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Beginning April 1, 2021, a change is coming for New York Medicaid recipients who newly become enrolled in Medicare and become "Dual Eligibles" - someone who has both Medicare and Medicaid. Every month about 3,000 - 4,000 Medicaid recipients in New York State become enrolled in Medicare. They become eligible for Medicare either because:
There are about 800,000 Dual Eligibles in New York State. The change beginning in April 2021 affects how Medicare and Medicaid services will be accessed by new Dual Eligibles. Members in the Medicaid managed care (MMC) and HARP plans listed here will be "default enrolled" into a Medicare Advantage plan for Dual Eligibles ("Dual-Special Needs Plan" or "Dual-SNP") unless they opt out, and will remain in their Mainstream Medicaid plan to provide secondary coverage. For these new dual eligibles, the Mainstream plan is now called an "IB-DUAL" plan for "Integrated benefits - Dual Eligible." This article explains what notices they will receive and their rights, and what will happen going forward.
UNTIL NOW - What happens when Medicaid recipients become enrolled in Medicare
NEW - April 2021 - Default Enrollment of New Duals in Dual-SNP or MAP Plans
Two types of Medicare Plans for Default Enrollment - Dual-SNPs and Medicaid Advantage Plus (MAP)
60-Day Notice Sent by Medicaid Plan of Default Enrollment and the Right to Opt Out
Which Plans Are Approved for Default Enrollment as of March 2021
Member Right to Continuity of Care After Default Enrollment - and Changing Plans
2023 Update - Issues in the Unwinding of the Pandemic
LAW, REGULATIONS and GUIDANCE AUTHORIZING DEFAULT ENROLLMENT
Nearly 5 million Medicaid recipients who do not have Medicare are enrolled in Medicaid Managed Care (MMC) health insurance plans, sometimes called "mainstream" plans.
These are the "Health Plans" or Individual & Family Plans on the NY Medicaid Choice website. See official brochures (English Spanish Russian).
Some of these plans are called "Health and Recovery Plans" (HARP), which are for individuals who have serious behavioral health impairments. Also see DOH site on HARP and ICAN HARP brochure (Spanish)(Russian)
Lists of MMC and HARP plans by region are here - scroll down to the heading "HEALTH PLAN LISTS ---Individual and family health plans"
Click here for HRA list of all Managed Care plans in NYC (Aug. 2022), These are the "Medicaid Managed Care plans" and HIV Special Needs Plans (SNP) listed on page one. (List also includes MAP and MLTC plans, discussed below.)
2. Until now, except for special rules during the pandemic, when a Medicaid recipient becomes enrolled in Medicare (at age 65 or based on disability), here is what happens:
For Medicaid -- they are disenrolled from their Medicaid managed care plan and then have "regular" or "fee-for-service" Medicaid.
Those Medicaid recipients who received Medicaid home care (personal care or Consumer-Directed Personal Assistance (CDPAP)) from their Medicaid managed care plan are transitioned to a Managed Long Term Care (MLTC) plan for their Medicaid home care services. See NYS DOH MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC. They have fee for service or regular Medicaid for services not covered by MLTC.
Normally, before the pandemic, once they became enrolled in Medicare their Medicaid was transferred from NYSOH to the local Medicaid agency to redetermine Medicaid eligibility under the stricter non-MAGI rules. These transfers to the local Medicaid agency and redeterminations were not done during the COVID-19 Public Health Emergency.
For Medicare, they may choose between Original Medicare or a Medicare Advantage Plan. If they choose Original Medicare, they must also enroll in a Medicare Part D plan. See this Toolkit produced by the Medicare RIghts Center, Coverage Options for Dually Eligible New Yorkers.
During the COVID-19 pandemic, Medicaid managed care members have remained in their Medicaid managed care plan once they became enrolled in Medicare. This is an unusual departure from the past, described above. See NYS Dept. of Health - April 2, 2020 GIS 20 MA/04 – Coronavirus (COVID-19) – Medicaid Eligibility Processes During Emergency Period (page 2). These individuals use their Medicare card as their new "primary" insurance and their Medicaid managed care plan as secondary coverage, which includes Medicaid home care services like personal care or CDPAP. So they are not transitioned to MLTC at this time.
