Resumption of Certain MLTC Involuntary Disenrollments

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

TO: Health Plan CEOs, Government Program Liaisons, and Medical Directors:

SUBJECT: Third-Party Health Insurance (TPHI) Disenrollment to Resume

Please share this information with staff as appropriate.

This applies to MMC plans, including Mainstream MMC plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs). This is a follow up to the notice sent on March 30, 2020, COVID-19 Extension of Medicaid Coverage, under the Families First Coronavirus Response Act (FFCRA). Recent CMS rulemaking and guidance permits State Medicaid programs to resume certain disenrollment processes as long as comparable coverage is maintained. For further information, please go here.

Medicaid members with comprehensive commercial Third-Party Health Insurance (TPHI) are excluded from enrollment in Mainstream, HARP and HIV-SNP. As comparable coverage will remain for these members, the Department of Health (DOH) will be resuming the disenrollment from these products to Medicaid fee for service. Please note that this process does not include enrollees with Medicare Parts A, B or C.

The effective date of disenrollment for identified Mainstream, HARP and HIV-SNP enrollees will begin February 28, 2021. Plans will be notified of disenrollments via the 834 process. This process will then continue on a monthly basis.

As done prior to FFCRA, for Medicaid members enrolled through the local district, DOH will provide a monthly list to New York Medicaid Choice (NYMC) to prospectively disenroll members with comprehensive commercial TPHI. NYMC will process the disenrollments around the 1st of the month for end of month disenrollments.

Likewise, for members enrolled through New York State of Health (NYSoH), the process of prospectively disenrolling members with comprehensive commercial TPHI will resume. NYSoH receives daily updates of comprehensive commercial TPHI and will process prospective disenrollments. The date of disenrollment depends on the date the TPHI indicator is received. If prior to the 15th of the month, the disenrollment will be the end of the current month. If on or after the 15th of the month, the disenrollment will be the end of the next month.

Individuals will be notified of their disenrollment due to comprehensive commercial TPHI. Fair Hearing rights apply to this notice including Aid to Continue. The disenrollment notice has contact information if the individual disputes the disenrollment (for local district cases NYMC at 800-505-5678, and for NYSoH cases at 855-355-5777). Any disputed disenrollments will be reviewed by the DOH.

If you have any questions about this notice, please contact the Bureau of Program Implementation and enrollment at mcsys@health.ny.gov.