Involuntary Disenrollment Confirmation Notice

  • Involuntary Disenrollment Confirmation Notice also available in Portable Document Format (PDF, 408KB)

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]

[If Participant is being involuntarily disenrolled for any reason other than death (see below for note in event of death):

You may not get your services and medicines through [FIDA plan name] after [disenrollment date].

Dear [Consumer Name]:                                 [CIN]

You may not get your services and medicines through [FIDA plan name] after [disenrollment date], and you cannot stay in the FIDA program because:

[Insert one of the following reasons]

  • You called 1-800-MEDICARE to join a Medicare plan or you directly called that plan to join it. You cannot stay in both [FIDA plan name] and your new Medicare plan. If you want to join a FIDA plan again, call New York Medicaid Choice at the phone number below.
  • You do not have Medicare Part A and/or Part B any more.

    We learned that your Medicare ended on [disenrollment date]. You must have Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) to be in [FIDA Plan] FIDA Plan. If you believe there has been a mistake and you should still have Medicare Part A and/or Part B:

    Call the Social Security Administration at the phone number below.
    • Ask them to fix your records.
    • Also, ask them to send you a letter that says they have fixed your records.
  • After that, call New York Medicaid Choice at the phone number below.
    • Tell us that you got the letter from the Social Security Administration. After you call us, we will ask Medicare and Medicaid if they have fixed your records.
  • You do not have Medicaid any more.
  • You do not meet one or more FIDA program requirements.
  • You informed us that you have moved from the area where FIDA program works.
  • You have been living outside the area where FIDA program works for more than six consecutive months. FIDA Program rules require us to disenroll you if you are out of the service area for six months or more.
  • You are in a county jail, New York Department of Corrections facility, or Federal penal institution. Individuals who are incarcerated may not participate in FIDA.
  • You materially misrepresented whether you had other insurance that also covers healthcare services when you were applying for enrollment. This is not allowed and the FIDA Program has decided [that you cannot stay in the program any more.] [or] [to move you to another FIDA plan for doing this. You will soon receive a separate notice with information about your new plan.].
  • You have willfully misused or loaned your [FIDA plan name]ID to another person to get services and/or medicines. This is not allowed and the FIDA Program has decided [that you cannot stay in the program any more] [or] [to move you to another FIDA plan for doing this. You will soon receive a separate notice with information about your new plan.].
  • You have been disruptive, unruly, threatening or uncooperative. [FIDA plan name] cannot provide quality service to you and/or other people because of your behavior. In addition, you do not have a physical or behavioral health condition that caused such behavior. This is not allowed and the FIDA Program has decided [that you cannot stay in the program any more] [or] [to move you to another FIDA plan for doing this. You will soon receive a separate notice with information about your new plan.].
  • You have knowingly failed to complete and submit any necessary consent or release form. Because of this, [FIDA plan name] and providers could not access necessary health care and service information about you. This is not allowed and the FIDA Program has decided [that you cannot stay in the program any more] [or] [to move you to another FIDA plan for doing this. You will soon receive a separate notice with information about your new plan.].

This action has been taken in accordance with Public Health Law 4403-f.

You have the right to ask us to review our decision. After our review, if you still disagree with the decision to disenroll you, you have the right to appeal our decision.

You may ask New York Medicaid Choice and/or the State of New York to review this decision. Once we review this decision, we will notify you of the decision of our review.

  • If you disagree and would like to talk to someone about this decision, you may ask for a "conference." A conference is an informal meeting in person or on the phone. At the conference, you may ask why New York Medicaid Choice made the decision. You may also provide more information and ask New York Medicaid Choice to look again at the decision.
  • If you still disagree, you may "appeal," or formally ask the state of New York to review the decision. To do that, you can ask for a State fair hearing.

Please read "How to Ask New York Medicaid Choice and/or the State of New York to Review This Decision" included in the envelope. It has more information on how to ask for a conference and/or a State fair hearing.

If you decide to ask for a State fair hearing, please read, for more information, "You May Ask for a Fair Hearing within 60 Days from the Date of This Notice", also included in the envelope.

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.

