Enrollment in a Medicaid Managed Long Term Care (MLTC) plan is mandatory for most adult Dual Eligibles (people who have Medicare or Medicaid), who need Medicaid personal care (PCS) or Consumer Directed Personal Assistance Program (CDPAP) services, with some exceptions - See also DOH list of exclusions and exemptions here.
However, an MLTC plan MAY -- and in some cases MUST -- involuntarily disenroll a member from the plan for certain reasons These involuntary disenrollments were paused during the COVID pandemic, except for those based on a long-term nursing home stay. NYS DOH reinstated some involuntarily disenrollments with various directives in 2022. Since then, the State Dept. of Health has revised the guidance on involuntary disenollments several times.
Most recently, on April 7, 2026 DOH issued MLTC Policy 26.01: Managed Long Term Care Involuntary Disenrollment that will be effective June 1, 2026.
MLTC Policy 26.01 adds new grounds for disenrollment if an enrolleee who does not have "Legacy Status" no longer meets the Minimum ADL Thresholds that went into effect Sept. 1, 2025. See this article and the following state guidance:
- MLTC Policy 25.04: Minimum Needs Requirement Update to the Eligibility Requirements for Managed Long Term Care Enrollment - 6.30.2025
This article has been updated to incorporate and track the organization of MLTC Policy 26.01 that went into effect June 1, 2026.
DISENROLLMENT PROCEDURE -- TWO NOTICES should be received by the MEMBER BEFORE DISENROLLMENT - The plan -- and then NY Medicaid Choice -- each send the member a notice prior to the disenrollment. The second notice from NY Medicaid Choice has Fair Hearing and AId Continuing rights. See more about the notices and procedures below. These procedures include the right to STOP the disenrollment if the ground for the disenrollment is corrected before the effective date of the disenrollment.
DEFINITIONS. MLTC Policy 26.01 at pp. 1-2 has a section on definitions of some terms, discussed below, including :
- Active Discharge Plan,
- Designee
- MLTC Mandatory individuals and MLTC Voluntary individuals.
- Involuntary Disenrollment: a disenrollment initiated by the Plan without agreement from the Enrollee.
- Voluntary Disenrollment: A verbal or written disenrollment requested by the Enrollee at any time for any reason.
MLTC Policy 26.01 has three Tables (Table 1 p. 15, Table 2 at p. 25, Table 3 at 28 of PDF), that give the "disenrolment outcomes," which specify for each of the involuntarily disenrollment grounds, what happens after disenrollment. Either the member is transitioned to another MLTC plan or to Fee for Service (FFS). FFS presumably means the local county Dept. of Social Services will authorize PCS/CDPAP, but this is not clear.
Plan members should have Transition Rights if involuntarily disenrolled from a plan for most of the reasons discussed below. MLTC Policy 26.01 at page 32 of PDF describes plans' Transition of Care Responsibilities:
...Prior to the effective date of the disenrollment, the MLTC Plan must work with the Enrollee and other individuals designated by the Enrollee, to make all necessary referrals to the LDSS, another Plan, other community resources, health care providers, alternative service providers and/or programs to facilitate a transition of care for services identified in the Enrollee’s PCSP.
Note: Individuals with MLTC Plan Legacy status, who are transferred to another MLTC plan as result of an involuntary disenrollment, will maintain their MLTC Plan Legacy status. ..
This guidance fails to state specifically that the member has the right to continue the same plan of care (same hours of home care) after they are disenrolled, whether through a different MLTC plan or through FFS. However, under federal regulations, the State agency must arrange for Medicaid services to be provided without delay "for any Medicaid enrollee who is disenrolled from [a plan]... for any reason other than ineligibility for Medicaid. 42 C.F.R. § 438.62(b). This means that the State must ensure continuity of services after disenrollment.
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If you VOLUNTARILY disenroll from one plan and switch to another plan, you do not have Transition rights in the new plan. WARNING: for some involuntary grounds for disenrollment, the enrollee will be asked if they want to VOLUNTARILY disenroll - if they say YES they will have no transition rights. See, e.g. being absent from county for 30 days and See more here about when you do NOT have transition rights. MLTC Policy 26.01at page 3 of PDF states, "In no instance is the Plan allowed to pressure or coerce the Enrollee to consent to a disenrollment. When the Enrollee no longer meets the conditions for continued enrollment and the Enrollee does not request a voluntary disenrollment, the Plan must initiate the involuntary disenrollment process.
However, watch out for pressure to "voluntarily" disenroll.
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Notably missing from the section of MLTC Policy 26.01 about Transition Rights is a specific requirement that was in DOH MLTC Policy 24.02 that stated, "If the member is auto-assigned to a MLTCP plan, the receiving plan should continue the current PCSP until a new PCSP is completed. within fifteen (15) calendar days of the enrollment. This new PCSP should be based on the existing New York Independent Assessor Program CHA, if current. If the Enrollee is due for reassessment, a new CHA should be conducted." (emphasis added).MLTC Policy 24.02. Even that language, now omitted, failed to require the new plan or LDSS to continue the same plan of care for a certain amount of time -- it is only required until they complete a new assessment.
Also, the policy fails to require that if the new plan of care REDUCES PCS/CDPAP services, they must provide advance written notice with appeal rights, and may do so only for reasons consistent with MLTC Policy 16.06, such as a change in medical condition or if a mistake was made in the prior authorization. Under a change in a state regulation effective Nov. 8, 2021, MLTC plans may try to reduce your hours after the Transition Period if the Plan determines that the previous plan gave you “more services than are medically necessary,” based on "a clinical rationale that shows review of the client’s specific clinical data and medical condition." 18 NYCRR Sec. 505.14(b)(4)(viii)(c)(3)(vii), 505.28(i)(4)(iii)(h).
