Default Enrollment Summary

April 5, 2021

On March 5, the NYS Council sent a communication to our members regarding the default enrollment issue that will (over time) impact an increasing number of the individuals we serve who are turning 65 or who have become legally disabled. Since then, we have held a number of members only meetings designed to educate key staff and CEOs regarding this important issue that could potentially result in a significant loss of revenue for our member agencies.

The NYS Council has spearheaded a statewide advocacy effort designed to compel state leaders to require insurers to pay the APG government rate in all instances where a beneficiary has been default enrolled.

On April 14 the Medicare Rights Center in NYC will be hosting an important training for advocates, entitlement coordinators and others with responsibility for informing and assisting the individuals we serve regarding the default enrollment process.

Here’s a link to register for the upcoming 4/14 training from the Medicare Rights Center:

Attached and below please find some of the information we have sent to our members over the last month.


NYS Council Issue Brief:  Default Enrollment of Dual Eligibles

(Revised and sent to members on 3/17; Original NYS Council Brief sent 3/5) 

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”, Original Medicare or 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.

Potential Issue:  It is not clear whether Agencies will be able to have Article 163 providers continue to provide services to clients that have been default enrolled. 

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 D-SNP, Empire HealthPlus D-SNP and MAP and Healthfirst MAP

May 1st – Fidelis D-SNP and MAP and United Healthcare D-SNP

On February 1st, 700 notices went to individuals who would become eligible for Medicare on April 1st.  On March 1st, 1300 notices went to individuals who would become eligible for Medicare on May 1st.  These numbers will continue to grow as more Plans become eligible to default enroll.