Medicare Transition (M-File) and Dual Default (DF-File) Process Training
| Q: For individuals that are excluded from MLTC, will the excluded populations be disenrolled to Fee-for-Service Medicaid? A: Yes. Populations that are excluded from the MLTC Program, including the Long Term Nursing Home Stay (LTNHS) population, will be disenrolled to Fee-for-Service (FFS) Medicaid through the Medicare Transition process. |
| Q: Is a New York Independent Assessor Program (NYIAP) assessment needed prior to enrollment into a Managed Long Term Care (MLTC) plan for individuals in the Dual Default and Medicare Transition process? A: No, a new NYIAP assessment is not needed prior to transferring to a MLTC plan. These individuals are identified as mandatory for MLTC and should have a valid assessment on file from their prior plan. |
| Q: Is there a list of plan contacts that plans can access to enable the receiving plan to request a plan of care for continuity of care? A: The Department will provide instructions to MLTC Plans on how to contact other Medicaid managed care plans to request the Person Centered Service Plans (PCSP). |
| Q: What is the process for an MMC/HARP/HIV SNP Enrollee, designated as Long Term Nursing Home Stay (LTNHS)? A: Individuals designated as LTNHS are disenrolled to FFS Medicaid. LTNHS are excluded from enrollment into a Managed Long Term Care Partial Capitation (MLTCP) plan. |
| Q: Will the PowerPoint be distributed? A: Yes, the presentation was distributed on Friday, September 19, 2025. The presentation can be found here: MLTC Presentations. |
| Q: Are New York State of Health (NYSOH) individuals included in the Dual Default and Medicare Transition process? A: Yes, Individuals enrolled through NYSOH are included in both Default Enrollment and the M-File process. |
| Q: The presentation states that in October 2025 MLTC Plans will begin receiving enrollment files due to DF-File auto-transfers for an 11/1/25 effective date. Would it be for 1/1/2026 effective dates since we must enroll 90 days in advance? I may have missed something. A: Plans are required to enroll individuals 90 days in advance when the individuals are identified for Default Enrollment by the State and the Enrollment Broker. Therefore, individuals getting enrolled in October (and every month thereafter) are identified 3 months prior. Only those health plans that offer the IB-Dual program and are approved for default enrollment will receive the DF File. |
| Q: What is the difference between the Medicare Transition (M-file) and the Dual Default (DF-File) process? A: Both the M-File and the DF-Files include individuals who are gaining Medicare. The difference is that the DF-File will only process individuals whose plans are offering Default Enrollment while the M-File will be all inclusive of individuals gaining Medicare. Additionally, Default Enrollment allows members to automatically enroll on the Medicare side into an aligned D-SNP, remaining in MMC/HARP or joining MAP. The M- File disenrolls to FFS Medicaid or transfers to MLTC. |
| Q: In the Dual Default process, if an individual opts-out the aligned Medicare plan after enrollment into MAP will the individual automatically transferred to the MLTC plan or does the MAP plan needs to initiate the transfer? A: Prior to the enrollment effective date, if an individual opts-out of chooses not to enroll into the MAP plan, NYMC will initiate the transfer, sometimes resulting in one month of unalignment depending upon timing. |
| Q: Did I just hear that an individual can be enrolled in a MAP with either Medicaid or Medicare portion misaligned? Per CMS guidance, an individual cannot be enrolled in a MAP with either the Medicare or Medicaid portion missing. A: Individuals cannot remain enrolled in MAP if unaligned. However, due to the timing of when an individual changes their Medicare plan, one month of unalignment may occur. |
| Q: What is the process for plans if a member who is enrolled into the MAP program, but has lost Medicare eligibility and still have the Medicaid/LTSS eligibility? Will that member be disenrolled from MAP and automatically enrolled into the sister MLTC plan by Maximus or DOH? A: While it is extremely rare for an individual to lose Medicare eligibility, in this instance the member would need to be disenrolled from MAP. If the member was eligible for MLTC, the individual may go to MLTC to continue receiving their services. |
| Q: Can an individual call New York Medicaid Choice (NYMC) to opt-out? A: Yes, individuals may call NYMC to opt-out of Default Enrollment. |
Acronyms
| Acronym or Term | Description |
|---|---|
| CMS | Centers for Medicare and Medicaid Services |
| DF-File | Default Enrollment File |
| D-SNP | Duals Special Needs Plan |
| FFS Medicaid | Fee-for-Service Medicaid |
| HARP | Health and Recovery Plans |
| HIV-SNP | HIV Special Needs Plans |
| IB-Dual | Integrated Benefit for Dually Eligible Enrollees Program |
| LTNHS | Long Term Nursing Home Stay |
| LTSS | Long Term Services and Supports |
| MAP | Medicaid Advantage Plus |
| M-File | Medicare File |
| MLTC | Managed Long Term Care |
| MLTCP | Managed Long Term Care Partial Capitation |
| MMC | Medicaid Managed Care (Mainstream) |
| NYIAP | New York Independent Assessor Program |
| NYMC | New York Medicaid Choice |
| NYSoH | New York State of Health |