INSERT AS MANY OF THE FOLLOWING AS ARE APPLICABLE BUT DO NOT INSERT ANY IF THE PERSON IS BEING TRANSFERRING TO ANOTHER FIDA PLAN:

[[INSERT FOR PARTICIPANTS THAT REMAIN MEDICAID ELIGIBLE if consumer moves from FIDA to FIDA AS A RESULT OF AN APPROVED DISCRETIONARY INVOLUNTARY DISENROLLMENT]

Starting [new effective date], you will get all of your Medicare and Medicaid services, including your long-term care like home care or nursing care, and all of your medicines from [name of new FIDA Plan].]

[[INSERT FOR PARTICIPANTS THAT REMAIN MEDICAID ELIGIBLE if consumer moves from FIDA to Partial plan]

What will happen to your Medicaid benefits:

Starting [new effective date], you will get your long-term care like home care or nursing home care from [name of partial plan].

  • [New Partial Plan] will mail you a welcome letter and your new plan ID card. It will also contact you within 30 days. If you have any questions, call [Plan Name] at the phone number below.
  • For at least the first 90 days after you join [New Partial Plan], you will be able to get all of your current services, including doctor visits and long-term care like home care or nursing home care.
  • If you do not hear from [New Partial Plan] or if you need help with any problems with [New Plan], call New York Medicaid Choice at the number below.]

[[INSERT FOR PARTICIPANTS THAT REMAIN MEDICAID ELIGIBLE if consumer is moving from FIDA to a MAP or PACE plan]

Starting [new effective date], you will get all of your Medicare and Medicaid services, including your long-term care like home care or nursing care, from [name of MAP or PACE].

What happens next:

  • [New Plan] will mail you a welcome letter and your new plan ID card. It will also contact you within 30 days. If you have any questions, call [Plan Name] at the phone number below.
  • For at least the first 90 days after you join [New Plan], you will be able to get all of your current services, including doctor visits and long-term care like home care or nursing home care.
  • If you do not hear from [New Plan] or if you need help with any problems with [New Plan], call New York Medicaid Choice at the number below.]

[[INSERT FOR PARTICIPANTS THAT REMAIN MEDICARE AND MEDICAID ELIGIBLE]

What will happen to your Medicare benefits:

Starting [Medicare enrollment effective date], you will get your Medicare services like doctor visits from Original Medicare and medicines from a Medicare prescription drug plan, which will be assigned to you unless you call 1-800-Medicare to make a choice of plan. To get your Medicare services, you will need to use your red-white-and-blue Medicare card. If you prefer to receive you Medicare through a Medicare Advantage Plan instead of through Original Medicare, please call 1-800-Medicare to choose your Medicare Advantage Plan.].

[[INSERT FOR PARTICIPANTS THAT REMAIN MEDICARE ELIGIBLE BUT ARE NO LONGER MEDICAID ELIGIBLE]

What will happen to your Medicare benefits:

Starting [Medicare enrollment effective date], you will get your Medicare services like doctor visits from Original Medicare and medicines from a Medicare prescription drug plan, which will be assigned to you unless you call 1-800-Medicare to make a choice of plan. To get your Medicare services, you will need to use your red-white-and-blue Medicare card. If you prefer to receive you Medicare through a Medicare Advantage Plan instead of through Original Medicare, please call 1-800-Medicare to choose your Medicare Advantage Plan.

You have some time to join another Medicare plan. Act now!

Because you cannot stay in the FIDA program and [FIDA plan name], you have until [two months after the FIDA plan disenrollment date] to join a Medicare health plan or a Medicare prescription drug plan. If you sign up for a new Medicare health plan or Medicare Part D (prescription drug) plan by the end of a month, you will become a member of that plan on the 1st of the following month. If you do not act, you will keep getting your Medicare benefits from [FIDA plan] only until [disenrollment date].

After [two months after the FIDA plan disenrollment date], you can join a new Medicare Part D (prescription drug) plan or Medicare health plan only from October 15 through December 7 each year.

