Q. If an Enrollee agrees to disenroll, can the Plan submit a voluntary disenrollment request?

1. When the Enrollee requests to voluntarily disenroll from the Plan for any reason, the Plan is required to initiate the voluntary disenrollment process by submitting a completed voluntary disenrollment request to New York Medicaid Choice.

The Plan must provide the member with details on the voluntary disenrollment process. The Plan cannot ask nor encourage the member to voluntarily disenroll.

Enrollee no longer resides in the Plan's service area.

Q. If a recipient came from New York City via a LUBERTO but was disenrolled prior to being transferred and has not been enrolled with their MLTC Plan since, is the recipient eligible for a "re-link"?

1. Although this issue spans beyond an involuntary disenrollment, members who are disenrolled for moving from New York City to an Upstate county via a county-to-county move request, these members are eligible to have their enrollment transferred (re-linked) in the new county if that Plan is available in the new county. If the enrollment transfer has not been processed, the Plan should contact the new LDSS office.

Please see the 08 OHIP / ADM-5: District of Fiscal Responsibility Change for SSI Cases and Changes to Auto-SDX Processing for Moves Into and Out of NYC for more information.

Enrollee enters an OMH, OPWDD, OASAS residential program or OMH state operated psychiatric center that is not a MLTC Plan covered benefit for 45 consecutive days or longer.

Q. Can the Department clarify if some of the services are MAP covered benefits, but not a covered benefit for a Partial Capitation or a PACE Plan? Would entry into these programs require disenrollment from a Partial Capitation or PACE Plan?

1. Entry into an OMH, OASAS or OPWDD residential program of any type would require that the Partial Capitation and PACE Plan submit an involuntary disenrollment if the Enrollee has been admitted for forty-five (45) consecutive days or longer from the effective date of the MLTC 23.03 policy.
   
   The MAP program includes some residential services as of January 1, 2023 with MLTC Policy 22.03 - Behavioral Health Benefits Carve into Medicaid Advantage Plus (MAP). Therefore, involuntary disenrollment from the MAP plan would not be appropriate when the residential services are covered under the MAP benefit package.

For PACE or MAP, Enrollee 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, and cannot be deemed eligible.

Q. Why is there a deemed eligibility review request available for a MAP member but not for Partial Capitation enrollees?

1. Section 8.8 (Contractor Initiated Disenrollment), Item vi. of the Medicaid Advantage Plus model contract allows MAP Plans to deem members as eligible based on specific criteria. The Partial Capitation model contract does not allow the MCO to deem members as eligible.

Q. How should MLTC and MAP Plans handle individuals who are unhoused, living in a shelter, and/or have temporary housing where the Plan cannot provide CBLTSS?

1. The Care Manager should assist the enrollee in transferring to another residential location that would allow the Enrollee to receive needed services. In the event the member is unwilling or unable to transfer to a facility where they are able to receive services and more than 30 days have passed, the Plan should follow the Enrollee Has Not Received CBLTSS in the Previous Month disenrollment reason.

Q. What is the definition of a mandatory or voluntary member? How would the Plan identify the difference, in order to send the intent to disenroll letter?

Plans should look at demographics of the member and their categories of eligibility to determine if the member is mandatory or voluntary. Please see the model contracts for the Managed Long Term Care Program located here.

Mandatory members are:

dual eligible individuals (having both Medicare and Medicaid), who are age 21 and older and who are assessed as needing community based long term care services and supports for a continuous period of more than 120 days must enroll in MLTC in order to receive those services.
Note: These Medicaid beneficiaries will receive outreach letters and calls from

New York Medicaid Choice 90 days in advance, notifying them of their mandatory enrollment status, to voluntarily choose a plan, or an auto-assigned enrollment selection will be made to a MLTCP Partial Capitation plan in their county.

Voluntary members are:

1. dual eligible individuals, age 18-20, who have been assessed as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care services for more than 120 days; and
2. non-dual eligible individuals, age 18 and older, who have been assessed as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care services for more than 120 days.

Questions can be sent to mltcinfo@health.ny.gov with the subject line: Resumption of MLTC Involuntary Disenrollments.