Integrated Coverage Determination Notice (ICDN)

Important: This notice explains your right to appeal our decision. Read this notice carefully. If you need help, you can call one of the numbers listed on the last page under "Get help & more information." Oral interpretation is available for all languages. Acess this service by calling [phone number].

[FIDA PLAN NAME/LOGO]

Appeal Level: 2

ACKNOWLEDGMENT OF AUTO-FORWARD OF APPEAL

Name:                                                   Date of Notice:

Participant Number:                             Date of Level 1 Appeal Decision:

[Insert other identifying information, as necessary (e.g., provider name, Participant´s Medicaid number, service subject to notice, date of service)]

Dear [Participant name],

Because our Level 1 Appeal decision was not fully in your favor, we forwarded your case to theFIDA Integrated Administrative Hearings Office (IAHO) on [insert date sent to IAHO]. This means that you have reached Level 2 of the appeal process, and someone from the IAHO will contact you to schedule a hearing about the following action:[Insert a detailed description of the FIDA Plan action/IDT decision (e.g. denial, reduction, PCSP renewal, etc.) being appealed, the benefits involved, and which benefits remain at issue after the FIDA Plan's appeal decision.]




Why was your case forwarded?

[Plan name] forwarded your case to the IAHO because our Level 1 Appeal decision was not fully in your favor. The IAHO is an independent organization that is not connected to [plan name]. The IAHO will do a careful review of our Level 1 decision, and decide whether it should be changed.

What happens next?

The IAHO should contact you within [Insert "24 hours" for an expedited appeal or "5 calendar days" for a standard Medicaid prescription drug appeal or "10 calendar days" for all other standard appeals] after receiving your case. They will call you or your representative (if you have one) to schedule a hearing. If the IAHO has not contacted you within [Insert "24 hours" for an expedited appeal or "5 calendar days" for a standard Medicaid prescription drug appeal or "10 calendar days" for all other standard appeals], you should call the IAHO at 1-844-523-8777. TTY users call 711, then follow the prompts to dial 844-523-8777.

You have the right to do your hearing over the phone or in-person. If you need reasonable accommodations because of a disability, tell the IAHO and they will provide those accommodations for you. If you are homebound, or if transportation could be harmful to your health, make sure to request that the hearing is conducted at your home or other residence.

When will the IAHO decide your Level 2 Appeal?

Standard Appeal - If your standard appeal is about Medicaid prescription drugs, the IAHO must give you an answer within 7 calendar days of when it gets your appeal. For all other standard appeals, the IAHO must give you an answer within [insert "90" in demonstration year one; insert "62" in demonstration years two and three] calendar days from the date you asked for an appeal with [plan name]. The IAHO will give you a decision sooner if your health condition requires it.

Fast Appeal - If you had a fast appeal at Level 1, you will automatically have a fast appeal at Level 2. Additionally, if the IAHO determines that you need a fast appeal, they will give you one. The IAHO will give you a decision on a fast appeal within 72 hours after they get your appeal.

When the IAHO makes a decision, it will send you a letter that explains its decision and provides information about your further appeal rights.

Continuation of services during your Level 2 Appeal

[[Insert the following two paragraphs if any of the disputed services are continued:]
Because you had continuing services during Level 1 of your appeal, the following disputed services will also continue pending the outcome of Level 2: [List the disputed services that qualify for continuation of benefits.]




If these services are stopped before the IAHO makes a decision, contact us at [phone number] or the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800. TTY users call 711, then follow the prompts to dial 844-614-8800. You will not be charged for the services that are continued while your appeal is pending. Even if the IAHO upholds our decision, you will still not be charged for any services that were continued.

[Insert the following paragraph if none of the disputed services qualify for continued benefits:] You will not receive the disputed services at this time. [Plan name] will not take any action regarding these benefits until your appeal is resolved by the IAHO, or until we come to an agreement about the disputed services.

[Insert the following paragraph if the Participant did not qualify for continuation of services, but the plan partially (but not fully) approved any of the disputed benefits from the original FIDA Plan action/IDT decision:]
You requested [insert benefit and amount requested]. [Plan name] approved [insert benefit and amount approved]. You are appealing this approval because it is not what you requested. We will provide you with the approved services while your appeal goes to Level 2 of the appeal process to decide whether we have to provide you with what you requested.

Getting your case file and submitting evidence

You have the right to get a copy of any documents from your case file with [plan name] that will help you show why our decision was wrong. You or your representative (if you have one) may request these documents, at no cost, by calling [phone number] or by fax to [fax number].

If you would like the IAHO to consider information that was not considered by [plan name], you should submit it as soon as possible. We recommend that you submit the information by phone, fax, or email. You may also submit it by mail, bring it to the IAHO office, or present it at an in-person hearing:

FIDA Integrated Administrative Hearings Office (IAHO)
Mailing Address: FIDA/IAHO-10A, P.O. Box 1930, Albany, NY 12201
Physical Address: 317 Lenox Avenue, 7th Floor, New York, NY 10027

Phone: 1-844-523-8777
TTY Phone: Call 711, then follow the prompts to dial 844-523-8777
Fax: 518-474-8742

Email: otda.sm.FIDA.Integrated.Appeals.Office@otda.ny.gov

If you want someone to represent you

You can have someone else represent you during your appeal. You can choose anyone to represent you, like a family member, friend, doctor, attorney, or an ICAN staff member (see below).

If you already named someone to represent you when you requested this appeal, or if you have someone who is otherwise able to act for you because he or she is a legal guardian, power of attorney, or otherwise authorized to make health care decisions on your behalf, you do not have to do anything else.

If you have not already named someone to represent you and want to choose someone now, both you and the person you want to act for you must sign and date a statement confirming this is what you want. You can write a letter or use the Appointment of Representative form available at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. Send your letter or form to us by fax or mail. If you have any questions about naming your representative, such as what to say in your letter, contact IAHO using the information above or call us at: [phone number]. TTY users call [TTY number].

The state created the Independent Consumer Advocacy Network (ICAN) to help you with appeals and other issues with the FIDA program. ICAN is independent, and the services are available to you for free. They can help answer your questions about the appeals process, give you advice, and may even represent you. Call ICAN at 1-844-614-8800. TTY users call 711, then follow the prompts to dial 844-614-8800.

[Plans must send a copy of this notice to relevant parties (e.g. representative, designated caregiver, etc.) and include the following text:]

A copy of this notice has been sent to:

[name]
[address]
[phone number]

Get help & more information

(TTY users call 711, then use the phone numbers below)

  • [Plan name]
    Toll Free Phone: [phone number]
    TTY users call: [TTY number]
    [hours of operation]

  • Independent Consumer Advocacy Network (ICAN)
    Toll Free Phone: 1-844- 614-8800
    8:00am - 8:00pm, Monday - Sunday

  • Elder Care Locator
    Toll Free Phone: 1-800-677-1116

  • 1-800-MEDICARE (1-800-633-4227)
    TTY users call: 1-877-486-2048
    24 hours a day, 7 days a week

  • NYS Department of Health
    Toll Free Phone: 1-866-712-7197

  • Medicare Rights Center
    Toll Free Phone: 1-888-HMO-9050

[Plan´s legal or marketing name] is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

You can get this information for free in other languages. Call [toll-free number] and [TTY/TDD numbers] during [hours of operation]. The call is free. [This disclaimer must be in English and all non-English languages that meet the Medicare or State thresholds for translation, whichever is most beneficiary friendly. The non-English disclaimer must be placed below the English version and in the same font size as the English version.]

You can also ask for this information in other formats, such as Braille or large print.

The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by [plan name]. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org.