FIDA Demonstration Non-Renewal Notice for Individuals in FIDA Plans

• Notice is also available in Portable Document Format (PDF)

<Plan letterhead>

IMPORTANT: <Plan Name> won´t be offered in 2020. Keep this notice for your records

<Date>

<Participant Name>
<Participant Address>
<City>, <State> <ZIP>

Dear <Participant Name>,

<Plan Name> will no longer be participating in the Fully Integrated Duals Advantage (FIDA) program as of December 31, 2019. This means that you will not be able to get your services through <Plan Name> after December 31, 2019. In addition, if you don´t take action by December 31, you will be enrolled into <Medicare Dual Eligible Special Needs Plan Name>, which is a Medicare Dual Eligible Special Needs Plan (D–SNP) and <Medicaid Advantage Plus Plan Name>, a Medicaid Advantage Plus (MAP) Plan effective January 1, 2020. These plans are both offered by <Parent Organization´s Name>, which is the same company as your FIDA Plan. The <MAP Plan Name> MAP identification number is <MAP identification number>. You will be able to get all of your services through the D– SNP and MAP plans. These are special kinds of Medicare and Medicaid health plans called Medicaid Advantage Plus (MAP) paired with a Medicare Dual Eligible Special Needs Plan (D–SNP). These plans are offered by private companies that contract with Medicare and with the New York State Medicaid program. These plans cover all services that Original Medicare covers and prescription drugs.

You will soon get a letter from New York Medicaid Choice regarding your Medicaid Advantage Plus enrollment.

If you do not want to be enrolled in the <Medicare Dual Eligible Special Needs Plan Name> you have several options listed below.

What are my options?

Option 1: You can join a different plan that combines your Medicare and Medicaid coverage under one plan (through a different MAP plan and a D–SNP than the one that you are assigned in the letter from New York Medicaid Choice).

These plans will cover all of your current Medicare and Medicaid benefits, including prescription drugs. You will have a network of doctors and other providers you can see to receive care.

If you want to join a MAP plan paired with a D–SNP, please call New York Medicaid Choice at 1–855–600–3432.

Option 2: You can join another Medicare health plan, called a Medicare Advantage plan. A Medicare Advantage plan is offered by a private company that works with Medicare to provide benefits. Medicare Advantage plans cover all services that Original Medicare covers. Most include prescription drug coverage as well.

Option 3: You can change to Original Medicare. Original Medicare is coverage managed by the Federal government. If you choose Original Medicare, you should also pick a Medicare prescription drug plan. If you don´t pick a prescription drug plan yourself, Medicare will enroll you in one and send you a letter telling you the name of your new drug plan.

If you join a Medicare health plan or go back to Original Medicare (Option 2 or Option 3), you must continue to receive your community based long term care services, such as personal care services, through a partially capitated Managed Long Term Care (MLTC) plan. You will need to call New York Medicaid Choice at 1–855–600–3432 to select a MLTC plan or you will be assigned to one.

Even if Medicare places you in Original Medicare and/or chooses a drug plan for you, you still have other opportunities to join a Medicare health or drug plan. Because your plan will no longer be available to you, and to provide you additional time to evaluate your options, you have a special opportunity to join a new plan anytime until February 29, 2020.

NOTE: If you have End–Stage Renal Disease (ESRD), you have a one–time right to join a new Medicare health plan. Keep a copy of this letter as proof of your right to join a new Medicare health plan.

To find out which Medicare health plans are in your area, or to enroll in a Medicare health plan, call 1–800–MEDICARE (1–800–633–4227) or TTY: 1–800– 486–2048, 24 hours a day, 7 days a week. The calls are free. You may also visit Medicare.gov, Medicare´s official web site has tools that can help you compare plans and answer your questions. Click "Find health & drug plans" to compare the plans in your area.

Option 4: You can enroll in the Program of All–Inclusive Care for the Elderly (PACE). PACE is available in your county. If you choose to enroll in PACE, it will cover all of your current Medicare and Medicaid benefits, including prescription drugs. You will go to a single center in your area to receive all of your care.

To get more information about PACE, call New York Medicaid Choice at 1– 855–600–3432.

MAP and PACE may be good options if you want to continue to receive all your services through a single plan. You may prefer MLTC if you are looking for greater flexibility in choosing your doctors and other providers.

If you do not pick the above choice by December 31, 2019, you will be enrolled into a new MAP and D–SNP Plan as of January 1, 2020. You will continue to see your current Medicaid providers for 120 days after enrollment in the new Medicaid plan or until the new plan has conducted an assessment and you agree to the new plan of care. For Medicare, you will continue to get your current Part D medications for up to 90 days until your new care plan is in place.

You will also get a letter from New York Medicaid Choice with more information about your new MAP and D–SNP Plan.

No matter what choice you make, you will still have Medicare and Medicaid benefits, including prescription drugs.

We recognize the inconvenience this may cause and are committed to making this transition as smooth as possible.

Sincerely,

<Signature>

________________________________________________________________________________________________

<Plan Name> FIDA Plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by <Plan Name> FIDA Plan. ICAN may be reached toll–free at 1–844–614–8800 or online at icannys.org.