Situation Report | May 23, 2022
The state Department of Health (DOH) has issued guidance on the disenrollment of Managed Long Term Care (MLTC) plan enrollees who have not received at least one community based long term services and supports (CBLTSS) within the previous calendar month.
The guidance is available here. Additional guidance for local departments of social services can be found here.
CBLTSS include:
- Nursing services in the home
- Therapies in the home
- Home health aide services
- Personal care services in the home
- Adult day health care o Private duty nursing, or
- Consumer Directed Personal Assistance Services (CDPAS)
With the initiation of this additional involuntary disenrollment reason, the plan informs the enrollee that they cannot remain in the MLTC plan if they are not receiving at least one of the CBLTSS services authorized in their plan of care within the previous calendar month.
If the enrollee agrees to voluntarily disenroll, the plan must follow contractual requirements for an enrollee-initiated disenrollment; if the enrollee does not agree to voluntarily disenroll, the plan must follow the requirements for involuntary disenrollment in this notice.
During the public health emergency, additional enrollee outreach prior to initiating this involuntary disenrollment reason is required. The plan must first identify the members that have not received CBLTSS in the previous calendar month and then conduct outreach to the enrollee, prior to initiating the involuntary disenrollment to discuss why services have not been received, when an involuntary disenrollment will be initiated, or when to restart service that would stop the involuntary disenrollment from proceeding.
The guidance lists examples of when plans must and when they would not initiate involuntary disenrollment due to not receiving CBLTSS.
Individuals who are disenrolled from their MLTC plan will continue to receive their Medicaid coverage through the Medicaid fee for service program or through a managed care plan if the individual is eligible and chooses to enroll in a new plan. Plans are reminded that an involuntary disenrollment does not eliminate the plan’s contractual obligations upon disenrollment, including referral to other plans, local districts, agencies and/or services such as Level I house-keeping services, Adult Protective Services, or non-Medicaid community services that may be available.
MLTC plans should continue to submit involuntary disenrollments for the following reasons which were previously resumed:
- Enrollee is no longer a member of the plan’s Medicare Advantage Program (Resumed effective October 1, 2021, and thereafter).
- Enrollee no longer resides in the plan’s service area. (Resumed effective October 1, 2021, and thereafter).
- Enrollee or family member engages in behavior that seriously impairs the Contractor’s ability to furnish services for reasons other than those resulting from the Enrollee’s special needs. (Resumed effective January 1, 2022, and thereafter).
- Enrollee has been absent from the plan’s service area for more than 30 consecutive days. (Resumed effective January 1, 2022, and thereafter).