MLTC Policy 26.01: MLTC Involuntary Disenrollment Policy

Date of issuance: 4/7/2026
Effective Date: 6/1/2026

Purpose:

The purpose of this policy is to provide guidance and instructions for the Managed Long Term Care (MLTC) Involuntary Disenrollment process. Effective June 1, 2026, MLTC plans, including Partial Capitation (MLTCP), Programs of All-Inclusive Care for the Elderly (PACE), and Medicaid Advantage Plus (MAP) plans, must follow the below guidance for involuntary disenrollments. This policy has been updated to reflect the implementation of Minimum Needs Requirements, including the newly associated involuntary disenrollment reasons.

Note: This policy does not include the involuntary disenrollments that result from a Medicaid discontinuance. Local Department of Social Services (HRA/LDSS) initiated disenrollment reasons include instances where the Enrollee is no longer eligible for Medicaid, the Enrollee is deceased, or the Enrollee is incarcerated, etc.

Version

This policy supersedes MLTC Policy 24.02 – Update Resumption of MLTC Involuntary Disenrollments based on updates to the existing involuntary disenrollment reasons and the implementation of the Minimum Needs Requirements as set forth in MLTC Policy 25.04.

Background

In September 2024, the Department released MLTC Policy 24.02, to address non-compliance with reassessments.

In June 2025, the Department released MLTC Policy 25.04: Minimum Needs Requirement Update to the Eligibility Requirements for Managed Long Term Care Enrollment. Effective September 1, 2025, the New York State Department of Health (Department) implemented a change in the MLTC Program eligibility criteria for MLTCP and MAP plans. The new program eligibility criteria are referred to as the Minimum Needs Requirements. To remain eligible, an individual must meet the eligibility criteria as outlined in Table A and B based on their MLTC Plan Legacy status in MLTC Policy 25.04.

Definitions

Active Discharge Plan: This term describes a comprehensive plan for an individual to discharge from a residential program or hospital and return to the community. The discharge plan documents current goals and specifies the arrangements required for a safe return to the community.

Designee This term describes one or more adult individual(s) appointed by a self-directing Enrollee to receive information or communicate on behalf of the Enrollee. With respect to a non-self-directing Enrollee, a "designee" means the Enrollee's authorized representative, who may be a parent or legal guardian, or power of attorney, and is willing and able to act on the Enrollee's behalf.

MLTC Mandatory Individuals: Individuals are mandated to enroll into MLTC plan to continue to receive CBLTSS, if they are:

  • Dual eligible, age 21 and older, receiving CBLTSS for more than 120 days and meet the Minimum Needs Requirements, unless excluded.

MLTC Voluntary Individuals: Individuals can voluntarily enroll into MLTC if they are:

  • Dual eligible, age 18 through 20, who have been assessed as in need of CBLTSS for more than 120 days and meet the Minimum Needs Requirements.
  • Non-dual eligible, age 18 and older, who have been assessed in need of CBLTSS for more than 120 days and who meet the Minimum Needs Requirements.

Involuntary Disenrollment (Plan Initiated): An involuntary disenrollment is a disenrollment initiated by the Plan without agreement from the Enrollee.
Voluntary Disenrollment: A verbal or written disenrollment requested by the Enrollee at any time for any reason.

Applicability

☒ Managed Long Term Care (MLTC) Policy
☐ Technical Assistance
☐ General Guidance

Policy Content

Involuntary Disenrollments

A Plan initiated MLTC involuntary disenrollment is a disenrollment initiated by the MLTC plan without agreement from the Enrollee. The disenrollment is submitted when that Enrollee no longer meets the conditions for continued enrollment. An involuntary disenrollment requires approval by the entity designated by the Department. The Department has designated New York Medicaid Choice (NYMC), the State's enrollment broker, as the entity which will receive plan initiated involuntary disenrollment requests for reasons outlined in this policy. The Plan must submit the disenrollment request to NYMC in the required time, form, and with the required documentation, as specified by the Department.

Note: The Enrollee may initiate the voluntary disenrollment process at any time for any reason including during the Plan initiated involuntary disenrollment process. In no instance is the Plan allowed to pressure or coerce the Enrollee to consent to a disenrollment. When the Enrollee no longer meets the conditions for continued enrollment and the Enrollee does not request a voluntary disenrollment, the Plan must initiate the involuntary disenrollment process.

MLTC Involuntary Disenrollment Request Form

This policy is organized to present the involuntary disenrollment reasons based on the MLTC Plan Legacy status of the Enrollee. The Managed Long Term Care Involuntary Disenrollment Form has been divided into three sections based on the individual's MLTC Plan Legacy status and the reason for disenrollment:

  1. MLTC Plan Legacy or Non Legacy Reasons: Involuntary Disenrollment reasons applicable all Enrollees regardless of their MLTC Plan Legacy Status.
  2. MLTC Plan Legacy Reasons: Involuntary Disenrollment reasons applicable to Enrollee's with MLTC Plan Legacy.
  3. Non Legacy Reasons: Involuntary Disenrollment reasons applicable to Enrollee's without MLTC Plan Legacy.

There are two types of involuntary disenrollment reasons, mandatory or optional:

  • A mandatory involuntary disenrollment reason is a required action that the Plan MUST take following a specific triggering event. The Plan MUST initiate the involuntary disenrollment process within five (5) business days of the date the Plan knows of the triggering event.
  • An optional involuntary disenrollment reason is an action where under limited circumstances the Plan MAY initiate the involuntary disenrollment process.

