DRAFT

Disenrollment Cancellation and Reinstatement Notice - Confirmation of Continued FIDA Plan Enrollment

New York Medicaid Choice
1-855-600-FIDA

New York State Medicaid Managed Care Enrollment Program
P.O. Box 5081, New York, NY 10274-0792

[Date]

[Barcode] [Letter Code]
[Name]
[Address]
[City], [State], [Zip]

You are still in [Plan name].

Dear [Consumer Name]:                                 [CIN]

You will re-join [FIDA plan] on [effective date] because:

[reason for reinstatement]

This means that starting [effective date], you can keep getting all of your Medicare and Medicaid services - like doctor visits, home care and nursing home care - and medicines through [FIDA Plan name].

Important! If you have already signed up for a Medicare health plan or Medicare Part D prescription drug plan:

  • To stay in [FIDA Plan name], you must call the Medicare health plan or Part D prescription drug plan and cancel the plan before it starts!
  • Tell the Medicare health plan or Part D prescription drug plan that you do not want to be a member of it anymore and you will stay in [FIDA Plan name].

If you need help understanding this letter, if you have questions about differences between various Medicare and Medicaid programs, or if you have questions about your rights, please call the ombudsman office through the Independent Consumer Advocacy Network (ICAN) at the phone number below.

Thank you,
New York Medicaid Choice

Questions?

New York Medicaid Choice

For questions about FIDA program and your Medicaid benefits

Call: 1-855-600-3432
TTY users: 1-888-329-1541
A free interpreter: 1-855-600-3432

Monday-Friday, 8:30 am - 8:00 pm
Saturday, 10:00 am - 6:00 pm

The call and the help are free.

Website: www.nymedicaidchoice.com

Medicare

For questions about your Medicare benefits

Call: 1-800-MEDICARE (1-800-633-4227)
TTY users: 1-877-486-2048

24 hours a day, 7 days a week

The call and the help are free.

Website: www.medicare.gov

Independent Consumer Advocacy Network (ICAN)

For questions about your rights

Call: 1-844-614-8800
TTY users: 711
A free interpreter: 1-844-614-8800

Monday-Friday, 8:00 am - 8:00 pm

The call and the help are free.

Website: www.icannys.org

This is an important document. If you need help to understand it, please call 1-855-600-3432. We can give you an interpreter for free.

Please refer to language sheet for additional information.