DRAFT

Voluntary Disenrollment Denial Notice #1

  • Denial Notice also available in Portable Document Format (PDF, 451KB)

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]

We cannot disenroll you at this time.

Dear [Member Name]:                                 [CIN]

You´ve asked to be disenrolled from (leave) [Plan], a FIDA (Fully Integrated Duals Advantage) plan. We cannot process your request to disenroll from [Plan] because:

Someone other than you asked if you could leave [Plan]. That person is NOT your authorized representative. You have NOT told us before that this person can make legal decisions for you.

Please call us so that we can process your request to leave [Plan Name].

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

You have the right to ask us to review our decision. If you still disagree, 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.

  • 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 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?

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

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

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.