Managed Care Transfer Request

Confirmation Notice

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 asked to change your plans.
You will be in [MedicalPlan] on [PlanEffectiveDate].

Dear [MemberName; B-3]:                                 [MedicaidCIN; B-16]

You asked to change your plan(s). This letter is to confirm that on [PlanEffectiveDate], you will be in [MedicalPlan], a Managed Long-Term Care (MLTC) plan.

After [EndDate], you will not be in [OldHealthPlan] any more. This means that after [EndDate], [OldHealthPlan] will stop paying for your Medicare and Medicaid services.

[[ProgramIndicator] = F

Starting [PlanEffectiveDate], 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 [MedicalPlan]. Your 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 [MedicalPlan] at the phone number on the last page of this letter.

IMPORTANT! For at least the first 90 days after you join [MedicalPlan], 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 your new plan or if you have any problems with it, please call New York Medicaid Choice at the phone number on the last page of this letter.]

[[ProgramIndicator] = A or P

Starting [PlanEffectiveDate], 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 [MedicalPlan]. Your 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 for [MedicalPlan], please call it at the phone number on the last page of this letter. If you do not hear from your new plan or if you have any problems with it, call New York Medicaid Choice.]

[[ProgramIndicator] = R or L

Starting [PlanEffectiveDate], you will get your Medicaid services like home care, adult day care, or nursing home care from [MedicalPlan], a Managed Long-Term Care (MLTC) plan. Your 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 for [MedicalPlan], please call it at the phone number on the last page of this letter. If you do not hear from your new plan or if you have any problems with it, call New York Medicaid Choice.

Starting [PlanEffectiveDate], you will get your Medicare health services like doctor visits from Original Medicare. To get your Medicare services, including doctors and hospital care, you will need to use your red-white-and-blue Medicare card.]

Can I join a FIDA plan in the future?

Yes. You can join a FIDA Plan at another time. Call New York Medicaid Choice to learn more about the FIDA program and join a FIDA plan.

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 on the last page of this letter.

Thank you,
New York Medicaid Choice

Questions?

[MedicalPlan]

Call: [PlanPhone]
TTY users: [PlanTty]

Hours of Operation: 8:00 am - 8:00 pm
7 days a week

The call and the help are free.

Website: [PlanWebsite]

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