Mandatory or optional involuntary disenrollment reasons must be followed as outlined in this policy. Due to the changes outlined in MLTC Policy 25.04, prior to initiating the involuntary disenrollment process, the Plan must determine the MLTC Plan Legacy status and select the applicable reason on the MLTC Involuntary Disenrollment Request Form.
Reminder: For all involuntary disenrollments that result in disenrollment from the MLTC Program, the MLTC plan is required to follow MLTC Policy 25.04 and end date the MLTC Plan Legacy, if applicable.

A. MLTC Plan Legacy and Non Legacy Reasons:

This section is divided into mandatory and optional involuntary disenrollment reasons which apply to MLTC Plan Legacy and Non Legacy individuals. As noted above, when disenrollments result in an individual no longer continuously enrolled in the MLTC program, MLTC Policy 25.04 must be followed to update the MLTC Plan Legacy Status accordingly.

  1. Mandatory Involuntary Disenrollment Reasons:
    1. Enrollee no longer resides in the Plan's service area.
      This reason is applicable to all MLTC plan types. The Plan is required to initiate the involuntary disenrollment process within five (5) business days of notification that the Enrollee no longer resides in the Plan's service area.

      The Plan must immediately notify the HRA/LDSS of the new residential address when the Plan has verified that an Enrollee has moved out the Plan's service area.

      The Enrollee's residential address must be updated by the HRA/LDSS in order for the disenrollment/transfer to be processed by NYMC.

      The Plan must submit the Involuntary Disenrollment Package and the required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons. The Plan must also follow the instructions in the Process for Involuntary Disenrollments section below.

      When an involuntary disenrollment request for this reason is approved, NYMC will send a disenrollment notice. The notice will reflect the disenrollment outcomes outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons.
    2. Enrollee has been absent from the Plan's service area for more than 30 consecutive days.
      This reason is applicable to all MLTC plan types. The Plan is required to initiate the involuntary disenrollment process with NYMC within five (5) business days of notification that the Enrollee has been absent from the Plan's service area (i.e., visiting family in another state) for more than thirty (30) consecutive days.

      Before sending the Intent to Disenroll letter, as part of initiating the involuntary disenrollment process, the Plan is required to make reasonable attempts to contact the Enrollee and/or their designee, as outlined below. All contact attempts must be documented in the monthly Care Management record.

      Upon a successful contact with the Enrollee and/or their designee, the Plan must inform the Enrollee of the disenrollment potential. The Plan must advise the Enrollee and/or their designee of the requirement to be in the service area to maintain their membership with the Plan.
      • If the Enrollee confirms with the Plan that they will not be returning to the service area with the required thirty (30) day period, the Plan is required to initiate the involuntary disenrollment process.
      • If the Plan is unable to contact the Enrollee, the Plan is required to initiate the involuntary disenrollment process.
      The Plan must submit the Involuntary Disenrollment Package and the required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      When an involuntary disenrollment request for this reason is approved, NYMC will send a disenrollment notice. The notice will reflect the disenrollment outcomes outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons.

      Reasonable Attempts to Contact the Enrollee include:
      • At least five (5) outreach attempts (as described below) over the five (5) calendar days to contact the Enrollee and educate the Enrollee of the disenrollment potential. The outreach attempts must be conducted on different days of the week and different times of the day.
        • Out of the 5 outreach attempts, there must be at least one (1) visit to the Enrollee's home which may include the utilization of existing providers.
    3. Enrollee enters an OMH, OPWDD, or OASAS residential program that is not an MLTC plan covered benefit for 45 consecutive days or longer.
      This reason is applicable to all MLTC plan types. The Plan is required to initiate the involuntary disenrollment process within five (5) business days from the date the Plan knows the Enrollee has been in a residential program with the Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD), or Office of Addiction Services and Supports (OASAS) that is not an MLTC plan covered benefit for forty-five (45) consecutive days or longer and does not have an active discharge plan. MLTC plans must have up-to-date case management notes while the Enrollee is admitted to the residential program including the ongoing status of the Enrollee during the admission.

      The Plan must submit the Involuntary Disenrollment Package and the required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      When an involuntary disenrollment request for this reason is approved, NYMC will send a disenrollment notice. The notice will reflect the disenrollment outcomes outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons.

      More information on the OMH state operated psychiatric centers are available with Office of Mental Health (OMH) and details on the OMH/OASAS residential program are provided in the New York State MAP Plans Behavioral Health Billing and Coding Manual. Details on the OPWDD residential program can be found at here.
    4. Enrollee is hospitalized for 45 days or longer.
      This reason is applicable to MLTCP plans only. The Plan is required to initiate the involuntary disenrollment process within five (5) business days from the date the Plan knows the Enrollee has been hospitalized for forty-five consecutive (45) days or longer and does not have an active discharge plan. MLTCP plans must have up-to-date case management notes while the Enrollee is hospitalized and ongoing status of the Enrollee during the hospitalization.

      The Plan must submit the Involuntary Disenrollment Package and the required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      When an involuntary disenrollment request for this reason is approved, NYMC will send a disenrollment notice. The notice will reflect the disenrollment outcomes outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons.
    5. Enrollee is no longer enrolled in the Plan's aligned Medicare Advantage product.
      This reason is applicable to MAP plans only. The Plan is required to initiate the involuntary disenrollment process within five (5) business days of notification that the Enrollee is no longer enrolled in the Plan's aligned Medicare Advantage product.

      Before sending the Intent to Disenroll letter, as part of initiating the involuntary disenrollment process, the Plan is required to make reasonable attempts to contact the Enrollee and/or their designee, as outlined below. All contact attempts must be documented in the monthly Care Management record.

