MLTC Policy 23.02: Attachment D

  • Attachment D is also available in Portable Document Format

<Date>

<Barcode> <Letter Code>
<Name>
<Address>
<City>, <State>, <Zip>

Important Notice About Your Plan Enrollment

Dear <Consumer Name>:                    <CIN>

Thank you for joining a Managed Long Term Care (MLTC) Plan. This letter is to confirm that you will be enrolled in <Plan Name> starting on <Effective date>.

Please Note: The Medicaid Program requires you to be in an MLTC plan to keep getting community based long-term care services, such as personal care or Consumer Directed Personal Assistance Services (CDPAS).

What happens next:

If [Medical Plan TTY Phone; B-7] in the B record position 108 - 121 is blank/null, CSG to print 711

  • Your new Plan will send you a welcome letter and health plan card.
  • You will also receive information about your benefits and the services your MLTC plan covers.
  • You may reach <Plan Name> at <Plan phone number>. TTY: <TTY Number>.

If [Program Indicator; A-28] in the A record position 261 is "R" for Partial, and [Voluntary Mandatory; A-23] in the A record position 240 is "M" for Mandatory, CSG to print the below bullets:

Changing health plans:
  • You have been enrolled into an MLTC Medicaid plan.
  • You can change your health plan within 90 days of your Enrollment Start Date. Call us before <lock in start date> if you want to change your plan.
  • After these 90 days, you will not be able to transfer to another MLTC Medicaid plan for nine (9) more months, unless you have a good reason to change plans.
  • If you qualify, you can change to another type of Managed Long Term Care plan such as Medicaid Advantage Plus (MAP), or Programs of All-Inclusive Care for the Elderly (PACE) at any time.
Questions? Call Us.

If you have any questions about this notice or you want to join another MLTC plan, please call us. Our counselors will tell you about your MLTC Plan options and put you in contact with the plan of your choice. You may call us at 1-888-401-6582 (TTY: 1-888-329-1541). You can call Monday - Friday, from 8:30 a.m. - 8:00 p.m. and Saturday, from 10:00 a.m. - 6:00 p.m. Our counselors can help you in any language.

Thank you,
New York Medicaid Choice

Information about The Independent Consumer Advocacy Network

The Independent Consumer Advocacy Network (ICAN) is the ombudsman program for health plan members. ICAN can answer your questions and give you free, independent advice about your coverage, complaints, and appeals' options. To learn more about ICAN, go to www.icannys.org, or call 1-844-614- 8800 between the hours of 8am to 6pm. TTY: 711. All services are free.

Questions? Call 1-888-401-MLTC or 1-888-401-6582 (TTY: 1-888-329-1541).
Monday-Friday, 8:30 a.m. to 8:00 p.m. and Saturday, 10:00 a.m. to 6:00 p.m.

SC - MAP and MLTC Enrollment Confirmation Notice - E - 08/2020