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WARNING RE LOSING "PLAN LEGACY STATUS." If the consumer is disenrolled from the MLTC plan and more than 30 days passes before they enroll in the same or different plan, they lose Plan Legacy status they had if they were enrolled in the MLTC plan before Sept. 1, 2025. This means that if they try to re-enroll in an MLTC plan, they would be required to meet the new 2-or-3 ADL minimum standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan, a mainstream managed care plan or from the local DSS. A lapse iof 30-days -- or any amount -- in receipt of that service does NOT cause the loss of Service Legacy Status. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC). DOH guidance has not yet made that clear.
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When a consumer is transfered to the Local DSS, transition procedures are especially weak. NYC HRA, for example, has no procedure for how an MLTC plan that disenrolls a member can convey the PCSP and for HRA to implement it. Also, if the plan of care includes services outside the purview of the LDSS, such as adult day care, private duty nursing, or medical supplies, the LDSS cannot implement those. The guidance is silent on how the consumer can continue receiving those services.
These grounds are in Part A of MLTC Policy 26.01.
Most MLTC plans only serve certain counties. If you move to a county that is not served by your MLTC, MAP, or PACE plan, you must notify your local Medicaid office (HRA in NYC) of the change of address so that your Medicaid administration transfers to your new county. See more about that here. You will then be disenrolled from your old MLTC, MAP or PACE plan. If you move to a county covered by your MLTC or MAP plan, your enrollment should be transferred to the new county (re-linked). See Policy 23.02 FAQs - which state that the plan should contact the local Medicaid office if the enrollment did not transfer.
Disenrollment procedures- under MLTC Policy 26.01 (replacing MLTC Policy 24.02 and MLTC Policy 23.03 and prior guidance)
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The plan must immediately notify the HRA/LDSS of the new residential address when the plan has verified that an Enrollee has moved out the plan's service area.
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Within five (5) business days of notification that the Enrollee no longer resides in the plan's service area, the plan must submit the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC with the new address, and include dates of when the plan notified HRA/LDSS of the new address.
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Note: The enrollee's residential address must be updated by the HRA/LDSS in order for the disenrollment/ transfer to be processed by NYMC. If the address has not been updated, the plan must resubmit the involuntary disenrollment to NYMC after the address is updated.
What Happens after Disenrollment - How Does Person Continue Receiving Home Care? These outcomes are in MLTC Policy 26.01 Table 1 (p. 14 of PDF).
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MANDATORY MLTC ENROLLEES (adults age 21+ who have Medicaid and Medicare, who are not in the OPWDD waiver and are not in home hospice, who meet the new ADL requirements or have legacy status) --
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will be notified by NYMC that they may transfer to another MLTC plan.
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Eligible enrollees who do not choose a plan will be auto-assigned to a MLTC plan in their service area.
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NYLAG COMMENT: This policy is an improvement over the now superseded GIS-21-MA/17 that merely referred them to their local medicaid office and did not auto-assign them to an MLTC plan.
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VOLUNTARY MLTC ENROLLEES (age 18-21.or age 18+ and do not have Medicare - and meet the new ADL requirements or have legacy status, plus need a nursing home level of care) - may enroll in a new MLTC plan but will not be auto-assigned if they do not choose one. If they do not choose one, they will have Fee for service Medicaid.
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Those not eligible for MLTC -- MLTC Policy 26.01 does not specifically address this group, possibly because other grounds for disenrollment would apply to them. Note that enrollees who became enrolled in home hospice while they were in the previous MLTC plan are NOT excluded from enrolling in a different MLTC plan when they move to a different county. See MLTC Policy 13.18(a): Update MLTC Guidance on Hospice Coverage, which states in part:
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"There are certain circumstances in which it would be appropriate for an MLTC enrollee receiving hospice benefits to transfer to another MLTC plan. Effective with the release of this policy, MLTC enrollees in receipt of hospice benefits will have the option to transfer to another MLTC plan and continue to retain access to hospice on a fee for service basis. Such enrollment will no longer be prohibited."
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WARNING re LEGACY STATUS: If the consumer is disenrolled from the MLTC plan for more than 30 days, they lose Service Legacy status if they had been enrolled in the MLTC plan since before Sept. 1, 2025. This means that if they try to re-enroll in an MLTC plan, they would be required to meet the new 2-or-3 ADL standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan or a mainstream managed care plan or from the local DSS. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC).
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TIP: Transferring Medicaid and MLTC services to a different county can be a complicated process. The procedure in this guidance should avoid disruption in coverage -- 2008 LCM-01 - Continued Medicaid Eligibility for Recipients Who Change Residency (Luberto v. Daines). It is helpful that MLTC Policy 26.01 like the earlier MLTC Policy 24.02 and MLTC Policy 23.03 require the plan to notify the local district of the change in address.
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NYLAG recommends that DOH issue further guidance to local districts that they must follow through with the Luberto process to transfer the case to the new county.
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In NYC, to notify HRA of a move to a different county, fax a signed MAP- 751k form (3/15/21) to 1-917-639-0837 or email by encrypted email to undercareproviderrelations@hra.nyc.gov. The form is posted in multiple languages on HRA site here. Be sure to mention on the form that requesting LUBERTO transfer for individual enrolled in an MLTC, MAP or PACE plan, and the name of the plan. Also call NY Medicaid Choice at 1-888-401-6582 about transferring to an MLTC plan in the new county.
Disenrollments on this ground began Jan. 1, 2022,. See GIS 21 MA/24 and amended list of MAP plans that may initiate disenrollment on this ground -- Attachment I of GIS 22 MA/03 (May 16, 2022) and Letter to Health Plan administrators 11/29/21 Resumption of Two Additional MLTC Involuntary Disenrollment Reasons - (Web) (PDF) - 11.29.2021.
Effective Nov. 1, 2023, the procedures have changed, and did not materially change in MLTC Policy 26.01, which replaced MLTC Policy 24.02, which replaced MLTC Policy 23.03,
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Within 5 days after the the plan is informed that the Enrollee has been absent from the plan's service area for 30 consecutive days, the plan is required to make five (5) reasonable attempts to contact the Enrollee and/or their Designee. The plan must document the status of each attempt in the monthly Care Management record. The record should reflect any services received during this period.