      Upon a successful contact with the Enrollee and/or their designee, the Plan must educate the Enrollee of the disenrollment potential. The Plan must advise the Enrollee and/or their designee of the requirement to be in the aligned Medicare product to maintain their membership with the Plan.
      • If the Enrollee would like to continue their enrollment with the MAP plan, the Plan must assist the Enrollee in reinstating the enrollment in the aligned MAP Medicare Plan. The Plan should ensure the Medicare enrollment is completed and that the Enrollee is aligned. The Plan must not initiate the involuntary disenrollment process in this instance.
      • If the Plan is unable to contact the Enrollee or if the Enrollee does not want to reinstate the enrollment in the aligned MAP Medicare plan, the Plan is required to initiate the involuntary disenrollment process.
      The Plan must submit the Involuntary Disenrollment Package and the required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      When an involuntary disenrollment request for this reason is approved, NYMC will send a disenrollment notice. The notice will reflect the disenrollment outcomes outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons.

      Reasonable Attempts to Contact the Enrollee include:
      • At least five (5) outreach attempts (as described below) over the five (5) calendar days to contact the Enrollee and educate the Enrollee of the disenrollment potential. The outreach attempts must be conducted on different days of the week and different times of day.
        • Out of the 5 outreach attempts, there must be at least one (1) visit to the Enrollee's home which may include the utilization of existing providers.
    6. Enrollee is not enrolled in the aligned Medicare health plan, if applicable.
      This reason is applicable to PACE plans only. The Plan is required to initiate the involuntary disenrollment process within five (5) business days of notification that the Enrollee is no longer enrolled in the Plan's aligned Medicare Health plan.

      Before sending the Intent to Disenroll letter, as part of initiating the involuntary disenrollment process, the Plan is required to make reasonable attempts to contact the Enrollee and/or their designee, as outlined below. All contact attempts must be documented in the monthly Care Management record.

      Upon a successful contact with the Enrollee and/or their designee, the Plan must educate the Enrollee of the disenrollment potential. The plan must advise the Enrollee and/or their designee of the requirement to be in the aligned Medicare product to maintain their membership with the Plan.
      • If the Enrollee would like to continue their enrollment with the PACE plan, the Plan must assist the Enrollee in reinstating the enrollment in the aligned PACE Medicare plan. The Plan should ensure the PACE Medicare enrollment is completed and that the Enrollee is aligned. The Plan should not initiate the involuntary disenrollment process in this instance.
      • If the Plan is unable to contact the Enrollee or if the Enrollee does not want to reinstate the enrollment in the aligned Medicare Health plan, the Plan is required to initiate the involuntary disenrollment process.
      The Plan must submit the Involuntary Disenrollment Package and the required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      When an involuntary disenrollment request for this reason is approved, NYMC will send a disenrollment notice. The notice will reflect the disenrollment outcomes outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons.

      Reasonable Attempts to Contact the Enrollee include:
      • At least five (5) outreach attempts (as described below) over the five (5) calendar days to contact the Enrollee and educate the Enrollee of the disenrollment potential. The outreach attempts must be conducted on different days of the week and different times of day.
        • Out of the 5 outreach attempts, there must be at least one (1) visit to the Enrollee's home which may include the utilization of existing providers.
    7. Enrollee refused to cooperate or was unable to be reached to complete the required assessment.

      This reason is applicable to all MLTC plan types. The Plan is required to initiate the involuntary disenrollment process when the Enrollee has either refused to or was unable to be reached to complete the required CHA. The Plan must initiate the involuntary disenrollment process within five (5) business days after required CHA due date.

      Before sending the Intent to Disenroll letter, as part of initiating the involuntary disenrollment process, the Plan is required to make reasonable attempts to contact the Enrollee and/or their designee, as outlined below. All contact attempts must be documented in the monthly Care Management record.

      Reminder: An Enrollee is required to have a valid CHA on file to continue the enrollment.

      Upon successful contact with the Enrollee and/or their designee, the Plan must educate the Enrollee about the requirement of the CHA. Enrollee education must include an explanation that the CHA is required to continue the enrollment and that services could be discontinued.
      • If the Enrollee would like to continue their enrollment with the Plan, the Plan must assist the Enrollee in scheduling the CHA. The Plan should ensure that the CHA is completed within 14 days of the required CHA due date. The Plan should not submit an involuntary disenrollment to NYMC in this instance.
      • If the Plan is unable to contact the Enrollee or if the Enrollee refuses to complete the required CHA, the Plan is required to initiate the involuntary disenrollment process.
      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      When an involuntary disenrollment request for this reason is approved, NYMC will send a disenrollment notice. The notice will reflect the disenrollment outcomes outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons.

      Reasonable Attempts to Contact Enrollee include:
      • At least ten (10) outreach attempts over the course of thirty (30) calendar days to schedule and complete the required CHA prior to the CHA due date. The outreach attempts must be conducted on different days of the week and different times of day.
        • Out of the 10 outreach attempts, there must be at least two (2) visits to the Enrollee's home which may include the utilization of existing providers.
      Each of the attempts must have a documented outcome of the attempts to reach, schedule, and complete the required CHA in the Care Management record. The Care Management record must be updated with the current status including when a follow up outreach attempt will be made.
    8. Enrollee does not receive at least one CBLTSS within previous month.

