MLTC Policy 21.04

Office of Health Insurance Programs
Division of Long Term Care

Managed Long Term Care Policy 21.04: Managed Long Term Care Partial Capitation Plan Enrollment Lock-In

Date of Issuance: August 4, 2021

The purpose of this policy is to advise that effective December 1, 2020, enrollment in a Managed Long Term Care Partial Capitation (MLTCP) plan will be subject to a lock-in period for dual eligible enrollees who are age 21 and older. A lock-in period is a time during which an enrollee may not transfer to another MLTCP plan unless the enrollee can demonstrate a Good Cause reason to leave the plan.

Previously, enrollees of MLTCP plans were not subject to lock-in periods and could transfer to another MLTCP plan at any time, subject to eligibility requirements. This policy is being issued pursuant to changes in Article 44 § 4403-f of New York State Public Health Law.

New enrollments into MLTCP plans with an effective date on or after December 1, 2020 will be subject to a lock-in period. Such new enrollments and transfers will begin with a 90-day grace period from their enrollment effective date, during which time the enrollee may elect to transfer to another MLTCP plan for any reason. If the enrollee does not change plans within the 90-day grace period, the enrollee will be locked into the MLTCP plan in which they are currently enrolled for the next nine (9) months (lock-in period), unless the enrollee can demonstrate Good Cause. After the lock-in period ends, enrollees may transfer to another MLTCP at any time for any reason. However, the lock-in period applies 90-days after each new enrollment into an MLTCP plan.

Note: Managed Long Term Care Enrollment Lock-in does not:

  1. apply to dual eligible enrollees age 18 to 20, or non-dual eligible enrollees age 18 and older;
  2. apply to integrated plans (Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD), Medicaid Advantage Plus (MAP), Program of All-Inclusive Care for the Elderly (PACE));
  3. impact an enrollee´s ability to transfer from an MLTCP plan to an integrated plan;
  4. impact an enrollee´s ability to transfer from an MLTCP plan to a Mainstream Medicaid Managed Care plan, Health and Recovery Plan (HARP), HIV-Special Needs Plan (SNP), a Waiver Program, or Medicaid Fee-for-Service (FFS) at any time, assuming the enrollee is eligible for Medicaid and/or for enrollment into those programs;
  5. impact MLTC exempt populations; or
  6. impact a plan´s ability to involuntarily disenroll an enrollee in accordance with the model contract as well as the Department´s policies and guidance pertaining to involuntary disenrollment.

New York Medicaid Choice (NYMC), the New York State Department of Health´s (Department) managed care enrollment broker, will be responsible for providing education on lock-in to all individuals enrolled or seeking to enroll into an MLTCP. Enrollment confirmation notices have been revised to include lock-in language and will be mailed to an enrollee after selection or auto assignment into an MLTCP plan. In addition, the MLTCP plan is responsible for providing education on lock-in upon enrollment and should inform their enrollee that they have 90-days to request a transfer to another MLTCP without good cause.

Grace Period

During the grace period, an MLTCP enrollee may elect to transfer to another MLTCP at any time for any reason by contacting NYMC. NYMC is required to document the enrollee´s intent to transfer during their grace period. When the new MLTCP plan and the enrollee contact NYMC to initiate a transfer, the documentation will be used to allow a transfer to be processed at any time.

Lock-in Period and Good Cause Determination Process

An enrollee requesting to transfer from a MLTCP plan to another MLTCP plan during their lock-in period must contact NYMC to request a Good Cause determination. NYMC will educate the enrollee of the lock-in period and that they are unable to transfer to another MLTCP plan unless they can demonstrate Good Cause. NYMC will determine if the enrollee´s circumstances meet the Department´s criteria for Good Cause. These criteria are described below.

  1. The plan has failed to furnish accessible and appropriate medical care, services, or supplies to which the enrollee is entitled according to the plan of care. This includes, but is not limited to, the failure to:
    • arrange for services with appropriately licensed or certified providers;
    • provide a quality of care that aims to maintain or improve the enrollee´s health status; or
    • provide adequate access to providers who are experienced in treating the enrollee´s unique care needs.
    For this Good Cause reason, NYMC will perform a 3-way call with the enrollee´s current plan to determine if the Good Cause reason is valid. NYMC will educate the enrollee accordingly and the enrollee will be informed of the good cause determination via a good cause determination notice.

