New York State Medicaid Billing Guidance for Coronavirus (COVID-19) Testing in School Based Health Centers

  • Letter is also available in Portable Document Format (PDF)

April 26, 2022

Dear MLTC Health Plan Administrators,

The Department of Health (Department) will begin resuming an additional involuntary disenrollment process effective for disenrollment dates of July 1, 2022, and monthly thereafter. Managed Long Term Care (MLTC) plans are required to begin submitting disenrollments May 11 through June 9, 2022, and thereafter per the attached 2022 MLTC Plan Processing Schedule for Involuntary Disenrollments revised 4 6 2022 for the following additional Disenrollment Reason:

Does Not Receive At Least One of The Following Community Based Long Term Services and Supports (CBLTSS) Within the Previous Calendar Month:
  • Nursing services in the home
  • Therapies in the home
  • Home health aide services
  • Personal care services in the home
  • Adult day health care
  • Private duty nursing, or
  • Consumer Directed Personal Assistance Services (CDPAS)

1. Enrollee Outreach and CBLTSS Analysis

  1. Background
    1. Managed Long Term Care Partial Capitation (MLTCP), Medicaid Advantage Plus (MAP) and Programs All-Inclusive Care for the Elderly (PACE) plans are required to reach out to the enrollee: upon enrollment to assess and develop the enrollee’s plan of care (care plan), monthly for care management updates, every 90 days if a voluntary care plan was temporarily put in place and when there is a change in condition. Refer to: COVID-19 Guidance: Voluntary Plan of Care Schedule Change
    2. Through these care management outreach activities, plans should have been identifying and engaging with their enrollees who have not been receiving any authorized CBLTSS services throughout the public health emergency.
  2. Outreach
    1. During the remainder of the public health emergency, the plan should continue this care management outreach as described above.
    2. With the initiation of this additional involuntary disenrollment reason, the plan informs the enrollee that they cannot remain in the MLTC plan if they are not receiving at least one of the CBLTSS services authorized in their plan of care within the previous calendar month.
      1. If the enrollee agrees to voluntarily disenroll, the plan must follow contractual requirements for an enrollee-initiated disenrollment.
      2. If the enrollee does not agree to voluntarily disenroll, the plan must follow the requirements for involuntary disenrollment in this notice.
      During the public health emergency, additional enrollee outreach prior to initiating this involuntary disenrollment reason is required. The plan must first identify the members that have not received CBLTSS in the previous calendar month and then outreach to the enrollee, prior to initiating the involuntary disenrollment to discuss why services have not been received, when an involuntary disenrollment will be initiated, or when to restart service that would stop the involuntary disenrollment from proceeding.

2. Examples of When to and Not to Initiate Involuntary Disenrollment for Not receiving CBLTSS

  1. The following are examples of instances in which a plan must initiate involuntary disenrollment due to lack of enrollee receiving CBLTSS in the previous calendar month:
    • 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 5 reasonable attempts within a 30 day period as described below in Section 4.c.
  2. The following are examples of instances in which a plan would not initiate involuntary disenrollment due to lack of enrollee receiving CBLTSS in the previous calendar month:
    • Nursing is the only service in the enrollee’s plan of care, and the scheduled frequency results in no scheduled nursing service in the previous calendar month.
    • An enrollee has been assessed to need personal care or personal assistance, 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.
    • Enrollees that have a current temporary and voluntary plan of care change on record reconfirmed every 90 days. 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 non- receipt of CBLTSS will result in initiation of disenrollment. Therefore, a plan should not initiate disenrollment until it reconfirms the voluntary care plan with the enrollee.
    • Enrollee is hospitalized during the previous calendar month that the enrollee was identified as not receiving CBLTSS.

3. Enrollee Notification required

  1. After the outreach is completed, the plan must send the plan’s existing preapproved Notice of Intent to Disenroll to each enrollee and their authorized representative at least 30 days prior to the requested disenrollment effective date (e.g., June 1, 2022, for the July 1, 2022, effective date).
  2. Plans will be notified of accepted disenrollments via the 834 file process.

4. Submission of the Involuntary Disenrollment Form to New York Medicaid Choice (NYMC)

  1. After conducting enrollee outreach and notification, plans must submit a completed Managed Long Term Care Involuntary Disenrollment Request Form to NYMC along with supporting documentation specified below.
  2. For involuntary disenrollment due to lack of receipt of CBLTSS, the plan must select the following involuntary disenrollment reason on the Form:
    Does not receive at least one of the following services:
    • Nursing services in the home
    • Therapies in the home
    • Home health aide services
    • Personal care services in the home
    • Adult day health care
    • Private duty nursing, or
    • Consumer Directed Personal Assistance Services (CDPAS)
  3. Plans must submit a signed letter with contact information, on plan letterhead, that includes the following information:
    • Reason: No CBLTSS received in previous calendar month
    • Name and CIN of enrollee that has not received at least one of the CBLTSS identified in his/her plan of care,
    • Specifying the authorized schedule of services that the enrollee should have been receiving and the name of the agency/agencies which should have provided service, if available,
    • The period of time the services have not been received (which is the previous calendar month),
    • If contact was made, include the reason why the enrollee has not received the services, and a description of the safe discharge plan which includes information about any referrals to other providers of applicable services or supports made on behalf of the enrollee and the status of such referral(s).
    • If no contact was made with enrollee and/or with their authorized representative, include the specific dates and times of combination of at least five phone and mail attempts within the last 30 days. During the public health emergency, a home visit is not required but may be utilized as an attempt to contact. The dates of the contacts should be reasonably spaced across the 30 day outreach period and on different days of the week and time of day. The 30 day clock starts the date the report of members not receiving CBLTSS is run, usually the beginning of each month.
  4. When the appropriate documentation is accepted by NYMC, individuals will be notified by NYMC of their disenrollment due to the above reason. Fair Hearing rights apply to this notice including Aid to Continue. The disenrollment notice has contact information if the individual disagrees with the disenrollment (NYMC at 1- 888-401-6582).