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Reasonable Attempts to Contact the Enrollee and/or their designee must include five (5) outreach attempts on five different calendar days at different times of day, and must include one visit to the Enrollee's home, which may utilize existing providers (ie the home care agency).
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"Designee" is defined as "one or more adult individual(s) appointed by a self-directing Enrollee to receive information or communicate on behalf of the Enrollee. With respect to a non-self-directing Enrollee, a "designee" means the Enrollee’s authorized representative, who may be a parent or legal guardian, or power of attorney, and is willing and able to act on the Enrollee’s behalf. MLTC Policy 26.01 (p. 2 of PDF).
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Upon a successful contact with the Enrollee and/or their designee, the plan must inform the Enrollee and/or their designee of the requirement to be in the service area to maintain their membership with the plan. If the Enrollee discloses that they will be out of the service area for more than thirty (30) consecutive days, the plan must initiate the involuntary disenrollment process.
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After making the 5 contact attempts, if the plan is unable to reach the enrollee or representative, or if the Enrollee or their designee confirms that they are not returning within 30 days, the plan must initiate the involuntary disenrollment process with NYMC. The referral to NYMC must include the Managed Long Term Care Involuntary Disenrollment Request Form along with:
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document at least five (5) attempts to contact the Enrollee or their Medicaid authorized representative (see above);
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a written statement from the Enrollee's Home Care Agency, or other pertinent evidence, that an effort was made to contact the Enrollee including the date of the last contact with the Enrollee.
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STOPPING THE DISENROLLMENT -- Consumer may remain in the plan if they return to the service area, and call the plan prior to the disenrollment effective date. "The MLTC plan must act to facilitate the continuation of the enrollment by working with NYMC and the Enrollee." MLTC Policy 26.01 Section titled. "Enrollee Contacts the Plan or NYMC to Continue MLTC Enrollment" (p. 30 of PDF).
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NYLAG comment: If the disenrollment has been postponed because the consumer requested a Fair Hearing to appeal the NY Medicaid Choice disenrollment notice, and they inform the plan that they have returned to the service area, NYLAG contends that the disenrollment should be canceled under this section of the guidance.
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What happens after disenrollment - NYMC will send a disenrollment confirmation notice that will tell Enrollee to contact NYMC to discuss enrollment options and will disenroll them to FFS through the local DSS. NYLAG COMMENT - the 2026 guidance, like that in 2023 and 2024, does not say the DSS must continue the same plan of care, unlike prior guidance GIS 21 MA/24.
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WARNING re LEGACY STATUS: If the consumer is disenrolled from the MLTC plan for more than 30 days, they lose Service Legacy status if they had been enrolled in the MLTC plan since before Sept. 1, 2025. This means that if they try to re-enroll in an MLTC plan, they would be required to meet the new 2-or-3 ADL standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan or a mainstream managed care plan or from the local DSS. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC).
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Also, consumers were allowed to pause home care during COVID, if they went to stay with family or wanted to limit exposure to home care aides. See COVID-19 Guidance for Voluntary Plan of Care Schedule Change issued April 23, 2020 (Web) (PDF). Those consumers should have been given a chance to reinstate services before they are disenrolled on this ground. See NYLAG Know Your Rights Fact Sheet for MLTC Members about this guidance allowing voluntary pause of services.
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Whether the enrollee must be disenrolled from the plan on this basis depends on whether the plan is a "partial capitation" MLTC plan or a "full capitation" plan that includes Medicare services, including Medicaid Advantage Plus (MAP) and PACE plans.
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For all types of plans, an active discharge plan from a residential program or hospital is "a comprehensive plan for an individual to discharge from a residential program or hospital and return to the community. The discharge plan documents current goals and specifies the arrangements required for a safe return to the community." MLTC Policy 26.01 pp. 1-2 of PDF).
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MLTC "partial capitation" plans only - if Enrollee has been hospitalized for forty-five consecutive (45) days or longer and does not have an active discharge plan - MLTC plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days from the date the plan knows 45 days has elapsed. The MLTC plans must have up-to-date case management notes while the Enrollee is hospitalized and ongoing status of the Enrollee during the hospitalization.
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MLTCP plans must submit the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC and include the name of the hospital, the date of the admission, and that Enrollee does not have a discharge plan
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What happens after disenrolled - NYMC will send a disenrollment confirmation notice that indicates that the Enrollee should contact NYMC to discuss enrollment options that may be available upon discharge from the hospital.
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For all MLTC plan types including MLTC, MAP and PACE - 45 days in a residential program run by OMH, OPWDD, or OASAS -- Per MLTC Policy 24.02, like MLTC Policy 23.03, the plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days from the date the plan knows the Enrollee enters a residential program with the Office of Mental Health (OMH), Office for People with Developmental Disabilities - see here.(OPWDD), Office of Addiction Services and Supports (OASAS) or an OMH state operated psychiatric center that is not a MLTC plan covered benefit for forty-five (45) consecutive days or longer.
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Plans must submit the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC and include the type and name of the program and date of admission
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What happens after disenrolled - NYMC will send a disenrollment confirmation notice that indicates that the Enrollee should contact NYMC to discuss enrollment options that may be available upon discharge from the residential program. According to MLTC Policy 26.01 Table 1, the sole option is Medicaid FFS.
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STOPPING THE DISENROLLMENT -- The enrollment in the plan can continue if the Enrollee contacts the plan or NY Medicaid Choice to say they have returned to a community setting or has an active discharge plan with an expected discharge date, but this must be prior to or near the disenrollment effective date. The plan must document the active discharge plan or the return to the community setting as an occurrence in the monthly Care Management record. MLTC Policy 26.01 pp. 30-31 of PDF).. If the consumer's call is to NY Medicaid Choice, it will do a 3-way call with the plan. "In the instance where NYMC has processed the disenrollment, prior to the disenrollment effective date, the Plan must submit an Upload file (U-file) to NYMC to reinstate the enrollment." MLTC Policy 26.01 p. 31 of PDF)..