      This reason is applicable to all MLTC plan types. The Plan is required to initiate the involuntary disenrollment process within five (5) business days of confirming that the Enrollee has not received any CBLTSS within the previous calendar month.
      1. The following are examples of instances in which a Plan must initiate involuntary disenrollment due to lack of Enrollee receiving CBLTSS within 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.
        • Pursuant to MLTC Policy, Enrollees must receive at least one CBLTSS within a calendar month to maintain their enrollment. Reminder: SADC and PCS/CDPAS Level 1 (Housekeeping services) do not meet the CBLTSS requirement for MLTC enrollment.
      2. The following are examples of instances in which a Plan must not initiate involuntary disenrollment due to the Enrollee not receiving CBLTSS within previous calendar month:
        • Nursing services in the home is the only service in the Enrollee's plan of care, and the scheduled frequency results in no scheduled nursing service within a 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.
        • Enrollee is hospitalized or admitted to a residential program during the calendar month that the Enrollee was identified as not receiving CBLTSS.
      Before sending the Intent to Disenroll letter as part of initiating the involuntary disenrollment process, the Plan is required to make reasonable attempts to contact the Enrollee and/or their designee, as outlined below. All contact attempts must be documented in the monthly Care Management record.

      Upon a successful contact with the Enrollee and/or their designee, the Plan must inform the Enrollee of the disenrollment potential. The Plan must advise the Enrollee and/or their designee of the requirement to receive CBLTSS in order to maintain their membership with the Plan.
      • If the Enrollee would like to reinstate their PCSP and resume services with the Plan, the Plan must resume their services. The Plan must confirm that the Enrollee is compliant with resuming services outlined in the PCSP within 7 days from the agreement to reinstate services. The Plan should not submit an involuntary disenrollment to NYMC in this instance.
      • If the Plan is unable to contact the Enrollee and/or their designee or the Enrollee does not want to reinstate their PCSP, the Plan is required to initiate the involuntary disenrollment process.
      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      Reasonable Attempts to Contact Enrollee include:
      At least five (5) outreach attempts over the five (5) calendar days to contact the Enrollee and educate the Enrollee of the disenrollment potential. The outreach attempts must be conducted on different days of the week and different times of day.
      • Out of the 5 outreach attempts, there must be at least one (1) visit to the Enrollee's home which may include the utilization of existing providers.
    9. Enrollee no longer meets the nursing home level of care.

      This reason is applicable to PACE only. The Plan is required to initiate the involuntary disenrollment process within five (5) business days of a CHA where the Enrollee was assessed as no longer meeting nursing home level of care and cannot be deemed eligible as outlined below.

      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      PACE Deemed Eligibility Process:

      Prior to initiating the involuntary disenrollment request, should a PACE plan believe that the absence of continued coverage under the PACE plan would negatively impact the Enrollee's condition, and the Enrollee would be reasonably expected to meet the nursing home level of care requirement within the next six months, the PACE plan must submit a deemed eligibility review request to the Department.

      The deemed eligibility review request must be submitted by the PACE plan including the supporting documentation within five (5) business days of the CHA determination. This information should be submitted to the Department at MLTCMDReview@health.ny.gov.

      The supporting documentation must include the CHA and a statement from the PACE plan's Medical Director or clinical staff clearly stating the rationale for deemed eligibility based on the member's chronic condition. Supporting documentation may include but is not limited to medical records, relevant tests, an assessment by specialists, formal and informal supports that may impact the stability of the member's condition in the next six months. The Department reserves the right to request additional supporting documentation including an attestation from the Enrollee's primary care provider. If the deemed eligibility review is approved, the Enrollee's enrollment would continue uninterrupted. However, if the deemed eligibility review request is not approved by the Department, the PACE plan is required to initiate the involuntary disenrollment process within five (5) business days of the deemed eligibility review determination. The PACE plan must submit the deemed eligibility review outcome with the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC. The Plan must indicate on the form that the Enrollee does not meet the deemed eligibility criteria.
    10. Enrollee no longer in need of CBLTSS for more than 120 days.

      This reason is applicable to all MLTC plan types. The Plan is required to initiate the involuntary disenrollment process within five (5) business days of the CHA where the Enrollee was assessed as not needing CBLTSS for more than 120 days.

      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.

      For approved involuntary disenrollment requests for this reason, the Enrollee will be disenrolled to FFS Medicaid.
    11. Enrollee no longer meets the nursing home level of care and is no longer in need of CBLTSS for more than 120 days.

      This reason is applicable to PACE only. The Plan is required to initiate the involuntary disenrollment process within five (5) business days of a CHA where the Enrollee was assessed as no longer meeting nursing home level of care and no longer in need of CBLTSS for more than 120 days.

      The Plan must submit the Involuntary Disenrollment Package and the required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.
  2. Optional Involuntary Disenrollment Reasons:
    1. Enrollee or Enrollee's family member or other person in the home engages in behavior that seriously impairs the Plan's ability to furnish services for reasons other than those resulting from the Enrollee's special needs.

      This reason is applicable to all MLTC plan types. The Plan may initiate an involuntary disenrollment process if the Enrollee or an Enrollee's family member or other person in the home engages in conduct or behavior that seriously impairs the Plan's ability to furnish services. The Plan is required to have made reasonable efforts to resolve the problems presented by the involved individual(s). However, with the Department's approval, the MLTC plan may immediately initiate the involuntary disenrollment process when the situation poses a serious risk of harm to an Enrollee, or service providers.

      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 1: MLTC Plan Legacy and Non Legacy Reasons and follow the instructions in the Process for Involuntary Disenrollments section below.
    2. Enrollee fails to pay spend down fee or Net Available Monthly Income (NAMI) within 30 days after such amount becomes due.

      This reason is on hold.
    3. Enrollee knowingly provides false information, otherwise deceives the Plan, or engages in fraudulent conduct with respect to any substantive aspect of their plan membership.