5. Referrals Required:

Individuals who are disenrolled from their MLTC plan will continue to receive their Medicaid coverage through the Medicaid fee for service program or through a managed care plan if the individual is eligible and chooses to enroll in a new plan. Plans are reminded that an involuntary disenrollment does not eliminate the plan’s contractual obligations upon disenrollment, including referral to other plans, local districts, agencies and/or services such as Level I house-keeping services, Adult Protective Services, or non-Medicaid community services that may be available.

6. Sample Steps

Identify Enrollees Outreach Enrollees Notice to Enrollees & Send Disenrollment Form to NYMC*
Plan identifies enrollees that are found not to be receiving CBLTSS in previous calendar month ex: April Upon contact with enrollee determine reason for not receiving services. ex: May Step 1 - Send Intent to Disenroll letter to enrollee at least 30 days prior to disenrollment effective date ex: no later than June 1 for July 1 disenrollment effective date
Step 2 - Send Involuntary Disenrollment Form to NYMC* ex: May 11-June 9 for July 1 disenrollment effective date
Plan identifies enrollees that are found not to be receiving CBLTSS in previous calendar month ex: April Make 5 attempts to contact enrollee within a 30 day period ex: May Step 1 - Send Intent to Disenroll letter to enrollee at least 30 days prior to disenrollment effective date ex: no later than June 1 for July 1 disenrollment effective date
Step 2 - Send Involuntary Disenrollment Form to NYMC* ex: June 1-June 9 for July 1 disenrollment effective date or June 10-July 8 for August 1 disenrollment effective date

*The effective date of disenrollment depends on the date the disenrollment request is received and accepted per the 2022 MLTC Plan Processing Schedule for Involuntary Disenrollments revised 4 6 2022 included with this notice. Member notice must be sent prior to sending the Involuntary Disenrollment request to NYMC.

7. Enrollees Contacting the MLTC plan or NYMC to Continue or Reinstate Enrollment:

  1. Prior to disenrollment effective date: Enrollment in plan can continue if enrollee agrees to receive CBLTSS according to plan of care.
    • If enrollee contacts plan:
      • If there is no disenrollment effective date in plan’s transaction files, plan must immediately contact NYMC to disregard the prospective disenrollment request. Enrollee remains in the plan.
      • If there is a disenrollment effective date as provided in plan’s transactions and reports, plans should immediately contact MLTCTAC@health.ny.gov for any enrollee who has a pending disenrollment date. MLTC Technical Assistance Center (TAC) will work to ensure enrollment reinstatements will occur, as needed. Enrollee would remain in the plan and has agreed to receive CBLTSS according to the plan of care.
    • If enrollee contacts NYMC directly:
      • NYMC refers information to MLTC Technical Assistance Center to work with the plan to verify whether enrollee will resume CBLTSS in the plan.
  2. After disenrollment effective date: The plan should refer the individual to NYMC for education about their options to enroll in another plan, prospective re- enrollment, or coverage of their choice. A new assessment is not required if a consumer requests new enrollment within 45 days of their disenrollment effective date.

8. Involuntary Disenrollment Reasons Already Resumed:

MLTC plans should continue to submit involuntary disenrollments for the following reasons which were previously resumed.

  • Enrollee is no longer a member of the plan’s Medicare Advantage Program
    (Resumed effective October 1, 2021, and thereafter)
  • Enrollee no longer resides in the plan’s service area.
    (Resumed effective October 1, 2021, and thereafter)
  • 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.
    (Resumed effective January 1, 2022, and thereafter)
  • Enrollee has been absent from the plan's service area for more than 30 consecutive days.
    (Resumed effective January 1, 2022, and thereafter). An updated Attachment 1 now listing all MAP plans with the 30 consecutive days absent from service area reason effective 4/25/2022 is now posted on the webpage link below.

9. Capitation Payment Recovery

  1. The resumption of involuntary disenrollment reasons reinstates regular contractual recoveries for capitation payments made on or after the effective date of resumption.
  2. Please note from March 1, 2020 through the resumption effective date for an involuntary disenrollment reason, recovery scenarios do not apply to capitation payments paid for such enrollments maintained per COVID-19 emergency guidance and contract amendment.

Please see webpage link for more involuntary disenrollment resumption information COVID-19 Guidance for Medicaid Providers (ny.gov) under the reformatted section titled Coverage and Billing Guidance subsection Other Guidance.

The Department will continue to evaluate resumption of other involuntary disenrollment reasons and will notify plans prospectively. If you have any questions about this notice, please contact mltcinfo@health.ny.gov.

Thank you.

Bureau of Managed Long Term Care
New York State Department of Health
Office of Health Insurance Programs

Attachment:
2022 MLTC Plan Processing Schedule for Involuntary Disenrollments revised 4.6.2022