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WARNING re LEGACY STATUS: If the consumer is disenrolled from the MLTC plan for more than 30 days, they lose Service Legacy status if they had been enrolled in the MLTC plan since before Sept. 1, 2025. This means that if they try to re-enroll in an MLTC plan, they would be required to meet the new 2-or-3 ADL standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan or a mainstream managed care plan or from the local DSS. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC).
BACKGROUND: MAP and PACE plans combine in one all-in-one plan a D-SNP (DUAL-SNP) Medicare Advantage Special Needs Plan for Dual Eligibles, plus an MLTC plan, plus all other Medicaid services not covered by MLTC. See more about MAP plans here.
To be enrolled in a MAP or PACE plan, you must be enrolled in the specific Medicare D-SNP plan that is "aligned" with your MAP or PACE plan. An "aligned" Medicare plan is one operated by the same insurance company that operates your MAP plan, and must be the specific plan that is aligned with the MAP or PACE plan. See 2026 list here (see Column R for Affiliated MAP plan in each county).
- See also DOH article about Integrated Plans for Dual Eligible New Yorkers - click on Dropdown for IB-DUAL and then scroll down to the table of plans. Plans with "MAP" in the third column labeled PRODUCT TYPE are the aligned D-SNPs for MAP plans. Beware to look at the plan ID numbers because plan names sound alike.
How do people enroll in a MAP with a D-SNP -- or a PACE plan?
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Voluntary enrollment -- Some people choose to enroll in a MAP or PACE plan instead of an MLTC plan. Some dual eligibles chosoe to enroll in a Medicare D-SNP because it can reduce some out of pocket costs, and offers an over-the-counter card, even if they do not need home care; these individuals just join the D-SNP but do not enroll in a MAP or PACE plan..
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Default Enrollment (with right to opt out)-- Since April 2021, some Medicaid recipients who had Medicaid on the NYSofHealth, have been "default enrolled" into Medicare Advantage Dual D-SNP plans when they first became enrolled in Medicare, at age 65 or based on disability. If they received personal care or CDPAP from their mainstream Medicaid Managed care plan, and if they were default enrolled into a D-SNP plan that was "aligned" with a MAP plan, they they were also default enrolled into the MAP plan. "Aligned" plans are specific plans operated by the same insurance company that operate as a component of a MAP plan.
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See more about default enrollment in this article - which also explains default enrollment into an IB-Dual plan (Integrated Benefits-Dual) plan for people who do not receive personal care or CDPAP from their mainstream health plan.
WARNING: Just switching to a Medicare Part D plan or switching to a different D-SNP or Medicare Advantage Plan could cause home care to STOP - because it would cause the individual to be disenrolled from their MAP or PACE plan.
Many MAP and PACE members do not realize that if they enroll in a Part D drug plan, or switch to a different D-SNP or Medicare Advantage plan, they will be disenrolled from the D-SNP or PACE Medicare plan that is aligned with their MAP or PACE plan. This will then result in being disenrolled from their MAP or PACE plan. Many MAP or PACE members don't realize that just joining a Part D plan or switching Medicare Advantage plans could cause them to lose their home care! They don't realize that their home care is provided by the MAP or PACE plan, which requires enrollment in the "aligned" D-SNP or Medicare PACE plan.
- BEWARE OF MEDICARE PLAN MARKETING!! Unfortunately, many Part D and Medicare Advantage plans do heavy marketing to attract new members. A promise of an Over the Counter card can lure a MAP or PACE member to switch plans -- not realizing this will lead to LOSS OF THEIR HOME CARE.
Steps of disenrollment from MAP or PACE plan - under MLTC Policy 26.01 pp. 7-10, 17 and 31 of PDF)..
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The plan is required to initiate the involuntary disenrollment process within 5 business days of being informed that the member is no longer in the aligned Medicare Advantage Dual Eligible Special Needs Plan [MA D-SNP].
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The plan must make five (5) reasonable attempts at different times of day over five (5) calendar days to contact the Enrollee to inform them that the plan received notification that the Enrollee was no longer enrolled in the aligned D-SNP. One of the 5 outreach attempts must be at the enrollee's home. Upon a successful contact with the Enrollee and/or their designee, the plan must inform the Enrollee of their disenrollment from the aligned MA D-SNP.
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If upon contact int the Enrollee, the Enrollee indicates they would like to remain enrolled in the MAP plan, the plan would assist the Enrollee in reinstating the enrollment in the aligned MA D-SNP to remain enrolled in the aligned MAP plan. The MAP plan would not submit an involuntary disenrollment to NYMC in this instance.
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If upon contact the Enrollee does not want to reinstate the enrollment in the aligned D-SNP, OR if the plan is unable to reach the ENrollee after the 5 attempts, the plan is required to submit the Involuntary Disenrollment Request Form to NYMC.
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STOPPING THE DISENROLLMENT --The enrollment in currrent MAP or PACE plan can continue if, prior to the disenrollment effective date, the Enrollee re-enrolls in the aligned Medicare plan. P. 31 of MLTC POlicy 26.01 PDF)..
What Happens after Disenrollment from the MAP or PACE Plan - How Does Person Continue Receiving Home Care? Under MLTC Policy 26.01 p. 17 of PDF)..
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MANDATORY MLTC ENROLLEES (adults age 21+ who have Medicaid and Medicare and who are not in the OPWDD waiver and are not in home hospice) --
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If disenrollment is involuntary under the policy described above, mandatory enrollees will be notified by NYMC that they may transfer to another MLTC plan.
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Eligible enrollees who do not choose a plan will be auto-assigned to a MLTC plan in their service area.
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NYLAG COMMENT: This policy is an improvement over the now superseded (GIS 21 MA/17) that merely referred them to their local medicaid office and did not auto-assign them to an MLTC plan.
