MLTC Policy 26.01: involuntary disenrollment in New York

MLTC Policy 26.01 is the New York State Department of Health rule for how a Managed Long Term Care (MLTC) plan removes a member who no longer meets the conditions to stay enrolled. It was issued April 7, 2026 and took effect June 1, 2026. It covers MLTC Partial Capitation plans, Medicaid Advantage Plus (MAP) plans, and PACE. Its main change is a new reason for people who joined a plan on or after September 1, 2025: a plan reassessment finds they "no longer meet the Minimum Needs Requirement."

If you got a letter, two things matter most. First, the plan cannot remove you on its own. It sends you an Intent to Disenroll letter, then sends a package to New York Medicaid Choice (NYMC), the State's enrollment broker, and NYMC sends the notice that counts. Second, that NYMC notice carries fair hearing rights, including Aid to Continue. The rest of this page covers who the policy hits, what each letter means, and what to do in the first days.

Three different letters get mixed up. Read the letterhead and the first line.

• An Intent to Disenroll letter from your plan, or an Involuntary Disenrollment Confirmation Notice from New York Medicaid Choice. That is this policy, 26.01. The question is whether you stay in the plan at all.
• A notice from your plan that reduces or ends your CDPAP or personal care hours. That is a service decision, not a disenrollment. The deadlines and the appeal steps are in home care hours cut appeals in New York.
• A call or letter about one personal assistant working very long weeks. That is MLTC Policy 26.02, the excessive hours policy from July 2026. It is a different document about a different problem, and it does not remove anyone from a plan by itself. It is explained in the CDPAP excessive hours review.

One more line to clear up. Policy 26.01 does not cover people who lose Medicaid itself. The Department says those disenrollments come from HRA or the county district, not the plan, and are outside this policy.

The policy is written to plans, not to members. That is useful. It tells the plan what it must do and by when, so you can tell whether it is following its own rules.

A plan-started disenrollment is one "initiated by the Plan without agreement from the Enrollee." It needs NYMC's approval. The plan must submit the request "in the required time, form, and with the required documentation." If NYMC disregards or overturns the package, the Department says "the Enrollee will remain enrolled in the Plan."

The policy also draws a line the plan may not cross. You can leave a plan voluntarily at any time, even during this process. But "in no instance is the Plan allowed to pressure or coerce the Enrollee to consent to a disenrollment." If a care manager suggests you sign something to leave, you do not have to.

The policy sorts every member by "MLTC Plan Legacy status," which comes from MLTC Policy 25.04. Plain version:

• Plan Legacy means you were enrolled in any MLTC plan, including PACE, before September 1, 2025. The Department granted it to everyone enrolled as of August 1, 2025, and plans add it for people assessed after August 31, 2024 who enrolled within a year of that assessment. At each reassessment you are judged on the old rules. For a dual-eligible adult 21 or older in an MLTC Partial plan, the old rule is one line: a need for community based long term services and supports for more than 120 days.
• Non-Legacy means you enrolled on or after September 1, 2025 with a new assessment. You are judged on the Minimum Needs Requirements at every reassessment.

The Minimum Needs Requirements have two parts. First, a need for community based long term services and supports for more than 120 days. Second, in the Department's words, either "at least limited assistance with physical maneuvering with more than two activities of daily living (ADLs)," or, for a person "with a Dementia or Alzheimer's diagnosis," at least "supervision with more than one ADL." The dementia path needs form DOH-5821, signed off by a physician (M.D. or D.O.), at each assessment. Without the form, the Department says "the lower threshold cannot be applied."

Legacy has one catch. Policy 25.04 says "in order to retain Plan Legacy, the member must be continuously enrolled in the MLTC Program." The plan removes Legacy only "when a member is disenrolled from the MLTC Program." A transfer to another plan with no break keeps it. Policy 26.01 repeats this: people with Plan Legacy "who are transferred to another MLTC plan as result of an involuntary disenrollment, will maintain their MLTC Plan Legacy status." A disenrollment to regular Medicaid ends it. Plans "must educate members about the loss of Plan Legacy Status prior to disenrollment."

A separate status, Service Legacy, covers people who were already getting or authorized for personal care or CDPAP before September 1, 2025. The Department says it "is not impacted by an MLTC disenrollment and should not be changed."

For a mandatory reason the plan "MUST initiate the involuntary disenrollment process within five (5) business days of the date the Plan knows of the triggering event." For most of these, the plan first has to try to reach you and tell you what is at risk. The Department's own table, in plain words:

Two details from the "no service last month" reason. Social adult day care and Level 1 housekeeping "do not meet the CBLTSS requirement." And the plan must not start the process in three cases: nursing is your only service and the schedule simply skipped a month; the plan could not find a provider for the care you were assessed to need; or you were in a hospital or residential program that month.

One optional reason exists. A plan "may" start the process if you, a family member, or another person in the home "engages in behavior that seriously impairs the Plan's ability to furnish services." The plan must first have "made reasonable efforts to resolve the problems." Two other reasons, unpaid spend-down and fraud, are marked "on hold" and are not in use.

This is what is new in 2026. Section C of the policy applies "to Non Plan Legacy only" and to MAP and MLTC Partial plans. It has two mandatory reasons:

1. "Enrollee no longer meets the Minimum Needs Requirement."
2. "Enrollee no longer meets the Minimum Needs Requirements and is no longer in need of CBLTSS for more than 120 days."

Both start "within five (5) business days of a CHA" with that finding. Both end in regular fee-for-service Medicaid, not a transfer to another plan. The plan's package must include the date of the CHA and, if you have Alzheimer's disease or dementia, form DOH-5821. The Department's April 2026 slides show the request form. The plan checks one of two boxes: more than two ADLs at "Limited Assistance level or above," or "Diagnosis of Alzheimer's disease or dementia and Supervision with more than one ADL or above."

