As Promised: Summary of Default Enrollment Issue

March 5, 2021

Thanks to all NYS Council members who attended yesterday’s weekly NYS Council Member Support and Public Policy call.  As promised please see below for a brief summary of the issue we discussed regarding Default Enrollment.  We are on it!  Stand by for more.


The following information brings together the great minds of Diane Novy, Senior Director, Managed Care at The Jewish Board, and our attorney Adam Falcone from Feldesman, Tucker, Leifer and Fidell, and reflects our understanding of this complicated issue as of 3/4.  Many thanks are due to Diane and Adam for their ongoing efforts to support our members!

Note:  We are still fact finding.  We will keep all members apprised of what we learn as our efforts to uncover additional details continues.  If you want to talk it over, please feel free to reach out to Lauri at (518) 461-8200.

Issue:  Default Enrollment of Dual Eligibles

Currently, when a Medicaid Managed Care member becomes eligible for Medicare – either because he/she turns 65 or becomes disabled – the Medicaid Managed Care Plan has to disenroll the member from its Medicaid plan and the individual goes back to Medicaid FFS for their Medicaid coverage.  The individual has the choice to go into Original Medicare or join a Medicare Advantage Plan for their Medicare coverage.  The care recipient is now considered “dually eligible”, Medicare Advantage is primary and Medicaid FFS is secondary.

Beginning April 1st, Medicaid Managed Care Plans will no longer have to disenroll the individual from their Medicaid plan and they will be able to default enroll the individual into their Medicare Advantage Plan. This means that an individual will have the same Plan for both his/her Medicare and Medicaid  coverage.  There will be no additional billing to Medicaid FFS for Medicare-covered services.

Medicaid Managed Care enrollees will receive a letter 60 days prior to the default enrollment giving them notice and the opportunity to opt-out.  

There are currently approximately 800,000 dually eligible individuals in NYS who are eligible to be default enrolled.  In addition, every month approximately 3,000 – 4,000 Medicaid Managed Care enrollees become eligible for Medicare.  The number of dually eligible individuals who could be default enrolled is growing every month.

Potential Issue:  It appears that some Plans may only reimburse providers up to whatever their contracted Medicare rate is for a Medicare-covered service, with no opportunity to balance bill the Plan or Medicaid FFS for the balance up to the APG government rate.

Status:  Plans are applying to the Office of Health Insurance Programs at DoH for permission to default enroll their members into one of their Medicare plans.  Each plan is approved individually.  The plans that are approved so far are as follows:

April 1st – MetroPlus, Empire HealthPlus and Healthfirst

May 1st – Fidelis and United Healthcare

The NYS Council will continue to share information as it becomes available.  We have reached out to DOH leads to discuss this critical issue and to request immediate state intervention that ensures full payment of APG rates and ensures provider viability and continued timely access to care for any New Yorker seeking our services.