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VOLUNTARY OR EXEMPT ENROLLEES (Adults age 21+ who do not have Medicare, persons age 18-21) -
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If they do not select a new MLTC plan, they will receive a disenrollment confirmation notice that will tell them to contact NYMC to discuss enrollment options that may be available to them.
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NYLAG COMMENT: They will not be auto-assigned to an MLTC plan, unlike mandatory MLTC enrollees. Unfortunately, MLTC Policy 26.01 unlike previous guidance that it supersedes (GIS 21 MA/17) does not say that the local Medicaid office (Dept. of Social Services or "LDSS") should continue the same Plan of Care that the MAP plan provided until the next reassessment. See more on Transition Rights here.
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WARNING re LEGACY STATUS: If the consumer is disenrolled from any MLTC, MAP or PACE plan for more than 30 days, they lose Service Legacy status if they had been enrolled in the MLTC plan since before Sept. 1, 2025. This means that if they try to re-enroll in an MLTC plan, they would be required to meet the new 2-or-3 ADL standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan or a mainstream managed care plan or from the local DSS. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC).
This ground for disenrollment became effective on Nov. 1, 2024 under MLTC Policy 24.02, updated by MLTC Policy 26.01 pp. 9-10, 18 and 31 of PDF). This reason is applicable to all MLTC plan types - MLTC, MAP and PACE.
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"The Plan is required to initiate the involuntary disenrollment process when the Enrollee has either refused to or was unable to be reached to complete the required Community Health Assessment (CHA). The CHA is the nurse's assessment that must be completed annually and after certain changes in status. The Plan must initiate the involuntary disenrollment process within five (5) business days after required CHA due date.
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Before sending the Intent to Disenroll letter, ... the Plan is required to make reasonable attempts to contact the Enrollee and/or their designee, which must include at least ten (10) outreach attempts over the course of thirty (30) calendar days to schedule and complete the required assessment. The outreach attempts must be conducted on different days of the week and different times of day. There must be at least two (2) visits to the Enrollee's home which may include the utilization of existing providers.
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NYLAG comment - MLTC Policy 26.01 removes specific requirements of DOH MLTC Policy 24.02, which it replaces, requiring the plan to do outreach to the authorized or designated representative, if any in at least five (5) of the ten (10) outreach attempts.
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If upon these outreach attempts "the Enrollee would like to continue their enrollment with the Plan, the Plan must assist the Enrollee in scheduling the
CHA. The Plan should ensure that the CHA is completed within 14 days of the required CHA due date. The Plan should not submit an involuntary disenrollment to NYMC in this instance." p. 9 of PDF..
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STOPPING THE DISENROLLMENT - If the enrollee has contacted the plan or NY Medicaid Choice and has "completed the CHA within 30 days of the original Intent to Disenroll Letter date" - the disenrollment should be canceled. MLTC Policy 26.01 p 18 of PDF)..
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What Happens After Disenrollment - per MLTC Policy 26.01 p 18 of PDF). - the consumer is disenrolled to FFS. The guidance does not specify how the consumer could receive CDPAP or personal care services.
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See notice to consumer, fair hearing and aid continuing rights here)
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WARNING re LEGACY STATUS: If the consumer is disenrolled from any MLTC, MAP or PACE plan for more than 30 days, they lose Service Legacy status if they had been enrolled in the MLTC plan since before Sept. 1, 2025. This means that if they try to re-enroll in an MLTC plan, they would be required to meet the new 2-or-3 ADL standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan or a mainstream managed care plan or from the local DSS. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC).
This reason is applicable to all MLTC plan types. - MAP, PACE and MLTC. The plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of confirming that the Enrollee has not received any CBLTSS within the previous calendar month. The seven services are not listed in MLTC Policy 26.01 but were listed in MLTC Policy 24.02 as:
- Nursing services in the home (but if this is the only CBLTSS service, then should not be disenrolled if the scheduled frequency results in no nursing service visit in the previous month -see MLTC Policy 26.01 p. 11 of PDF,
- Physical, Speech or Occupational Therapies in the home
- Home health aide services
- Personal care services in the home (Level 2)(but if did not receive this service because the plan could not find an in-network provider, it is not a ground for disenrollment. MLTC Policy 26.01 p. 11 of PDF),
- Adult day health care
- Private duty nursing
- Consumer Directed Personal Assistance Services (CDPAP)
MLTC Policy 26.01 pp. 10-12, 18 of PDF. The plan must first make five (5) outreach attempts to the enrollee and/or their designee on different days of the week and different times of day. One of these attempts must be at the member's home. "If the Enrollee would like to reinstate their PCSP and resume services with the Plan, the Plan must resume their services. The Plan must confirm that the Enrollee is compliant with resuming services outlined in the PCSP within 7 days from the agreement to reinstate services."
What happens after disenrollment -- the Enrollee will be disenrolled to FFS, regardless of whether their enrollment was mandatory or voluntary. The disenrollment confirmation notice will indicate that the Enrollee should contact NYMC to discuss enrollment options that may be available to them.
Note that receipt of Social Adult Day Care or Housekeeping or Level I personal care serviuces services alone does not count as it is not enough for MLTC enrollment. See MLTC Policy No. 13.03, 13.05, and 13.11, and MLTC Policy No. 13.15,
EXCEPTION - A plan would not initiate involuntary disenrollment due to the Enrollee not receiving CBLTSS within previous calendar month if the Enrollee is hospitalized or admitted to a residential program during the calendar month that the Enrollee was identified as not receiving CBLTSS.
Members who are unhoused or living in a shelter -- FAQ for MLTC Policy 23.03 states how plan should handle this if Plan cannot provide CBLTSS in these settings - but note that this language is not in the more recent policy MLTC Policy 26.01 -
- "The Care Manager should assist the enrollee in transferring to another residential location that would allow the Enrollee to receive needed services. In the event the member is unwilling or unable to transfer to a facility where they are able to receive services and more than 30 days have passed, the Plan should follow the Enrollee Has Not Received CBLTSS in the Previous Month disenrollment reason."
