DRAFT

Voluntary Disenrollment 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 are not in [FIDA Plan] anymore. You will be placed in [MLTC plan] starting [eff.enrollment date].

Dear [Member Name]:                                 [CIN]

On [date], we confirmed that you would not be in [FIDA plan] after [eff. disenrollment date]. We also told you that you might have to be placed in [MLTC plan] for a short period of time if your safe discharge process was not complete by the end of the month.

As of [letter date] you are NOT in [FIDA plan name] anymore. Additionally, you will NOT be placed in [MLTC Medicaid plan] starting [eff. enrollment date] because you and [FIDA plan] completed the safe discharge process.

How will I get my Medicaid services?

After [date], you will need to use your New York State Benefit Identification Card (BIC) to get your Medicaid services. Please keep in mind that you will not be able to get your long term care services any more, including personal care, adult day care, and nursing home care. This is because you chose to leave the FIDA program and the Managed Long-Term Care (MLTC) altogether.

How will I get my Medicare services?

  • Starting [date], you will get your Medicare health services like doctor visits from Original Medicare. To get services from Original Medicare, including doctors and hospital care, you will need to use your red-white- and-blue Medicare card.
  • IMPORTANT: You need to choose a Medicare Prescription Drug Plan

    When [FIDA plan] services end on [eff. disenrollment date], [FIDA plan] prescription drug coverage ends too. You can enroll in a Medicare Advantage plan that includes prescription drug coverage or a Medicare Prescription Drug Plan. If you don't select a new prescription drug plan, Medicare will enroll you in one.
  • If you have questions or would like to join a Medicare Advantage or Medicare Prescription Drug Plan in your area, call Medicare at the phone number on the last page of this letter.

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 join a FIDA plan.

If you have any questions, call the ombudsman office through the Independent Consumer Advocacy Network (ICAN) at the phone number on the other side of this letter.

Thank you,
New York Medicaid Choice

Questions?

New York Medicaid Choice (NYMC)

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.