Grounds for Involuntary Disenrollment from MLTC Plans to Be Expanded

The Department of Health (DOH) issued guidance on Oct. 18, 2023 expanding the bases for involuntary disenrollments from Managed Long Term Care (MLTC) plans. The guidance applies to partially capitated MLTC plans, Medicaid Advantage Plus (MAP) plans, and Programs of All-Inclusive Care for the Elderly (PACE programs) and is effective as of Nov. 1, 2023. The guidance does not apply to disenrollments arising from termination of Medicaid eligibility.

Most of the involuntary disenrollment triggers were suspended by the federal government during the early months of the COVID-19 pandemic. Certain types of MLTC disenrollments were restored in 2021 and 2022 under prior guidance. The recent guidance supersedes the prior guidance and resumes the following types of involuntary disenrollment:

• Mandatory Disenrollment: (must be implemented within five business days of the date the plan is notified of the triggering event)
  • Enrollee no longer resides in the service area.
  • Enrollee is absent from the service area for more than 30 days.
  • Enrollee enters an Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD), or Office of Addiction Services and Supports (OASAS) residential program or State-operated psychiatric center for 45 consecutive days or more that is not an MLTC-covered benefit.
  • Enrollee is hospitalized for 45 days or more (partial capitation only).
  • For MAP only: Enrollee is not enrolled in the aligned Medicare Advantage Dual-Eligible Special Needs Plan.
  • For PACE only: Enrollee is not enrolled in the aligned PACE Medicare Health Plan, if applicable.
  • For PACE or MAP: Enrollee is no longer eligible for enrollment because they no longer meet the nursing home level of care based on the assessment tool prescribed by the Department and cannot be deemed eligible.
  • For partial capitation plan only: non-dual-eligible Enrollee or dual-eligible Enrollee aged 18 to 20 is no longer eligible for enrollment because the Enrollee no longer meets the nursing home level of care based on the assessment tool prescribed by the Department.
  • Enrollee is no longer eligible for enrollment because the Enrollee was assessed as no longer in need of Community Based Long Term Services and Supports (CBLTSS) for more than 120 days.
  • Enrollee is not receiving one of the required services in the previous month.
• Optional Disenrollment:
  • Enrollee or Enrollee’s family member or other person in the home engages in behavior that seriously impairs the plan’s ability to furnish services for reasons other than those resulting from the Enrollee’s special needs.

The guidance sets forth detailed procedures for outreach to the affected Enrollee, a template notice to the Enrollee, and processes for submission of information to NY Medicaid Choice and local social services districts as applicable, and supporting documentation required.

The following categories of plan-initiated involuntary disenrollments are on hold pending the development of additional guidance, and MLTC plans should not submit involuntary disenrollment packages for them:

• Enrollee knowingly provides false information, otherwise deceives the plan, or engages in fraudulent conduct with respect to any substantive aspect of their plan membership.
• Enrollee fails to pay spend-down fee or Net Available Monthly Income (NAMI) within 30 days after such amount comes due.

For partial capitation MLTC plan Enrollees who are in long-term nursing home stays for more than three months, the Department will continue to initiate the involuntary disenrollments on behalf of the MLTC plan via a batch disenrollment cycle until the end of 2024.

The guidance further notes that the Department has a "right to recover premiums in instances where the Enrollee was inappropriately enrolled." Plans must repay the premiums inappropriately paid on or after the effective date of the involuntary disenrollment reason resumption.

The Department will be publishing Frequently Asked Questions to address inquiries raised about the guidance. Questions can be submitted here with the subject line "Resumption of MLTC Involuntary Disenrollments."

Contact: Karen Lipson, klipson@leadingageny.org