      This reason is on hold.
    4. Table 1: MLTC Plan Legacy and Non Legacy Reasons

      The MLTC Plan Legacy and Non Legacy table identifies:
      • Reason: Lists the involuntary disenrollment reason for the MLTC Plan Legacy and Non Legacy Reasons.
      • Plan Type: Indicates the plan types that are applicable to the reason.
      • Required Supporting Documentation: Lists the required supporting documentation that must be provided for the indicated Involuntary Disenrollment reason.
      • Disenrollment Outcome: Explains how the disenrollment is processed based on the enrollee's status (Mandatory or Voluntary).
        • Any individual that is no longer eligible for continued enrollment in the MLTC program will be disenrolled.
        • Individuals with MLTC Plan Legacy Status, who are eligible for MLTC enrollment and meet the Legacy Criteria as outlined in MLTC Policy 25.04 will be included in the voluntary population and provided an option to choose a plan.
      5. Reason Plan Type Required Supporting Documentation Disenrollment Outcome
      Mandatory Voluntary
      MLTC Plan Legacy and Non Legacy Reasons
      Enrollee no longer resides in the Plan's service area. MAP
      PACE
      MLTCP
      • Copy of the Enrollee's Intent to Disenroll letter.
      • MLTC Involuntary Disenrollment Request form completed with:
        • Date HRA/LDSS was notified
        • Enrollee's New Address
      Note: The enrollee's residential address must be updated by the HRA/LDSS in order for the disenrollment/transfer to be processed by NYMC.      		 Enrollee must join a different MLTC plan.

      If the Enrollee does not choose a new plan, the Enrollee will be auto transferred to an MLTCP plan.      		 Enrollee may join a different MLTC plan.

      If the Enrollee does not choose a new plan, the Enrollee will be disenrolled to FFS Medicaid.
      Enrollee has been absent from the Plan's service area for more than 30 consecutive days. MAP
      PACE
      MLTCP
      • Copy of the Enrollee's Intent to Disenroll letter.
      • Statement from the Enrollee's Home Care Agency, or other pertinent evidence, that an effort was made to contact the Enrollee.
      • MLTC Involuntary Disenrollment Request form completed with:
        • Start date of Enrollee's absence from the service area
      		 Enrollee is disenrolled to FFS Medicaid.
      Enrollee enters an OMH, OPWDD, or OASAS residential program that is not an MLTC plan covered benefit for 45 consecutive days or longer. MAP
      PACE
      MLTCP
      • Copy of the Enrollee's Intent to Disenroll letter.
      • MLTC Involuntary Disenrollment Request form completed with:
        • Name of Residential Program
        • Type of Program: ☐OMH, ☐OPWDD or ☐OASAS
        • Date of admission
      		 Enrollee is disenrolled to FFS Medicaid.
      Enrollee is hospitalized for 45 days or longer. MLTCP
      • Copy of the Enrollee's Intent to Disenroll letter.
      • MLTC Involuntary Disenrollment Request form completed with:
        • Name of Hospital
        • Date of admission
        • ☐ Enrollee does not have a discharge plan
      		 Enrollee is disenrolled to FFS Medicaid.
      Enrollee is no longer enrolled in the Plan's aligned Medicare Advantage Product. MAP
      • Copy of the Enrollee's Intent to Disenroll letter
      • MLTC Involuntary Disenrollment Request form completed with:
        • Medicare Disenrollment Date
      		 Enrollee must join a different MLTC plan

      If the Enrollee does not choose a new plan, the Enrollee will be auto transferred to an MLTCP plan      		 Enrollee may join a different MLTC plan

      If the Enrollee does not choose a new plan, the Enrollee will be disenrolled to FFS Medicaid
      Enrollee is not enrolled in the aligned Medicare health plan, if applicable. PACE
      • Copy of the Enrollee's Intent to Disenroll letter
      • MLTC Involuntary Disenrollment Request form completed with:
        • Medicare Disenrollment Date
      		 Enrollee must join a different MLTC plan

      If the Enrollee does not choose a new plan, the Enrollee will be auto transferred
      to an MLTCP plan      		 Enrollee may join a different MLTC plan

      If the Enrollee does not choose a new plan, the Enrollee will be disenrolled to FFS
      Medicaid
      Enrollee refused to cooperate or was unable to be reached to complete the required assessment. MAP
      PACE
      MLTCP
      • Copy of the Enrollee's Intent to Disenroll letter
      • MLTC Involuntary Disenrollment form completed with:
        • Written statement (on Plan Letterhead) indicating all efforts used to gain the Enrollee's cooperation with scheduling and completing the required assessment.
      		 Enrollee will be disenrolled to FFS Medicaid
      Enrollee does not receive at least one of the CBLTSS within the previous month. MAP
      PACE
      MLTCP
      • Copy of the Enrollee's Intent to Disenroll letter.
      • MLTC Involuntary Disenrollment form completed with:
        • Written statement (on Plan letterhead) indicating the reason the Enrollee is not receiving one of the listed services and evidence of all outreach attempts, along with a description of the safe discharge plan and/or any referrals.
        • ☐ Contact or ☐ No Contact
      		 Enrollee will be disenrolled to FFS Medicaid
      Enrollee no longer meets the nursing home level of care. PACE
      • Copy of the Enrollee's Intent to Disenroll letter.
      • MLTC Involuntary Disenrollment form completed with:
        • Date of the Community Health Assessment
        • NHLOC Score
      		 Enrollee must join a different MLTC plan

