Voluntary Disenrollment

Confirmation Notice with Notice of Safe Discharge Transfer to MLTC

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 [Consumer]:                                 [CIN]

As of [letter date], you are NOT in [FIDA plan] anymore. However, you will be placed in [MLTC plan] on [eff. enrollment date] because you and [FIDA plan] did not yet complete the safe discharge process and we do not think the process will be completed by the end of this month.

[MLTC plan] is run by the company that runs [FIDA plan]. You will stay in [MLTC plan] until the safe discharge process is complete. You will not stay in this plan for more than one month. If you have any questions for [MLTC plan], please call at [MLTC phone number].

Once the safe discharge process is complete, you will not be in [MLTC plan] anymore. 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.

If you do not hear from [MLTC plan] or if you have any problems with that plan, call New York Medicaid Choice (NYMC) or the ombudsman office through the Independent Consumer Advocacy Network (ICAN) at the phone numbers on the last page of this letter.

How will I get my Medicare services?

  • Starting [effective enrollment 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 [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 Drugs Plan in your area, call Medicare at the phone number below.
  • 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 numbers below.

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.

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

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.