STOPPING THE DISENROLLMENT - After receiving an Intent to Disenroll letter or an involuntary disenrollment notice, an Enrollee may contact the plan or NYMC to request reinstatement of their Plan of Care and continue enrollment in the plan. The plan must document the continued enrollment request as an occurrence in the monthly Care Management record including any changes to the existing PCSP. This should cancel the disenrollment. MLTC Policy 26.01 p. 30 of PDF.
NYLAG COMMENT: This ground of disenrollment is not listed in the Model MLTC Contract (pages 22-23 of the PDF), which might be a basis to challenge disenrollment. Also, if the consumer did not receive services because of the aide shortage, this should be raised as a defense. Also, see here for those who voluntarily paused services because of COVID.
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WARNING re LEGACY STATUS: If the consumer is disenrolled from any MLTC, MAP or PACE plan for more than 30 days, they lose Plan Legacy status if they had been enrolled in the plan since before Sept. 1, 2025. This means that if they try to re-enroll in an MLTC plan, they would be required to meet the new 2-or-3 ADL standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan or a mainstream managed care plan or from the local DSS. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC).
A Nursing Home Level Of Care is required only for PACE plans only, not MLTC or MAP, for adults age 21+ who have Medicare and Medicaid.. Per MLTC Policy 26.01 (pp. 12-13,. 19 of PDF), as in MLTC Policy 24.02 and MLTC Policy 23.03 that it replaced, the plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of a Community Health Assessment (CHA) that assessed the Enrollee as no longer meeting nursing home level of care.
A nursing home level of care is indicated by a "score" of 5 or more on the CHA.
Note: Nursing home level of care may be identified at any reassessment. CHA's are conducted by plan nurses, unlike initial CHA's conducted prior to enrollment, which are conducted by the NY Independent Assessor Program.
PACE Deemed Eligibility Process - Prior to initiating the involuntary disenrollment request, within five (5) business days of the CHA determination. the plan must submit supporting documentation to the Department at MLTCMDReview@health.ny.gov should the plan believe that:
- the absence of continued coverage under the plan would negatively impact the Enrollee's condition and
- the Enrollee would be reasonably expected to meet the nursing home level of care requirement within the next six months,
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The supporting documentation must include the CHA and a statement from the plan's Medical Director or clinical staff clearly stating the rationale for "deemed eligibility" based on the member's chronic condition. Supporting documentation may include but is not limited to medical records, relevant tests, an assessment by specialists, formal and informal supports that may impact the stability of the member's condition in the next six months. The Department reserves the right to request additional supporting documentation including an attestation from the Enrollee's primary care provider.
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If NY Medicaid Choice agrees that the member has deemed PACE eligibility, the Enrollee's enrollment would continue uninterrupted.
- If the deemed eligibility review request is not approved, the plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of the deemed eligibility review determination. The plan must submit the deemed eligibility review outcome with the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC. See further procedures here.
What Happens After Involuntary Disenrollment -- (MLTC Policy 26.01 p. 19-20 of PDF.) - MANDATORY and VOLUNTARY PACE ENROLLEES who: no longer have a Nursing Home Level of Care and:
- still need CBLTSS for 120 days or more. and who do not choose an MLTC or MAP plan will be auto assigned to a MLTC plan. MLTC Policy 26.01.does not specify transition rights for these enrollees - that the new MLTC plan must continue the same plan of care.. See more about Transition Rights here. (This is disenrollment reason No. ix.)
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do not need CBLTSS for 120 days or more are NOT assigned to an MLTC plan. Instead, they are referred to FFS Medicaid. (This is disenrollment reason No. XI).
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WARNING re LEGACY STATUS: If the consumer is disenrolled from any PACE plan for more than 30 days, they lose Plan Legacy status f they had been enrolled in the plan since before Sept. 1, 2025. This means that if they try to re-enroll in a MLTC or MAP plan, they would be required to meet the new 2-or-3 ADL standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan or a mainstream managed care plan or from the local DSS. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC).
This reason is applicable to all MLTC plan types (MLTC, MAP and PACE). The plan is required to initiate the involuntary disenrollment with NYMC within five (5) business days of the comprehensive reassessment.
The plan must submit the CHA with the Managed Long Term Care Involuntary Disenrollment Request Form to NYMC. See notice to member and other procedures here.
What happens after disenrollment -- the Enrollee will be disenrolled to FFS. The disenrollment confirmation notice will indicate that the Enrollee should contact NYMC to discuss enrollment options that may be available to them.
Note: New York Independent Assessor Program (NYIAP) CHA Determinations -- Once the reassessments are transferred to NYIAP, there may be circumstances where a plan disagrees with the clinical determination impacting the Enrollee's CBLTSS eligibility. Should the plan disagree with the CBLTSS determination, the plan must initiate the CHA Variance request process by completing the NYIAP CHA Variance Form with supporting documentation as described in MLTC Policy 22.01.
WARNING re LEGACY STATUS: If the consumer is disenrolled from any MLTC, MAP or PACE plan for more than 30 days, they lose Plan Legacy status if they had been enrolled in the plan since before Sept. 1, 2025. This means that if they try to re-enroll in an MLTC plan, they would be required to meet the new 2-or-3 ADL standards. However, they should still have Service Legacy Status if they received personal care or CDPAP before Sept. 1, 2025, whether from the MLTC plan or a mainstream managed care plan or from the local DSS. This means that even if they fail the ADL test to enroll in an MLTC plan, they should be able to access personal care or CDPAP services from the Local DSS (HRA in NYC).
XI. PACE only - No Longer Needs Nursing Home Level of Care AND no longer needs 120 days+ of CBLTSS. See here
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This ground for disenrollment is not listed in MLTC Policy 26.01 because for the time being, plans may not initiate disenrollment on this ground. These disenrollments are still initiated by DOH in batches, after DOH identifies those enrollees in nursing homes for 3+ months who have been approved for Institutional Medicaid, and asks the plans to identify those who do not have an active discharge plan. Down the road, DOH will allow PLANS to initiate these disenrollments. DOH MLTC Policy 24.02: Part E.
