Disenrollment Policy for Medicaid Managed Care
In New York City, expedited and retroactive disenrollments are manual processes handled by the New York City Human Resources Administration (HRA) and are outside of the State Department of Health's routine roster production. These disenrollments are not to be confused with routine disenrollments, which are processed through the State Department of Health's roster process and become effective on a prospective basis -2 to 6 weeks from the date of request, depending on when the request is received. Notification of routine disenrollments is handled by New York Medicaid CHOICE.
Enrollee requests for disenrollment may require a completed exemption or exclusion form. For instructions on completing exemption and exclusion forms, call New York Medicaid CHOICE at 1-800-505-5678.
Please see below for details on Retroactive Disenrollments and Expedited Disenrollments
Retroactive Disenrollments
Circumstances warranting a retroactive disenrollment are rare and include the following:
The enrollee has:
- • entered a residential institution, which renders the individual excluded from managed care;
- • been incarcerated;
- • moved out of the contractor's service area subject to any time remaining in the enrollee's guaranteed eligibility period*
- • died - as long as the plan was not at risk for provision of medical services for any portion of the retroactive period.
Also, SSI infants less than six months of age shall be disenrolled back to the first day of the month of birth.
NEW Retroactive Disenrollment EFFECTIVE DATES
| Reason for Disenrollment | Effective Date of Disenrollment |
| SSI infant | First day of month of birth |
| Death of enrollee | First day of month after death |
| Enrollee entered a residential institution, which renders the individual excluded from managed care (includes incarceration). | First day of month following entry** |
| Move by enrollee outside of New York City | First day of month after the update of system with new address |
*In New York City, enrollees, not in guaranteed status, who move out the Contractor's service area but not outside of the City of New York (e.g. move from one borough to another), will not be involuntarily disenrolled, but must request a disenrollment or transfer. These disenrollments will be performed on a routine basis unless there is an urgent need to expedite the disenrollment.
**Local districts should make adjustments as necessary to allow a residential institution which constitutes an exclusion category to be reimbursed for services provided from the date of the recipient's entry to the residential institution. However, in such instances, if the plan was at risk for providing medical services to the enrollee for a portion of the month, the plan is entitled to keep the capitation payment for the month.
Expedited Disenrollment Policy
Pursuant to New York City and New York State policies and procedures, expedited processing of disenrollments may occur in instances of non-consensual enrollment and in instances of urgent medical need.
Individuals who are to be disenrolled from managed care based on their HIV, ESRD, or SPMI/SED status are categorically eligible for an expedited disenrollment on the basis of urgent medical need.
In New York City where homeless individuals are exempt from participation in managed care, homeless individuals residing in the shelter system will be categorically eligible for disenrollment on an expedited basis. These expedited disenrollment requests must be accompanied by a brief letter from the homeless facility documenting shelter residence. Homeless individuals not residing in the shelter system must file for an exemption based on urgent medical need in order to qualify for an expedited disenrollment. Otherwise, the disenrollment will be handled as routine.
HRA, to the extent possible, will process an expedited disenrollment within two business days of its determination that an expedited disenrollment is warranted.
NEW Expedited Disenrollment EFFECTIVE DATES
| Reason for Disenrollment | Effective Date of Disenrollment |
| Urgent Medical Need | First day of next month where medical need requires an earlier disenrollment |
| Non-consensual enrollment | Retroactive to the first day of month of enrollment |
| NYC homeless enrollees residing in a shelter system. | Retroactive to the first day of the month of the request |
