for-service Medicare and a partially-capitated managed long term care (MLTC) plan or enrolling in another integrated plan or Program of All-Inclusive Care for the Elderly (PACE).

The default enrollment proposal is intended to improve care coordination and integration of benefits for dual eligibles. In December 2017, there were nearly 700,000 dual eligibles in New York State who were not enrolled in a managed care plan. Approximately 60,000 used a long term care service; the vast majority were in nursing homes.

LeadingAge NY raised concerns in the meeting regarding the potential negative impact of the default enrollment proposal on PACE programs and provider-sponsored MLTC plans that do not operate mainstream Medicaid managed care plans. Stakeholders are encouraged to submit comments to the Department here through mid-January. LeadingAge NY will be submitting comments, and we welcome input from members. Please send your feedback and suggestions to Karen Lipson by Jan. 4th.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124