    Note: If the enrollee does not want to participate in a 3-way call for this reason, NMYC will mail the enrollee an MLTC Good Cause Request packet and follow the steps outlined below in the Good Cause Packet Process.
  2. The enrollee moves his/her residence out of the plan´s service area.
    • For this Good Cause reason, an enrollee may contact NYMC to transfer to another MLTCP plan. NYMC will determine if the enrollee´s new residence is out of the plan´s service area.
      1. If it is determined that the enrollee has moved out of the plan´s service area and the individual´s state reported residential address has been updated, NYMC will educate the enrollee accordingly on MLTCP plan transfer procedures and a Good Cause Transfer Approved Letter will be sent to the enrollee.
      2. If it is determined that the enrollee has moved out of the plan´s service area and the individual´s state reported residential address has not been updated, NYMC will educate the enrollee that the transfer cannot be processed until the address has been updated. NYMC will refer the enrollee to their Local Department of Social Services (LDSS) to have their address updated. Once the address is updated and the Good Cause transfer is approved, a Good Cause Transfer Approved Letter will be sent to the enrollee.
    • Note: The current plan must continue to assist their member to update their address.
  3. It is determined that the enrollee was enrolled into a plan without his/her consent. This determination could come from the LDSS, the Department or NYMC.
    • For this Good Cause reason, NYMC or the Department will receive a complaint for nonconsensual enrollment. NYMC will investigate and determine if the complaint is valid based on the criteria set forth by the Department.
    • If it is determined that the enrollment was non-consensual then good cause will be granted. NYMC will notify the enrollee with the MLTC Good Cause Transfer Approved Letter.
  4. The current home care provider does not have a contract/agreement with the enrollee´s plan.
    • For this Good Cause reason, NYMC will perform a 3-way call with the enrollee´s current plan to determine if the Good Cause reason is valid. NYMC will educate the enrollee accordingly and the enrollee will be informed of the good cause determination via a good cause determination notice
    • Note: If the enrollee does not want to participate in a 3-way call for this reason, NMYC will contact the MLTCP to confirm if the provider is not in the MLTCPs network.
  5. The enrollee and the plan agree that a transfer to another MLTCP plan is appropriate and would be in the best interest of the enrollee.
    • For this Good Cause reason, NYMC will perform a 3-way call with the enrollee´s current plan to determine if the Good Cause reason is valid. NYMC will educate the enrollee accordingly and the enrollee will be informed of the good cause determination via a good cause determination notice
    • Note: If the enrollee does not want to participate in a 3-way call for this reason, NMYC will contact the MLTCP to confirm that the MLTCP has agreed that a transfer would be appropriate.
  6. The Department determines that the plan has failed to meet its contractual obligations with the Department and such failure directly impacted enrollees.
    • For this Good Cause reason, NYMC receives direction from the State and processing staff handles the transfer process based on the State´s direction. In this scenario there will not be a denial situation.

Good Cause Packet Process

The MLTC Good Cause Transfer packet will be sent to the enrollee as outlined above in the Lock-in Period and Good Cause Determination Process. The MLTC Good Cause Transfer packet includes an instructional letter, the MLTC Good Cause Transfer Form, and a prepaid return envelope. The MLTC Good Cause Transfer Form will need to be completed and returned, along with supporting documentation, before a Good Cause determination can be made.

Once the MLTC Good Cause Transfer Form has been completed, and all necessary documentation has been collected, the form must be returned to NYMC, to the address or fax number provided in the instructional letter. MLTCP plans are required to assist enrollees with the Good Cause packet process.

If the MLTC Good Cause Transfer Form is not properly completed, NYMC will issue a MLTC Good Cause Incomplete & Missing Information Notice, notifying the enrollee that additional information is required. The enrollee has fifteen (15) days from the date the notice was issued to return the missing information. If after fifteen (15) days the information has not been received, the Good Cause request will be denied. Once all missing information has been received, NYMC will review the MLTC Good Cause Transfer Form, and render a determination.

Good Cause Determination

Enrollees who have demonstrated Good Cause and received an approval determination in the mail, may proceed with choosing a new MLTCP plan. The transfer request will be honored when the new plan and the enrollee contact NYMC to process the transfer. Once the new enrollment is effective, the enrollee will have a new 90-day grace period, followed by a nine (9) month lock-in period.

If an enrollee´s request for Good Cause is not granted, NYMC will issue a written determination to the enrollee explaining the denial and advising of fair hearing rights. The enrollee will continue in their current lock-in period but is not prohibited from requesting a transfer with Good Cause in the future.

End of Lock-in Period

NYMC will be responsible for providing a notice, at least sixty (60) days prior to the end of the enrollee´s lock-in period, that includes the date lock-in ends and the right to transfer MLTCP plan(s).

After the completion of the lock-in period, an enrollee may transfer to another MLTCP plan at any time and for any reason without cause. The enrollee can initiate transfer to another MLTCP plan within the last 30 days of their lock-in period for an enrollment effective the first day of the month after the end of their lock-in period, as long as the request to transfer is done prior to pull down date, noon on the 20th of the month. If the transfer request is initiated after the pull down date, the enrollment effective date will be on the first of the following month after the end of the Lock-in period. Each time an enrollee transfers to an MLTCP Plan a 90-day grace period will begin. After the 90-day grace period, the enrollee will be locked into the MLTCP plan in which they are currently enrolled for the next nine (9) months.

Note: When an enrollee contacts a plan directly for a transfer, the MLTC plan must verify that the prospective enrollee is eligible for a transfer by contacting NYMC prior to initiating the transfer. NYMC will inform the enrollee and the MLTCP Plan if they are not currently locked in.