3. April 2021 - NEW DEFAULT ENROLLMENT
Members in certain designated Medicaid Managed Care (MMC) and HARP plans will be "default enrolled" in a certain type of Medicare Advantage plan operated by the same insurance company that operates their Medicaid managed care plan.
The date of the enrollment in this "aligned" Medicare plan is the 1st day of the month in which their Medicare enrollment becomes effective. The individual will receive advance written notice of the right to opt out of this auto-enrollment and select alternate coverage. This right is described more below.
A. TWO TYPES OF "default enrollment" -
Default enrollment is always into a Medicare "Dual Special Needs Plan" (Dual-SNP or D-SNP). But which plan the consumer is assigned to depends on whether individual receives Medicaid Long Term Services & Supports (LTSS) such as Personal Care or CDPAP from their mainstream managed care (MMC) plan.
Not receiving Long Term Services & Supports (LTSS - Medicaid home care services such as personal care or CDPAP) from their MMC plan.
Consumer is assigned to an "aligned" Dual-SNP, meaning that it is operated by the same insurance company that operates their Medicaid managed care plan. The consumer remains in their original mainstream managed care plan, which is now considered an "IB-DUAL" plan or "Integrated Benefit-DUAL plan," providing secondary coverage to the primary Medicare D-SNP.
If receiving Long Term Services & Supports (LTSS) such as Medicaid personal care or CDPAP services from their MMC plan -
Consumer is assigned to a Dual-SNP "aligned" with their Mainstream plan, but also to an aligned Medicaid Advantage Plus (MAP) plan -- all operated by the same insurance company. The MAP plans are a combo of a Medicare HMO and an MLTC plan, plus they cover all Medicaid services not covered by MLTC plans. In other words, they cover ALL Medicare and Medicaid services. The member must only use providers in the plan's provider network for all Medicare and Medicaid services. SEE ICAN info on types of MLTC plans including MAP.
This is a big change from before, as Medicaid managed care members who first became enrolled in Medicare and had received home care from their mainstream plan were default enrolled into an MLTC plan, allowing them to keep their preferred Medicare coverage separately. MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC. Now default enrollment is to a MAP plan that is a type of Medicare Advantage plan.
See lists of New York City - All long term care plans - look for the Medicaid Advantage Plus plans. For other regions click here - scroll down to HEALTH PLAN LISTS for "Long Term Plans" by region
See Medicare RIghts Center fact sheets about MAP plans:
WARNING about Appeal rights in Medicaid Advantage Plus (MAP) Plans -
All MAP plans must use the new "FIDE" integrated appeal process, described here. This is a new appeal system, which was used in the now-closed FIDA program. FIDA had very few enrollees compared to MAP plans (6,000 in FIDA in its last year 2019 compared to 25,000 in MAP). So the integrated appeals system has had growing pains -- Advocates have seen long delays in scheduling these hearings and other problems. See more here.
One concern about MAP hearings is the State's position that appellants are not entitled to rights under the Varshavsky v. Perales class action. See this article about these important protections, including the right to a home hearing if an initial phone hearing is not decided fully favorably.
B. 60-Day Notice From Managed Care Plan Before Default Enrollment
Individuals subject to default enrollment should receive a notice from their Medicaid managed care or HARP plan at least 60 days before being default enrolled into the aligned D-SNP or Medicaid Advantage Plus plan (MAP). The Notice states that unless the member "opts out," they will be automatically enrolled in the aligned D-SNP on the first of the month of their initial Medicare enrollment. Plan notices should provide clear information comparing the new D-SNP and the beneficiary’s current MMC or HARP, including differences in benefits, premium costs, and cost-sharing.
Notices also include instructions to "opt out" of D-SNP enrollment and instead choose Original Medicare or a different Medicare Advantage Plan. A person can opt out of being default enrolled up until the calendar day prior to the enrollment effective date, which is also the individual’s Medicare effective date.