      If the Enrollee does not choose a new plan, the Enrollee will be auto transferred to an MLTCP plan
      Enrollee no longer in need of CBLTSS for more than 120 days. MAP
      PACE
      MLTCP
      • Copy of the Enrollee's Intent to Disenroll letter.
      • MLTC Involuntary Disenrollment form completed with:
        • Date of the Community Health Assessment
        • Need for 120 days continuous CBLTSS (Yes or No)
      		 Enrollee will be disenrolled to FFS Medicaid.
      Enrollee no longer meets the nursing home level of care and no longer in need of CBLTSS for more than 120 days. PACE
      • Copy of the Enrollee's Intent to Disenroll letter.
      • MLTC Involuntary Disenrollment form completed with:
        • Date of the Community Health Assessment
        • Need for 120 days continuous CBLTSS (Yes or No)
      		 Enrollee will be disenrolled to FFS Medicaid.
      Enrollee or Enrollee's family member or other person in the home engages in behavior that seriously impairs the Plan's ability to furnish services for reasons other than those resulting from the Enrollee's special needs. MAP
      PACE
      MLTCP
      • Copy of the Enrollee's Intent to Disenroll letter.
      • MLTC Involuntary Disenrollment form completed with:
        • Written statement from the Plan (on plan letterhead) describing the case situation, including the names of different home care agencies utilized and results of service attempts. Adult Protective Services (APS) reference is needed for safety issues.
      		 Enrollee must join a different MLTC plan.

      If the Enrollee does not choose a new plan, the Enrollee will be auto transferred to an MLTCP plan.      		 Enrollee may join a different MLTC plan.

      If the Enrollee does not choose a new plan, the Enrollee will be disenrolled to FFS Medicaid.
      MLTC Plan Legacy and Non Legacy Reasons – On Hold
      Enrollee fails to pay 'spend down' fee or Net Available Monthly Income (NAMI) within 30 days after such amount becomes due. On Hold
      Enrollee knowingly provides false information, otherwise deceives the Plan, or engages in fraudulent conduct with respect to any substantive aspect of their plan membership. On Hold

B. MLTC Plan Legacy Reasons:

This section includes mandatory reasons only and applies to MLTC Plan Legacy individuals only. As noted above, when disenrollments result in an individual no longer continuously enrolled in the MLTC program, the MLTC Policy 25.04 must be followed to update MLTC Plan Legacy Status accordingly.

  1. Mandatory Involuntary Disenrollment Reasons.
    1. Enrollee no longer meets the nursing home level of care

      This reason is applicable to MLTCP dual eligible enrollees aged 18 to 20, MLTCP non-dual eligible enrollees and all MAP enrollees. Refer to Table B in MLTC Policy 25.04 for enrollees with MLTC Plan Legacy Status.

      The Plan is required to initiate the involuntary disenrollment process within five (5) business days of a CHA where the Enrollee was assessed as no longer meeting the nursing home level of care.

      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 2: MLTC Plan Legacy and follow the instructions in the Process for Involuntary Disenrollments section below.

      When an involuntary disenrollment request for this reason is approved, NYMC will send a disenrollment notice. The notice will reflect the disenrollment outcomes outlined in Table 2: MLTC Plan Legacy.
    2. Enrollee no longer meets the nursing home level of care and is no longer in need of CBLTSS for more than 120 days.

      This reason is applicable to MLTCP dual eligible enrollees aged 18 to 20, MLTCP non-dual eligible enrollees and all MAP enrollees. Refer to Table B in MLTC Policy 25.04 for enrollees with MLTC Plan Legacy Status.

      The Plan is required to initiate the involuntary disenrollment process within five (5) business days of a CHA where the Enrollee was assessed as no longer meets the nursing home level of care and no longer in need of CBLTSS for more than 120 days.

      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 2: MLTC Plan Legacy and follow the instructions in the Process for Involuntary Disenrollments section below.

Table 2: MLTC Plan Legacy Reasons

The MLTC Plan Legacy Reasons table identifies:

  • Reason: Lists the involuntary disenrollment reason applicable for the MLTC Plan Legacy enrollees.
  • Plan Type: Indicates the plan types that are applicable to the reason.
  • Required Supporting Documentation: Lists the required supporting documentation that must be provided for the indicated Involuntary Disenrollment reason.
  • Disenrollment Outcome: Explains how the disenrollment is processed based on the enrollee's status (Mandatory or Voluntary).
    • Any individual that is no longer eligible for continued enrollment in the MLTC program will be disenrolled.
    • Individuals with MLTC Plan Legacy, who are eligible for MLTC enrollment and meet the Legacy Criteria as outlined in MLTC Policy 25.04 will be included in the voluntary population and provided an option to choose a plan.

Table 2:MLTC Plan Legacy Reasons

Reason Plan Type Required Supporting Documentation Disenrollment Outcome
Mandatory Voluntary
MLTC Plan Legacy Reasons
Enrollee no longer meets the nursing home level of care. MAP
MLTCP
  • Copy of the Enrollee's Intent to Disenroll letter.
  • MLTC Involuntary Disenrollment form completed with:
    • Date of the Community Health Assessment
    • NHLOC Outcome
    • MLTCP only:
      • ☐ Non-Duals
      • ☐ Dual Eligible 18-20 years
 Enrollee must join a different MLTC plan.

If the Enrollee does not choose a new plan, one of the MLTCP plans will be selected for the Enrollee.		 Enrollee may join a different MLTC plan.

If the Enrollee does not choose a new plan, the Enrollee will be disenrolled to FFS Medicaid.