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See this article for information on notices member and their representative should receive before disenrollment because of a Long Term Nursing Home Stay, and their appeal rights. Members should NOT be disenrolled if they have an active discharge plan to return home, and they need to appeal if disenrollment is threatened.
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Members have the right to re-enroll within 6 months of the disenrollment. However, if more than one month lapses before they re-enroll, they are at risk of losing Legacy Status and the ADL Minimum Needs thresholds could apply to block re-enrollment.
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MLTC Policy 26.01 and the previous guidance it replaces do not include the involuntary disenrollments that result from a Medicaid discontinuance. See page 1. Local Department of Social Services (HRA/LDSS) initiated disenrollment reasons include instances where the Enrollee is no longer eligible for Medicaid, the Enrollee is deceased, the Enrollee is incarcerated, etc.
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Since the pandemic began in March 2020, most people retained Medicaid coverage automatically unless they died or moved out of state. With the "unwinding" of these continuous coverage protections, beginning in July 2023, many MLTC members have had Medicaid discontinued, if they do not timely respond to a renewal request from their local Medicaid agency. They should receive 10-day advance notice of any discontinuance of Medicaid from their local DSS, with the right to request a Fair Hearing.
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See more about the "unwinding" here and tips for completing Renewals here.
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MLTC plans should help members respond to the renewal requests. See tips about responding to renewals here.
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WARNING: If Medicaid eligibility stops because of a problem with eligibility at the LDSS, the consumer will NOT receive notice from NYMC that they will be disenrolled from the plan. Plan enrollment lapses automatically upon discontinuance of Medicaid.
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Advocates have asked NYS DOH to tell plans to continue services for 90 days after Medicaid is discontinued to allow time to fix an error in the renewal process that caused the discontinuance. This is not yet required.
Applies to MAP, PACE & MLTC.
The plan must have made and documented reasonable efforts to resolve the problems presented. MLTC Policy 26.01 tates, "However, with the Department's approval, the MLTC plan may immediately initiate the involuntary disenrollment process when the situation poses a serious risk of harm to an Enrollee, or service providers."
DOCUMENTATION: Along with the Managed Long Term Care Involuntary Disenrollment Request Form , a MAP or MLTC plan must submit to NYMC the following. PACE plans send the request to DOH instead of NYMC:
- The plan's written statement describing the case situation and why the plan is unable to furnish services.
- The names of different home care agencies utilized, and the results of service attempts.
- Documentation of a referral to Adult Protective Services (APS) must be included when there is a report of safety issues.
What happens after disenrollment -- (Table 1)
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Mandatory MLTC enrollees (adults age 21+ who have Medicaid and Medicare and who are not in the OPWDD waiver and are not in home hospice) -- will be auto-assigned to another MLTC plan if they do not choose one when notified by NY Medicaid Choic
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Voluntary MLTC enrollees - will be disenrolled to the Local District for FFS.
- NYLAG comment - MLTC Policy 26.01 does not specify transition rights for these enrollees.
Possible defenses -- Under the model contract Article V section (D)(1)(c) and as required by 42 CFR 438.56(b) -- Disenrollment may not be based in whole or in part on an adverse change in the Enrollee’s health or on the capitation rate payable to the plan. Disenrollment may not be initiated because of the Enrollee’s high utilization of covered medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his/her special needs except as may be established under the contract Article V section D(5)(a). That section states the plan must have made and documented reasonable efforts to resolve the problems presented by the individual.
The model contract says that if an Enrollee fails to pay for or make arrangements satisfactory to the plan to pay the spenddown/surplus within thirty (30) days after such amount first becomes due, they may be disenrolled. This is provided that during that thirty (30) day period ,the plan first makes a reasonable effort to collect such amount, including making a written demand for payment and advising the Enrollee in writing of his/her prospective disenrollment.
iii. Enrollee knowingly provides false information, otherwise deceives the Plan, or engages in fraudulent conduct with respect to any substantive aspect of their plan membership
This reason is on hold.
Part B - Mandatory Disenrollment for Members WITH Legacy Status
The Plan is required to initiate the involuntary disenrollment process within five (5) business days of a CHA where the Enrollee was assessed as no longer meeting the nursing home level of care.
What Happens After Involuntary Disenrollment - (Table 2 of MLTC Policy 26.01)
- If the enrollee continues to need CBLTSS for more than 120 days -
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if the enrollee is in a MANDATORY enrollment category - they are auto-assigned to an MLTC plan if they do not select one. (This would apply to MAP enrollees only).
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If the enrollee is a VOLUNTARY enrollee - they MAY enroll in an MLTC plan, but will not be auto-assigned if they do not enroll. They will be disenrolled to FFS.
- If the enrollee NO LONGER continues to need CBLTSS for more than 120 days -
- Disenrolled to FFS Medicaid.
NYLAG Comment - Member should have transition rights with care transferred to a mainstream plan or FFS through the local DSS.
Part C - MLTC Disenrollment of Enrollees Without Plan Legacy Status
Enrollee of MAP or MLTC plan no longer meets the Minimum ADL Needs Requirement.
The Plan is required to initiate the involuntary disenrollment process within five (5) business days of a CHA where the Enrollee was assessed as no longer meeting the Minimum Needs requirement, whether or not the enrollee also no longer needs CBLTSS for more than 120 days.
What Happens After Involuntary Disenrollment - (Table 3 of MLTC Policy 26.01)
The enrollee is disenrolled to FFS.
Plans may not unilaterally or directly disenroll a member. New procedures in MLTC Policy 26.01.
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Plan sends the Enrollee an Intent to Disenroll letter (Template below in MLTC Involuntary Disenrollment Process Presentation FINAL (PDF) (2026) slide 7.
