Insert Plan Header

• Attachment C is also available in Portable Document Format

[Date; A-15]

<Name>
<In Care Of>
<Address>
<City>, <State>, <Zip>

PACE DIRECT ELIGIBILITY ASSESSMENT OUTCOME LETTER

Dear [First and Last Name]:

Thank you for your interest in joining our [Plan Name], a Program of All- inclusive Care for the Elderly (PACE) plan. Based on the Direct Eligibility assessment process completed by [Plan Name], you are not eligible to join our PACE plan.

You may contact the New York Independent Assessor (NYIA) to have an assessment to see if you may be eligible for PCS, CDPAS, and/or Managed Long Term Care (MLTC), including PACE. NYIA will provide you the results of their assessment and let you know your available options.

What is NYIA?

NYIA is the state contracted independent assessor, that conducts assessments for individuals seeking personal care services (PCS), consumer directed personal assistance services (CDPAS), or Managed Long Term Care (MLTC), including PACE. You can contact NYIA at 1-855- 222-8350 (TTY: 1888-329-1541). Monday-Friday, 8:30 a.m. to 8:00 p,m. and Saturday, 10:00 a.m. to 6 p.m.

If your situation changes and feel you may qualify for PACE, please contact us.

Questions?

Please feel free to reach out to [Insert Plan Name], [Insert Plan Phone Number], [Insert Plan Hours of Operation]. [Insert TTY/TDD Information].

Information for people in New York State's managed care plans

The Independent Consumer Advocacy Network (ICAN) is the ombudsman program for health plan members. If you have a problem with your health plan, doctor or other care provider - ICAN can help. To learn more about ICAN, go to www.icannys.org, or call 1-844-614-8800. TTY: 711. All services are free.

Thank you,

[Plan Name]