Situation Report | August 16, 2021
The state Department of Health (DOH) posted guidance on its Managed Long Term Care (MLTC) plan ‘lock-in’ requirement and Frequently Asked Questions (FAQs).
Effective December 1, 2020, enrollment in an MLTC plan is 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 MLTC plan unless the enrollee can demonstrate a ‘Good Cause’ reason to leave the plan.
New enrollments into MLTC 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 MLTC plan for any reason.
For those who enrolled on or after December 1, 2020 and thus whose enrollment/transfer is subject to lock-in, New York Medicaid Choice (NYMC) will mail End of Lock-in Notices on September 4, 2021.
If the enrollee does not change plans within the 90-day grace period, the enrollee will be locked into the MLTC plan in which they are currently enrolled for the next nine months (lock-in period), unless the enrollee can demonstrate Good Cause. After the lock-in period ends, enrollees may transfer to another MLTC plan at any time for any reason. However, the lock-in period applies 90-days after each new enrollment into an MLTC plan.
An enrollee requesting to transfer from a MLTC plan to another MLTC plan during their lock-in period must contact NYMC to request a Good Cause determination. The criteria for good cause include:
- 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.
- The enrollee moves out of the plan’s service area.
- It is determined that the enrollee was enrolled into a plan without his/her consent.
- The current home care provider does not have a contract/agreement with the enrollee’s plan.
- The enrollee and the plan agree that a transfer to another MLTC plan is appropriate and would be in the best interest of the enrollee.
- DOH determines that the plan has failed to meet its contractual obligations with the Department and such failure directly impacted enrollees.
NYMC will be responsible for providing a notice, at least sixty days prior to the end of the enrollee’s lock-in period, that includes the date lock-in ends and the right to transfer to other MLTC plan(s). After the completion of the lock-in period, an enrollee may transfer to another MLTC plan at any time and for any reason without cause.