However, if your situation is one of the described below, you can join a new Medicare Part D (prescription drug) plan or Medicare health plan at another time:

  • You move outside of the area where your Medicare plan works.
  • You want to join a Medicare plan in your area with a 5-star rating.
  • If we find that you need extra help paying for prescription drug coverage or if you are already getting extra help with your prescription drug costs, you may join or leave a plan at any time. If your extra help ends, you can still change your Medicare plan for two months after you find out that you are not getting extra help.

If you would like to learn how to re-join your Medicare Advantage plan that you had before joining [FIDA plan name], please call Medicare or New York Medicaid Choice at the phone numbers 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.

Online: 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.

Online: 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.

Online: www.icannys.org

How to Ask New York Medicaid Choice and/or the State of New York to Review This Decision

Your right to a conference:

You may have a phone or in-person conference with New York Medicaid Choice (NYMC) to review a decision regarding your eligibility. If you want a conference, you should ask for one as soon as possible. At the conference, if an NYMC representative finds that the decision is wrong, or if, because of information you provide, he or she changes the decision, NYMC will send you a new notice. Please see NYMC contact information below.

To ask for a fair hearing:

If you still disagree with NYMC, you may ask for a State fair hearing. To ask for a fair hearing, please see below the contact information of the New York State Office of Temporary Disability and Assistance.

____ I want a fair hearing. The Agency´s decision is wrong because:

________________________________________________________________________

________________________________________________________________________

Your name: _______________________________________________________________

Name of your plan: _________________________________________________________

Your address: _____________________________________________________________

Your phone #: _____________________________________________________________

Case #: _____________________________CIN #: _______________________________

Your signature: _____________________________________ Date: __________________

To ask New York Medicaid Choice for a conference:

Call: 1-855-600-3432
TTY users: 1-888-329-1541
A free interpreter: 1-855-600-3432
Fax: 1-917-228-8899

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

Mail:

Conference Unit
New York Medicaid Choice
P.O. Box 5016
New York, NY 10274

To ask Office of Temporary Disability and Assistance for a fair hearing:

Call: 1-800-342-3334
Fax: 1-518-473-6735.

Walk-In:

Office of Administrative Hearings
14 Boerum Place, 1st floor
Brooklyn, New York

Mail:

Fair Hearing Section, OTDA
P.O. Box 22023,
Albany, NY, 12201-2023

Online:
www.otda.ny.gov/hearings/

You May Ask for a Fair Hearing within 60 Days from the Date of This Notice

If you ask for a fair hearing:

The New York State Office of Temporary Disability and Assistance will send you a notice informing you of the time and place of the hearing. You have the right to be represented by a legal counsel, a relative, a friend or other person, or represent yourself. At the hearing, you, your attorney or other representative will have an opportunity to present written or oral evidence to show why the decision is wrong, as well as an opportunity to question any persons who appear at the hearing. Also, you have the right to bring witnesses to speak in your favor. You should bring to the hearing any documents that may be helpful in presenting your case.

If you need legal help:

If you need free legal help, you may be able to obtain such assistance by contacting the Independent Consumer Advocacy Network (ICAN), your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under "Lawyers" or by calling the number indicated on the first page of this notice.

If you need to get a copy of your case file:

To help you get ready for the hearing, you have the right to look at your case file. Call or write New York Medicaid Choice at the phone number below to get free copies of your case file. We will also give the same copies to the hearing officer at the fair hearing. You can also get free copies of other documents from your file that you may need to prepare for your fair hearing.

If you want copies of documents from your case file, you should ask for them ahead of time. Usually, they will be sent to you within three working days of when you ask for them. If your hearing is within three working days of when you ask for them, your case file documents may be given to you at the fair hearing.

New York Medicaid Choice

Call: 1-855-600-3432
TTY users: 1-888-329-1541
A free interpreter: 1-855-600-3432
Fax: 1-917-228-8899

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

Mail:

Record Access Unit
New York Medicaid Choice
P.O. Box 5016
New York, NY 10274

[If consumer died:

To the estate of [Consumer Name]:                                 [CIN]

We are sorry to hear that [Consumer name] has passed away. [FIDA plan name] will stop providing Medicare and Medicaid services and medicines on [disenrollment date]. If this information is incorrect, please call New York Medicaid Choice or the ombudsman office through theor 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.

Online: 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.

Online: 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.

Online: www.icannys.org