NYS Council Advocacy re: Default Enrollment

March 17, 2021

Below please find a slightly updated Issue Brief re:  the Default Enrollment Issue that we first sent to all NYS Council members on 3/5.  Today, I shared our Brief with our association colleagues so they could share it with their members if they choose to do so.

Also today I drafted a letter to State Medicaid Director Donna Frescatore requesting a meeting as soon as possible for advocates on this important topic.  Other associations are signing on to the letter and it will be going out momentarily.  Stand by for a copy of the letter.




Issue:  Default Enrollment of Dual Eligible Beneficiaries

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.  

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 continue to utilize Article 163 practitioners 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.