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The plan must send a copy of the enrollee and to enrollee's authorized representatives before sending the package to NY Medicaid Choice. PDF at 29.
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See the template for language tailored to different groups of enrollees (mandatory vs. voluntary enrollees) or different grounds for disenrollment.
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The plan must send a disenrollment request to NY Medicaid Choice. This includes the Managed Long Term Care Involuntary Disenrollment Request Form, which was significantly revised with MLTC Policy 26.01. See the updated template highlighting the changes in MLTC Involuntary Disenrollment Process Presentation FINAL (PDF) - slides 9-20. The plan must also submit the required supporting documentation for the selected disenrollment reason, a copy of the Intent to Disenroll letter, and the transmittal form requested from NYMC. TIMING -
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The Policy gives plans a deadline to submit the disenrollment request by the 7th - 9th of the current month to secure enrollment by the 1st of the next month. This allows time for NY Medicaid Choice to send the 10-day notice of involuntary disenrollment to the member, with the opportunity for the member to request a Fair Hearing. See below.
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Also, plan must "initiate an involuntary disenrollment within five (5) business days of the date the plan is notified of the triggering event." MLTC Policy 26.01 p. 3. The failure to comply with this deadline is penalized by having to repay capitation premiums for this period. See here.
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Notice of Involuntary Disenrollment -- If NY Medicaid Choice agrees that one of the above grounds for involuntary disenrollment is met, it sends a Notice of Involuntary Disenrollment to the member. Per MLTC Policy 26.01 p. 30. "Fair Hearing rights apply to this notice from NYMC including Aid to Continue. The involuntary disenrollment notice has contact information if the individual has questions regarding the disenrollment." While Policy MLTC Policy 26.01 does not so state, presumably this notice must be sent 10 days in advance of the proposed date of disenrollment, to allow time for the member to request a Fair Hearing with the NYS Office of Temporary & Disability Assistance (OTDA). If the hearing is requested before the effective date of disenrollment, the member is entitled to remain in the plan until the hearing is held and decided. This is Aid Continuing.
The guidance does not specify that the NY Medicaid Choice notice must also be sent to the designated representative.
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If Enrollee Corrects Issue Before EFFECTIVE DATE OF DISENROLLMENT - If member/designee contacts the plan or NY Medicaid Choice BEFORE the effective date of disenrollment, and makes the necessary change to address the ground for disenrollment, the disenrollment should be CANCELED. See MLTC Policy 26.01 pp., 30-31 and each of the grounds for disenrollment described above.
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NY Medicaid Choice notifies plan that disenrolled member that member was autoassigned or selected a different MLTC. This is so the plan will transmit the Person Centered Service Plan (PCSP) to the new plan. The policy does not state that the plan is notified if the consumer is transferred to the LDSS so that the plan can transmit the service plan.
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What happens to enrollee after disenrollment? See above and Tables 1 - 3 of MLTC Policy 26.01 for which disenrollments result in auto-assignment to another plan, which to LDSS for "FFS." . Advocates are concerned that some of these policies cause unnecessary disruption for continuity of care, where a better transition would be possible.
DOH MLTC Policy 24.02 in Section H. reinstated the State's right to recover premiums paid to plans for months in which the Enrollee should have been disenrolled. This recovery was on hold during the COVID public health emergency, and was reinstated for several disenrollment grounds earlier, but is reinstated for all grounds in the guidance eff. Nov. 1, 2024. MLTC Policy 26.01 continues this policy - see p. 29. Consumers should be aware that the threat of this recovery will be an incentive for plans to initiate disenrollment on the MANDATORY grounds listed above. There should be no recovery where a plan chose not to pursue an OPTIONAL disenrollment.
State directives were issued as GIS directives and as COVID guidance (under "Other Guidance" at this link but not as MLTC Policies
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GIS 21 MA/17 - Managed Long Term Care’s Involuntary Disenrollment Resumption (August 18, 2021)(No longer in D-SNP aligned with MAP plan; Moved to a different county not in plan's service area)
- GIS 21 MA/24 - Managed Long Term Care Involuntary Disenrollment Resumption – Additional Reasons - Absent from service area for more than 30 days AND enrollee or family member behavior interfere with care
- LETTER TO PLANS - Resumption of Two Additional MLTC Involuntary Disenrollment Reasons - (Web) - (PDF) - 11.29.2021
- Attachment I - 30 day absence from MAP service area - (Web) - (PDF) - revised 04.25.2022
- 2022 MLTC Plan Processing Schedule Involuntary Disenrollments - (Web) - (PDF) - 11.29.2021 - revised in 2022 below
- GIS 22 MA/03 - Managed Long Term Care Involuntary Disenrollment Resumption - Additional Reason - did not receive any of seven community-based long term care services in prior calendar month
- Attachment I (amended list of MAP plans that may initiate disenrollment because absent from service area for 30 days per (GIS 21 MA/24 (May 16, 2022)
- Attachment II -schedule of disenrollment dates
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- Plan Guidance - Dear MLTC Health Plan Administrator Letter - Resumption of Additional MLTC Involuntary Disenrollment Reason - 04.26.2022 (Web) - (PDF) -
- May 20, 2022 Webinar Plan Involuntary Disenrollment No CBLTSS Training, Recording, and Transcript - 5.25.2022
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MLTC Policy 23.03 (identifical to Policy 24.02 except that 24.02 adds a new ground for involuntary disenrollment - failure to cooperate with an assessment.
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DOH MLTC Policy 24.02 - Update to Resumption of MLTC Involuntary Disenrollments - 9.3.2024 - Effective date 11.1.2024
Most of the involuntary disenrollment reasons are in the Model MLTC contract (2022 version) Article V, Part D, sec. 3-4 pp. 21-22)(Find most recent contracts here under dropdown for MODEL CONTRACTS). Medicaid Advantage Plus (MAP) and PACE plans have a unique additional mandatory reason for disenrollment if the member no longer is enrolled in the "aligned" Medicare Special Needs Plan (D-SNP) - see here.