So for a non-Legacy member, the reassessment is the whole case. If the CHA scored you at fewer ADLs than the rule, the plan is required to start this process. If you have a dementia diagnosis and no DOH-5821 was in the file, the lower threshold was not applied. That is worth checking before anything else.

1. Contact attempts. For the contact-based reasons above, the plan must reach out first and document every attempt in your care management record.
2. The plan's Intent to Disenroll letter. The Department says that once the plan "has completed all required actions including outreach attempts," it must send "the approved Intent to Disenroll letter to the Enrollee and their authorized representative(s)" before it sends anything to NYMC. This is the warning. Every package NYMC accepts must include a copy of it.
3. The package to NYMC. The request form, the supporting documents for the reason, the Intent to Disenroll letter, and NYMC's transmittal form. NYMC processes packages on a monthly schedule, so the effective date "depends on the date the involuntary disenrollment request is received by NYMC and accepted."
4. NYMC's Involuntary Disenrollment Confirmation Notice. This is the notice that counts. The policy says "Fair Hearing rights will apply to this notice from NYMC including Aid to Continue," and that it "has contact information if the individual has questions." The Department's April 2026 slides add that a frequently asked questions section was added to the notice for each reason.

The NYMC notice also tells you where you land. Per the Department's slides: people who are no longer eligible for MLTC go to regular Medicaid. People still eligible who are in the mandatory group "must choose a plan" or are auto-transferred to an MLTC Partial plan. People still eligible who are in the voluntary group "can choose a Plan," and if they do not, go to regular Medicaid.

This page does not quote the letters. The Department shows them only as images in its slides. If your letter says something different from this page, your letter controls.

Aid to Continue means your plan enrollment and services stay as they are while the hearing is decided. The policy attaches that right to the NYMC notice. It does not print the deadline. The general Medicaid rule comes from the Department's August 2025 guidance, quoted on this site. Services continue if you request the hearing "prior to the effective date of a proposed action as contained in the notice of action or within 10 days of the mailing of the agency's notice of the action, whichever is later." Use the deadline printed on your NYMC notice. If the two differ, the notice wins, and ICAN can read it with you.

Three honest notes:

• The policy describes a State fair hearing on the NYMC notice. It does not describe a plan-level appeal for the disenrollment itself. That is different from a cut in hours, where the plan hears the first appeal. Ask ICAN which path your letter calls for.
• For the Minimum Needs reasons, the dispute is about the assessment. The fair hearing prep checklist covers the evidence packet, what the plan has to show, and hearing day. The same evidence, a doctor's letter on ADLs and a DOH-5821 if dementia is involved, is what the CHA should have reflected.
• How aid continuing works, and the risk if you lose, is explained in aid continuing and fair hearings when your home care hours are cut. The rules on repayment there come from the Department's guidance on service cuts; ask ICAN how they apply to a disenrollment.

The policy has a fix-it path. "The Enrollee must contact the MLTC plan to continue the enrollment prior to the involuntary disenrollment effective date." If you have "addressed the involuntary disenrollment reason" and are still eligible, "the Plan must provide an updated enrollment letter." You can also call NYMC, which "will initiate a three-way call" with the plan.

The Department's examples: you came back to the service area; you agreed to restart a covered service; you got an active discharge plan or came home; you re-enrolled in the aligned Medicare plan; or you completed the CHA you had missed. For the missed CHA, the policy says it "must be completed within 30 days of the original Intent to Disenroll Letter date." And: "If there is a valid assessment on file, a new assessment is not needed."

This path is written for the contact-based reasons. The Department's Legacy guidance lists the reasons that allow reinstatement before the effective date, and the Minimum Needs and "no longer needs services" reasons are not on it. For those, the fair hearing is the route.

1. Find the dates. The date on the letter, the disenrollment effective date, and any deadline printed for a fair hearing or Aid to Continue.
2. Find the reason. It will match one line in the tables above. Write down which one.
3. If it is fixable, call the plan now. Ask for the care manager. Say you want to continue your enrollment and what you have done to fix the reason. Ask for the updated enrollment letter in writing.
4. If it is an assessment reason, request the fair hearing and ask for Aid to Continue in those words. Do it before the effective date or within the window on the notice. Then call ICAN with the notice in front of you.
5. Ask for the CHA and the plan of care. For a Minimum Needs case, you need the ADL scores and, if dementia is involved, whether a DOH-5821 was in the file.
6. Ask the plan what it is doing about transition of care. Before the effective date, the plan "must work with the Enrollee" to make referrals to the local district, another plan, and providers for the services in your plan of care. Get names.
7. Tell your personal assistant. PPL, the statewide fiscal intermediary, pays only authorized hours. If aid continuing is granted, the Department's guidance says PPL "will accept and recognize the validity" of that authorization. What PPL does and does not decide is in what PPL does and does not decide.

• Treating the plan's Intent to Disenroll letter as the final word. It is the warning. NYMC's notice is the one with hearing rights, and you may still be able to fix the reason before the effective date.
• Signing a voluntary disenrollment because someone suggested it. You do not have to. The plan may not pressure you.
• Missing the CHA. Ten contact attempts over 30 days sounds like a lot, but the Department requires only that the plan try. A missed assessment is a mandatory reason.
• Assuming Legacy protects you from everything. It protects you from the Minimum Needs test only while you stay continuously enrolled in some MLTC plan. A disenrollment to regular Medicaid ends it.
• Assuming a Minimum Needs finding is not appealable. It is a CHA outcome with a notice. The fair hearing is where it gets tested.
• Waiting for the hours question to sort itself out. Disenrollment from the plan and the number of hours you get afterward are separate decisions. Ask about both.