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WHAT CHANGE IS HAPPENING APRIL 1, 2021
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:
- they reach age 65, or
- after they collect Social Security Disability Insurance (SSDI) for 24 months.
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. This article explains what notices they will receive and their rights, and what will happen going forward.
COVERED IN THIS ARTICLE:
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UNTIL NOW – What happens when Medicaid recipients become enrolled in Medicare
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NEW – April 2021 – Default Enrollment of New Duals in Dual-SNP or MAP Plans
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Two types of Medicare Plans for Default Enrollment – Dual-SNPs and Medicaid Advantage Plus (MAP)
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60-Day Notice Sent by Medicaid Plan of Default Enrollment and the Right to Opt Out
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How you Access MEDICAID Services After default enrollment
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Which Plans Are Approved for Default Enrollment as of March 2021
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Member Right to Continuity of Care After Default Enrollment – and Changing Plans
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Issues Down the Road – After the Pandemic
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LAW, REGULATIONS and GUIDANCE AUTHORIZING DEFAULT ENROLLMENT
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Fact Sheets and for More Info — and Getting Help
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1. Background – Most Medicaid Recipients are in “Mainstream” Medicaid Managed Care Plans Before They are Enrolled In Medicare.
Nearly 5 million Medicaid recipients who do not have Medicare are enrolled in Medicaid Managed Care (MMC) health insurance plans, sometimes called “mainstream” plans.
What happens when Medicaid recipients become enrolled in Medicare is changing.
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:
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For Medicaid — they are disenrolled from their Medicaid managed care plan and then have “regular” or “fee-for-service” Medicaid.
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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.
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But – with some exceptions, once they have Medicare they must have Medicaid eligibility redetermined under the stricter non-MAGI rules. These redeterminations are not being done during the COVID-19 Public Health Emergency. See here about concerns once these redeterminations start again.
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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.
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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 MEDICARE PLANS for “default enrollment” – which one used depends on if individual receives Medicaid Long Term Services & Supports (LTSS) such as Personal Care or CDPAP from their mainstream managed care (MMC) plan.
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Medicare Dual-eligible Special Needs Plan (Dual-SNP or D-SNP) – If Not receiving Long Term Services & Supports (LTSS – Medicaid home care services such as personal care or CDPAP) from their MMC plan.
The only type of Medicare plan that new dual eligibles may be enrolled in by default is a Medicare Advantage plan called a “Dual Special Needs Plan” or “Dual-SNP” or D-SNP. These plans are solely designed for Medicare beneficiaries who have Medicaid. The individual would be assigned to an “aligned” Dual-SNP, meaning that it is operated by the same insurance company that operates their Medicaid managed care plan.
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Medicaid Advantage Plus plan (MAP) – if receiving Long Term Services & Supports (LTSS)(Medicaid personal care or CDPAP services from their MMC plan – these plans are a combination of a Dual-SNP with 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.
Default enrollment would be into the “aligned” MAP plan operated by the same insurance plan that operates their MMC plan. This is a big change from before, as these individuals 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 will be to a MAP plan that is a type of Medicare Advantage plan.
See lists of Medicaid Advantage Plus plans in New York City – 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 DOH MRT 2 website here:
C. HOW WILL THOSE DEFAULT ENROLLED in a DUAL-SNP ACCESS MEDICAID SERVICES?
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.
D. WHICH PLANS HAVE BEEN APPROVED in NYS FOR DEFAULT ENROLLMENT?
April 1, 2021 — 700 members of the following plans received notice in February 2021 that they would be default enrolled into the following plans for a 4/1/2021 effective date, in the counties listed below – also download this list updated as of 3/3/21 and also see MRC Flier Default Enrollment in New York State.
