MLTC Policy 23.02: Attachment E

  • Attachment E is also available in Portable Document Format

<Date>

<Name>
<Address>
<City>, <State>, <Zip>

INTENT TO DISENROLL LETTER

Dear <Member Name>:

This letter is to tell you the process to disenroll you from [Plan Name], your PACE plan. NYIA conducted a quality review of the Direct Eligibility assessment and found that you are NOT eligible to be in a PACE plan, you must be disenrolled from your PACE Plan. You will be disenrolled from [Plan Name] on [Plan Disenrollment Effective Date].

[Plan Name] enrolled you in our PACE plan based on your Direct Eligibility assessment completed by our staff.
When someone is enrolled in our PACE plan under Direct Eligibility, the New York Independent Assessor (NYIA) will do a verification review of the PACE assessment. The NYIA verification review of your Direct Eligibility assessment found that you are NOT eligible to be in a PACE plan.

What happens next?

You will be sent a Notice of Disenrollment 10 days before [Plan Disenrollment Effective Date] from New York Medicaid Choice, the State's managed care enrollment broker. Your Disenrollment Notice will also tell you about your right to a conference to discuss your case and also file a Fair Hearing.

Can I still get services?

You may still be able to get services, even though you don't qualify for PACE. To see if you are eligible for other services, please call NYIA at 1- 855-222-8350 (TTY: 1-888-329-1541).

Questions or concerns?

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

You may also contact 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 appeal options. To learn more about ICAN, go to www.icannys.org, or call 1-844-614-8800 . TTY: 711. All services are free.

Sincerely,