GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare

The purpose of this General Information System (GIS) message is to advise local departments of social services (LDSS) of the Medicaid Managed Care (MMC) transition process for enrollees who gain Medicare eligibility.

1. Transition from MMC to MLTC

• To ensure that enrollees who are receiving long term services and supports (LTSS) do not experience a lapse in services when they are disenrolled from MMC due to receipt of Medicare, New York Medicaid Choice (NYMC) will process all managed care transfers and disenrollments for recipients with Medicare, including recipients residing in non-enrollment broker counties. Each month, NYMC performs an electronic search to identify MMC enrollees with current Medicare or Medicare that will become effective within the next 60 days. Once identified, NYMC contacts the Medicaid managed care plans to have the plans identify those enrollees in receipt of LTSS. If in receipt of LTSS, NYMC will enroll eligible recipients into a managed long-term care (MLTC) plan. If a recipient is receiving LTSS and is excluded from MLTC, NYMC will disenroll the consumer from MMC and notify the MMC plan that the recipient is excluded from MLTC. The MMC plan is required to provide the current service authorization plan to the local district managed care coordinator to coordinate the delivery of LTSS through fee-for-service Medicaid.

• The monthly Medicare disenrollment report produced by NYMC is available on MoveIt. Local district managed care coordinators and other designated staff have access to this report. The report identifies transfers and disenrollments for recipients with Medicare. The name of the report is the "Medicare Disenrollment and Transfer Report [County Name] _ Effective MMDDYYYY.xls."

2. Individuals Turning Age 65 and Enrollment in Medicare

• In many cases, enrollment in Medicare will coincide with the recipient turning age 65. For adults in the Modified Adjusted Gross Income (MAGI) category who are turning age 65, and who are not a parent or caretaker relative, Medicaid eligibility must be redetermined under the individual's non-MAGI category of assistance (SSI-related). If the individual is receiving coverage through NY State of Health (NYSOH), the individual will be transitioned to the district the month prior to the individual's 65th birthday for a redetermination of eligibility. Medicaid coverage must continue while eligibility is being redetermined. To avoid a gap in enrollment for individuals receiving LTSS, enrollment from a MMC plan to a MLTC can occur pending the district's redetermination of eligibility.

• Ideally, the district should have information concerning an individual's disenrollment from MMC or transition to MLTC (due to receipt of Medicare) in time to redetermine eligibility and issue a timely notice concerning the individual's on-going eligibility by the first day of the month following the individual's 65th birthday. However, if the district does not have the necessary MMC information concerning the individual's disenrollment or transition to a MLTC plan, the district should contact NYMC to obtain this information prior to taking any action on the eligibility edetermination. The resource documentation requirements will be different for an individual transitioning to MLTC or needing community-based long-term care than the requirements will be for a person who is not in need of long-term care services. If the district is not able to make the new eligibility determination and provide timely notice by the first day of the month following the individual's 65th birthday, Medicaid coverage must be extended until timely notice is provided.

3. Individuals Under Age 65 with Medicare

• Individuals under age 65 who gain Medicare eligibility remain in the MAGI category of assistance until their Medicaid renewal due to continuous coverage. Parents and caretaker relatives remain in the MAGI category regardless of Medicare eligibility. If these MAGI recipients are enrolled in MMC through NYSOH and are receiving LTSS, the individual will be transitioned to the district for enrollment in MLTC or for the delivery of services through fee-for-service Medicaid. The transition to the district is facilitated by staff in the Department of Health (DOH).

4. Reimbursement of Medicare Premiums

• NYSOH Medicaid recipients newly in receipt of Medicare will have their Medicare Part B premiums reimbursed by DOH through the Medicare Insurance Premium Payment (MIPP) process. For Medicare beneficiaries who are referred to the local district on the daily NYSOH "referral file," MIPP payments will be made through the end of the month, following the month of referral, for upstate recipients and through the month of referral, plus two prospective months, for New York City (NYC) recipients.

• Note: For Medicare beneficiaries who are referred to the district by DOH staff for LTSS (MLTC or fee-for-service Medicaid), MIPP payments will be made through the end date of the NYSOH authorization for upstate recipients (month of referral) and for the month of referral, plus three prospective months, for NYC recipients.

• For Medicaid recipients in receipt of Medicare who have coverage through the local district, the district is responsible for determining eligibility for the Medicare Savings Program (MSP). For adults in a MAGI category, the district should do a "scratchpad" MSP budget to determine eligibility for the Buy-in. If income is equal to or over 120% of the federal poverty level (FPL), reimbursement of the Part B premiums should be made through MIPP payments for the months the individual remains eligible under the MAGI category/budget. If income is below 120% of the FPL, the individual should be added to the Buy-in. For individuals transitioning from MIPP payments for reimbursement of Medicare Part B premiums to the Buy-in, the Buy-in begin date should be the first day of the month following the last MIPP payment. Recipients should never receive a MIPP payment and the Buy-in payment in the same month. MIPP payment dates are viewable on the eMedNY resource page.

• Effective immediately, dually eligible MMC enrollees who are transitioning to MLTC, or fee-for-service Medicaid, are entitled to have their Medicare premiums paid or reimbursed. It had been DOH's policy to not reimburse individuals their Medicare Part B premiums for months in which the individual was enrolled in MMC. Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare. To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC.

5. District MMC Dis-enrollment

• It should be noted that there are instances when the local district managed care coordinator or designated staff will need to process MMC dis-enrollments. This occurs when there is insufficient Medicaid eligibility in the system. For example, NYMC is unable to process a January 1, 2017 disenrollment if eligibility does not extend beyond December 31, 2016, which can occur at the end of an authorization period. In the case where a MLTC transfer is required, the district must re-determine eligibility and extend coverage, if the individual is determined eligible for MLTC or if additional time is needed to complete the eligibility re-determination for MLTC. The district will need to coordinate the MLTC enrollment with the eligibility change. The district has the option to either notify NYMC to process the enrollment, or the district can process the enrollment. For any actions processed by local district staff, the local district must either send managed care disenrollment/enrollment notices or advise NYMC to send the notice. If a MMC enrollee with Medicare is not found on the report, the local district managed care coordinator should contact NYMC so that NYMC can conduct outreach to the plan.

Please direct any questions concerning this message to your local district liaison.