The NYS-approved templates for the 60-DAY DEFAULT ENROLLMENT NOTICES are modeled after the CMS model notices. The NYS notices can be downloaded from the NYS Dual Eligibles webpage under the IB-Dual dropdown:
Non-LTSS Default Enrollment Notice -Notice for those MMC Members who are NOT receiving Home Care or other Long Term Services & Supports from the MMC plan
LTSS Default Enrollment Notice --Notice for those who ARE receiving Home Care or other Long Term Services & Supports from the MMC plan such as personal care or CDPAP - Default enrolled into a MAP plan
Once default enrolled, the individual will be enrolled in the aligned Medicare D-SNP for primary coverage and prescription drug coverage, AND will remain enrolled in the Medicaid managed care (MMC) or HARP plan for secondary coverage.
If the individual received Medicaid home care or other LTSS from the MMC plan, they are default enrolled into a MAP plan. These plans provide ALL Medicaid services, not just those covered by MLTC plans These members must make sure to use only providers in the plan's network, whether the provider is providing a Medicare or Medicaid service.
List as of February 2023 is posted on the NYS Dual Eligibles webpage under the IB-Dual dropdown. Additional plans can be approved by CMS on a rolling basis. These plans and any newly approved plans will continue using default enrollment for each following month as their MMC and HARP members become Medicare eligible.
The column labeled "Product Type" indicates either:
"MMC/HARP" -- the IB-Dual Plans that do not provide personal care, CDPAP, or other Medicaid community-based long term care services.
"MAP" - Those who do receive these communitybased long term care services are default enrolled in a "MAP" plan.
The column labeled "H/PB" shows the aligned MEDICARE Dual-SNP plan's ID number. Caution: The name of the MEDICARE plans is not always the same as the name of the aligned MEDICAID IB-DUAL or MAP plan. For example, the listed Fidelis plans are aligned with these Wellcare Medicare DUAL-SNP plans:
Wellcare Fidelis Dual Plus (HMO D-SNP)(Plan ID H5599/003) - aligned with Fidelis MAP plan
Wellcare Fidelis Dual Access (HMO D-SNP)(Plan ID H5599/001) - aligned with Fidelis IB-Dual plan (MMC/HARP)
The Medicare Dual-SNP Plan IDs are on charts issued each year by CMS and posted here. (See SNP Landscape Source File for most recent year). NYLAG sometimes posts an extract of these national lists for New York State - see 2023 lists here . The 2023 Dual-SNP list is here.
See MRC Flier Default Enrollment in New York State.
Enrollees are entitled to 60 days of continuity of care to continue receiving services under an existing plan of care from their previous plans, including services from any providers with whom they are under an episode of care if the provider is not in the D-SNP network. This information should be included in the MMC or HARP member materials for duals remaining in the plan.
For those MMC members who are default enrolled into a Medicare Advantage Plus plan, the MAP plan must continue the the same type and amount of home care or other Long Term Services and Supports they individual received from the MMC plan previously. See MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC.
Individuals eligible for both Medicare and Medicaid have access to special enrollment periods (SEP) to change their Medicare coverage. (See Medicare Rights Center SEP Chart). Therefore, if someone wants to switch the plan in which they were default enrolled, they can use a SEP to switch to Original Medicare with a Part D plan or to switch to a different Medicare Advantage plan.
If an individual enrolled into a D-SNP through default enrollment, if they voluntarily disenroll from the D-SNP, they will no longer be allowed to remain enrolled in the IB-Dual plan (their MMC or HARP plan) for their Medicaid coverage. They will be disenrolled from the IB-Dual plan and will have fee-for-service Medicaid.
Individuals enrolled in a MAP plan may change plans to a different MAP or PACE plan or to an MLTC plan. The new "lock-in" rules that prohibit MLTC members from changing plans after three months of enrollment, except for good cause, do not apply to MAP plans. However, even though they MAY change plans does not mean they should. When a consumer voluntarily changes between MLTC, PACE, or MAP plans, they do not have transition rights, meaning the right to continue the same hours of home care and other services in the new plan. See more about transition rights here.