Note: Non Dual and Dual 18 – 20 Enrollees will be disenrolled to FFS Medicaid as they are no longer eligible for MLTC enrollment unless they meet the Minimum Needs Requirements.
Enrollee no longer meets the nursing home level of care and no longer in need of CBLTSS for more than 120 days. MAP MLTCP
  • Copy of the Enrollee's Intent to Disenroll letter.
  • MLTC Involuntary Disenrollment form completed with:
    • Date of the Community Health Assessment
    • NHLOC Outcome
    • Assessment Outcome
    • Need for 120 days continuous CBLTSS (Yes or No)
    • MLTCP only:
      • ☐ Non-Duals
      • ☐ Dual Eligible 18-20 years
 Enrollee will be disenrolled to FFS Medicaid.
Enrollee no longer meets the nursing home level of care and no longer in need of CBLTSS for more than 120 days. MAP
MLTCP
  • Copy of the Enrollee's Intent to Disenroll letter.
  • MLTC Involuntary Disenrollment form completed with:
    • Date of the Community Health Assessment
    • NHLOC Outcome
    • Assessment Outcome
    • Need for 120 days continuous CBLTSS (Yes or No)
    • MLTCP only:
      • ☐ Non-Duals
      • ☐ Dual Eligible 18-20 years
 Enrollee will be disenrolled to FFS Medicaid.

C. MLTC Non Legacy Reasons:

This section includes mandatory involuntary disenrollment reasons only and applies Non Plan Legacy only. These individuals will not have MLTC Plan Legacy.

  1. Mandatory Involuntary Disenrollment Reasons:
    1. Enrollee no longer meets the Minimum Needs Requirement.

      This reason is applicable to MAP and MLTCP.

      The Plan is required to initiate the involuntary disenrollment process within five (5) business days of a CHA where the Enrollee was assessed as no longer meets the Minimum Needs requirement.

      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 3: MLTC Plan Legacy and follow the instructions in the Process for Involuntary Disenrollments section below.

      Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 3: MLTC Plan Legacy and follow the instructions in the Process for Involuntary Disenrollments section below.
    2. Enrollee no longer meets the Minimum Needs Requirements and is no longer in need of CBLTSS for more than 120 days.

      This reason is applicable to MAP and MLTCP only.

      The Plan is required to initiate the involuntary disenrollment process within five (5) business days of a CHA where the Enrollee was assessed as no longer meeting the Minimum Needs requirement and no longer in need of CBLTSS for more than 120 days.

      The Plan must submit the Involuntary Disenrollment Package and required supporting documentation as outlined in Table 3: MLTC Plan Legacy and follow the instructions in the Process for Involuntary Disenrollments section below.

Table 3: Non Legacy Reasons
The Non-Legacy Reasons table identifies:

  • Reason: Lists the involuntary disenrollment reason for the Non Legacy Reasons.
  • Plan Type: Indicates the applicable plan types that are applicable to the reason.
  • Required Supporting Documentation: Lists the required supporting documentation that must be provided for that reason in the Involuntary Disenrollment reason.
  • Disenrollment Outcome: Explains how the disenrollment is processed based on the enrollee's status (Mandatory or Voluntary).

Reason Plan Type Required Supporting Documentation Disenrollment Outcome
Mandatory Voluntary
Non Legacy Reasons
Enrollee no longer meets the Minimum Needs Requirement. MAP
MLTCP
  • Copy of the Enrollee's Intent to Disenroll letter.
  • MLTC Involuntary Disenrollment form completed with:
    • Date of the Community Health Assessment
    • DOH-5821 if Enrollee diagnoses with Alzheimer's disease or dementia
 Enrollee will be disenrolled to FFS Medicaid
Enrollee no longer meets the Minimum Needs Requirement and is no longer in need of CBLTSS for more than 120 days. MAP
MLTCP
  • Copy of the Enrollee's Intent to Disenroll letter.
  • MLTC Involuntary Disenrollment form completed with:
    • Date of the Community Health Assessment
    • DOH-5821 if Enrollee diagnoses with Alzheimer's disease or dementia
 Enrollee will be disenrolled to FFS Medicaid

Process for Involuntary Disenrollments

Once the Plan has completed all required actions including outreach attempts, then the next step in the involuntary disenrollment process is to send the Enrollee the applicable Intent to Disenroll letter. The Plan must send the approved Intent to Disenroll letter to the Enrollee and their authorized representative(s) prior to submitting the involuntary disenrollment package for the Enrollee to NYMC.

The Plan must submit an involuntary disenrollment package to the NYMC Health Plan Affairs Department via the NYMC secure portal, Secure Portal. The package must include the following:

  • A completed Managed Long Term Care Involuntary Disenrollment Request Form,
  • The required supporting documentation for the selected disenrollment reason,
  • The Intent to Disenroll letter, and
  • The transmittal form requested from NYMC

Note: NYMC is responsible for sending the MLTC Involuntary Disenrollment Request Form, NYMC transmittal form and the MLTC Involuntary Disenrollment Processing schedule on a yearly basis and any time there is an update. Plans are required to use the newest version when submitting the package.

The involuntary disenrollment package must be submitted within the required timeframe as outlined in this policy. Involuntary disenrollment packages will be processed according to the MLTC Involuntary Disenrollment Processing Schedule for the next available effective date. The failure to timely submit the completed involuntary disenrollment package to NYMC may be subject premium recoupment by the Department.

NYMC will issue the "D File" to each MLTC plan for all submitted involuntary disenrollment requests. The "D file" is a daily file provided by NYMC and contains the status of a Plan's involuntary disenrollment request including approved, disregarded, and overturned involuntary disenrollment outcomes.

In the case of disregarded or overturned involuntary disenrollment package, the Enrollee will remain enrolled in the Plan. Delays in correcting errors may result in a Statement of Deficiency and/or recoupment of the managed care premium.

Example: If the Enrollee no longer resides in the Plan's service area involuntary disenrollment package is disregarded by NYMC (as listed on the NYMC D File) because the address has not been updated, the Plan must resubmit the involuntary disenrollment request after the address is updated.