- MMC plans approved for default enrollment into a D-SNP (for those not receiving Long Term Services & Supports (LTSS) (Medicaid personal care or CPPAP care)(about 685 people)
- Metroplus MMC and HARP – will be enrolled into Metroplus Advantage Plan (HMO D-SNP) iin NYC ONLY
- Empire Health Plus D-SNP (a/k/a HealthPlus) MMC and HARP (NYC, Nassau Co. ) — the D-SNP is called Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
- MAP – MMC plans approved for default enrollment into a MAP plan (for those receiving Medicaid personal care or CDPAP services)(Only 16 of all of the 700 members being default enrolled received LTSS so will be default enrolled into these plans April 1st)
- Empire Health Plus MMC and HARP plans (NYC, Nassau) — enrolled into HealthPlus Medicaid Advantage Plus (MAP) – The MAP plan includes enrollment in Empire MediBlue HealthPlus Dual Advantage (HMO D-SNP)
- Healthfirst MMC and HARP plans (NYC, Nassau, Orange, Rockland, Suffolk, Westchester) – default enrolled into “Healthfirst CompleteCare” (HMO-SNP) MAP Plan
MAY 1, 2021 – 1300 members of the above plans and the following additional plans will be default enrolled into a Dual-SNP or a MAP plan (they should receive notices mailed 3/1/21)
JUNE 1, 2021 – 1500 members of the above plans and the following additional plans will be default enrolled into a Dual-SNP or a MAP plan (they should receive notices mailed 4/1/21)
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MMC plans approved for default enrollment into a D-SNP (for those not receiving Long Term Services & Supports (LTSS)
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UnitedHealthcare MMC/HARP – Default enroled into UnitedHealthCare Dual Complete (HMO D-SNP) -in MANY counties – see LIST HERE
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Fidelis MMC/HARP – Defauult enrolled into Fidelis Dual Advantage (HMO D-SNP) – In MANY COUNTIES – See LIST HERE
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MMC plans approved for default enrollment into a MAP plan (if receiving Long Term Services & Supports (LTSS)(28 of the 1300 members to be enrolled in May receive LTSS so will be enrolled in MAP plans)
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Fidelis MMC/HARP – Defauult enrolled into Fidelis Medicaid Advantage Plus (HMO D-SNP) – In NYC, Albany, Montgomery, Rensselaer, Schenectady – See LIST HERE
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To see how many members these plans have in each county, see the NYS managed care enrollment reports).
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.
E. Member Right to Continuity of Care After Default Enrollment into D-SNP or MAP Plan
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.
Changing coverage after being default enrolled
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 who enrolled into a D-SNP through default enrollment disenrolling from the D-SNP also will no longer allow the individual to remain enrolled in the MMC or HARP for their Medicaid coverage. They must switch to fee-for-service Medicaid through their local department of social services (HRA Medicaid in NYC).
Individuals enrolled in a MAP plan may also 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. Consumers receiving LTSS should consider their other coverage options, such as MLTC, MAP and PACE to avoid any interruptions with their LTSS. Anyone interested in disenrolling after being default enrolled should make sure that they choose coverage that better meets their needs.
The default enrollment process may work smoothly in 2021 because of special Medicaid rules apply during the COVID-19 Public Health Emergency. In the pandemic, new dual eligibles remain on Medicaid even if normally they many 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 Departments of Social Services 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.
Under “MAGI” Medicaid, there are higher income limits than apply for non-MAGI Medicaid. Also, 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.” 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. 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. But this cannot continue once the pandemic is over. Neither the federal or state government have explained how this can possibly work under the ordered time frames.
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.
- The rule was published in the Federal Register, Vol. 83, No. 73 (April 16, 2018) (pages 16440 et seq) and then amended in the Federal Register, Vol. 84, No. 73 (April 16, 2019) (pages 16495-16502)
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
H. FACT SHEETS AND FOR MORE INFORMATION
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 at bshyken@medicarerights.org or Jake McDonald at jmcdonald@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
Unfortunately, the NYS Dept. of Health has not posted information about this new initiative other than the two 60-day default notice templates on this page..