The default enrollment process started in 2021, during the COVID-19 Public Health Emergency. In the pandemic, new dual eligibles have remained on Medicaid even if normally they would no longer be eligible now that they have Medicare. In normal times, many may lose Medicaid when their Medicaid case is transferred from the NYSofHealth Exchange to the local Medicaid districts, which are charged with redetermining their eligibility under "non-MAGI" rules that apply to most people who are age 65+ or who have Medicare. See Medicare Rights Center toolkit for Moving from the Marketplace to Medicare in NYS. (registration required) and See GIS 16 MA/004 -Referrals from NY State of Health to Local DSS for Individuals who Turn Age 65 and Instructions for Referrals for Essential Plan Consumers (PDF); 2014 LCM-02 - Medicaid Recipients Transferred at Renewal from New York State of Health to Local Departments of Social Services
Under "MAGI" Medicaid used for those without Medicare, there is no resource limit. In Non-MAGI Medicaid, there are strict resource limits. Fortunately, in 2023 MAGI and non-MAGI Medicaid have the same income limits at 138% FPL. However, Workers Comp and Veterans' benefits do not count as income for MAGI Medicaid, but do for non-MAGI Medicaid. For this reason, many new dual eligibles lose Medicaid, or if they keep Medicaid, are determined to have a high "spend-down" when they get Medicare and Medicaid transitions to non-MAGI Medicaid. It generally takes many months for these eligibility determinations to be made by the local Medicaid agencies.
Yet the regulations about Default Enrollment require the mainstream Managed Care plan to send notice to its members 60 days before they become eligible for Medicare, telling them they will be default enrolled in a D-SNP plan. Those D-SNP plans may only enroll those with Full Medicaid, not those with a spend-down. But there hasn't been enough time in that short period to determine WHO is eligible for Full Medicaid.
In the pandemic, none of these complex transitions are required; Congress has said that no state may cut off Medicaid for anyone who was eligible or becomes eligible during the pandemic. Therefore, the NYS Dept. of Health appropriately has said that all new dual eligibles will remain in their Medicaid managed care plans. GIS 20 MA/04.
May 2023 Update -- Now that the Public Health Emergency is unwinding, these challenges will emerge. DOH has said that those mainstream members who are new to Medicare will have their Medicaid renewed on NYSOH rather than transferred to the local Medicaid office. However, unless the member is already in an IB-Dual or MAP plan, or eligible to enroll in such plans, they will be disenrolled from the mainstream plan once they have Medicare. Once disenrolled from the mainstream plan, they can no longer be "default enrolled" into a Dual-SNP, IB-Dual plan. Only those receiving Medicaid home care services from their mainstream plans will likely be default enrolled in either a MAP or MLTC plan. Neither the federal or state government have explained how default enrollment can possibly work under the ordered time frames.
For NYC, see this HRA Alert 6/30/23 which provides for the Resumption of Medicare Requirements - Disenrollment from Mainstream Managed Care will resume for clients in receipt of Medicare. Individuals who became eligible to apply for Medicare during the Covid emergency will be required to comply with the Medicare application requirement.
G. LAW, REGULATIONS and GUIDANCE AUTHORIZING DEFAULT ENROLLMENT
42 CFR §§ 422.66 (c) and 422.68 (d) (amended in 2018 to allow Default Enrollment of some dual eligibles into D-SNPs, with certain protections.
See also CMS Medicare Managed Care Manual- Chapter 2 § 40.1.4
CMS published Default Enrollment FAQ's in February 2019 and this Fact Sheet in 2019.
This process is a more limited version of seamless conversion, which CMS placed a moratorium on in 2016.
NYS DOH Stakeholder Meetings about Future of Integrated Care - Presentations
Medicare Rights Center provided much of the information in this article. You can register for newsletters here. See Medicare RIghts Center fact sheets:
If you have any questions, please email Beth Shyken-Rothbart at bshyken@medicarerights.org .
Those who received Personal Care or CDPAP services from the Medicaid Managed Care or HARP plan and become enrolled in Medicare may call the Independent Consumer Advocacy Network (ICAN) for counseling on their rights and options. 1-844-614-8800 or ican@cssny.org