The Plan will be notified of disenrollments via the eMedNY 834 TERM File. MLTCP plans will also be notified of auto assigned enrollments for individuals that are mandatory via the eMedNY 834 ADD File. The eMedNY 834 ADD file is sent to the receiving Plan when a disenrollment results in a transfer to an MLTCP, thereby a new enrollment. More information on the Department's roster files of all enrollment changes can be found here. The involuntary disenrollment reasons that result in a transfer to an MLTCP are outlined in Table 1 through Table 3.

The involuntary disenrollment process will continue on a monthly basis. The date of the disenrollment depends on the date the involuntary disenrollment request is received by NYMC and accepted per the NYMC Disenrollment Processing Schedule. Individuals will be notified of their involuntary disenrollment by NYMC via an Involuntary Disenrollment Confirmation Notice. Fair Hearing rights will apply to this notice from NYMC including Aid to Continue. The involuntary disenrollment confirmation notice has contact information if the individual has questions regarding the disenrollment.

Enrollee Contacts the Plan or NYMC to Continue MLTC Enrollment

Following the initiation of the involuntary disenrollment process, where the MLTC plan has completed the required Plan actions, there are certain instances when the Enrollee is able to maintain their enrollment by remedying the involuntary disenrollment issue. To initiate this process the Enrollee must contact the MLTC plan to continue the enrollment prior to the involuntary disenrollment effective date. The MLTC plan must act to facilitate the continuation of the enrollment by working with NYMC and the Enrollee.

When the Enrollee has addressed the involuntary disenrollment reason prior to the involuntary disenrollment effective date and is eligible to continue their enrollment, the Plan must provide an updated enrollment letter to the Enrollee. When NYMC processes the re-enrollment, the Enrollee will receive an enrollment confirmation notice.

The scenarios below are a few examples of actions that the Enrollee may take to continue their enrollment in the MLTC plan. Continuous enrollment can be applied if the Enrollee has addressed the involuntary disenrollment issue prior to the involuntary disenrollment effective date:

  • Enrollee has been absent from the Plan's service area for 30 consecutive days.
    The Enrollee must contact the MLTC plan after returning to the service area to request to continue their enrollment. The Plan must document the continued enrollment request as an occurrence in the monthly Care Management record including any changes to the existing PCSP.
  • Enrollee does not receive at least one CBLTSS in the previous month.
    The Enrollee must contact the MLTC plan and reinstate their PCSP including the CBLTSS. The CBLTSS must be scheduled and resumed according to the standard timeframes for service authorization requests. The Plan must document the continued enrollment request as an occurrence in the monthly Care Management record, which may include any changes to the existing PCSP.
  • Enrollee enters a residential program or is hospitalized for 45 consecutive days or longer.
    The Enrollee must contact the MLTC plan after establishing an active discharge plan with a discharge date or after returning to a community setting prior to disenrollment effective date. The Enrollee must contact the MLTC plan to request to continue the enrollment. The CBLTSS must be scheduled and resumed according to the standard timeframes for service authorization requests. The Plan must document the active discharge plan or the return to the community setting as an occurrence in the monthly Care Management record.
  • A MAP or PACE Enrollee is not enrolled in the aligned Medicare Plan
    The Enrollee must contact the MLTC plan and reenroll in the aligned Medicare plan.
  • Enrollee has refused the required CHA.
    The Enrollee must contact the MLTC plan and complete the required CHA. The required CHA must be completed within 30 days of the original Intent to Disenroll Letter date.
    Required Actions For Continued Enrollment Requests

    A. Individual Contacts the Plan:

    If the individual contacts the Plan prior to their disenrollment effective date, the MLTC plan must verify that the Enrollee has resolved the conditions that triggered the involuntary disenrollment process and therefore is able to continue the enrollment. Upon verification, the MLTC plan must contact NYMC Health Plan Affairs team (NYMC HPA) via Secure Portal to request assistance with reinstating the enrollment.

    In the instance where NYMC has processed the disenrollment, prior to the disenrollment effective date, the Plan must submit an Upload file (U-file) to NYMC to reinstate the enrollment.

    B. Individual Contacts NYMC

    If the individual contacts NYMC prior to their disenrollment effective date, NYMC will initiate a three-way call to notify the Plan of the Enrollee's request to continue the enrollment.

    The Plan must verify that the Enrollee has satisfied the conditions described below, according to the relevant scenario. Upon verification, NYMC HPA will withdraw the involuntary disenrollment request if the disenrollment has not been processed.
    In the instance where NYMC has processed the disenrollment and it is prior to the disenrollment effective date; the Plan must submit an Upload file (U-file) to NYMC to reinstate the enrollment.

    Reminder: If there is a valid assessment on file, a new assessment is not needed to continue the enrollment.

Transition of Care Responsibilities

Prior to the effective date of the disenrollment, the MLTC Plan must work with the Enrollee and other individuals designated by the Enrollee, to make all necessary referrals to the LDSS, another Plan, other community resources, health care providers, alternative service providers and/or programs to facilitate a transition of care for services identified in the Enrollee's PCSP.

Note: Individuals with MLTC Plan Legacy status, who are transferred to another MLTC plan as result of an involuntary disenrollment, will maintain their MLTC Plan Legacy status. For more information, refer to MLTC Policy 25.04 - Minimum Needs Requirement Update to the Eligibility Requirements for Managed Long Term Care Enrollment.

Contact Information

For inquiries or assistance regarding this guidance, please contact: Bureau of Managed Long Term Care - New York State Department of Health at mltcinfo@health.ny.gov.