Opt-Out Confirmation and Cancellation of Enrollment

from MLTC or FFS to FIDA Confirmation Notice

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 will NOT sign you up for a FIDA plan.

Dear [MemberName; B-3]:                                 [MedicaidCIN; B-16]

You recently told New York Medicaid Choice or 1-800 Medicare that you do not want to be a part of a FIDA plan. You will NOT become a part of that plan unless you later decide that you want to join the FIDA program.

You will keep getting your benefits from your current Medicare and/or Medicaid plan(s). The way you get you benefits - like medicines, doctor and hospital visits, home care and nursing home care - will stay the same.

IMPORTANT! If you were enrolled in another Medicare Advantage plan or Medicare prescription drug plan before joining FIDA, you should automatically stay in that plan now that you have chosen not to join FIDA. In the next 2 weeks, you should get a letter from your Medicare plan that says you are still a member of your plan.

What if I do not get a letter from my Medicare plan?

If you do not get the letter, please call your Medicare plan to confirm that you are still a member. Please save this letter. Your Medicare plan may ask for a copy of this letter.

Yes. If you change your mind, you can join a FIDA Plan at another time. Call New York Medicaid Choice (NYMC) at the phone number on the last page of this letter to learn more about FIDA plans and to join one of them.

If you need help understanding this letter, if you have questions about differences between various Medicare and Medicaid programs, 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.

Can I become a part of a FIDA plan in the future?

Yes. If you change your mind, you can join a FIDA Plan at another time. Call New York Medicaid Choice (NYMC) at the phone number on the last page of this letter to learn more about FIDA plans and to join one of them.

If you need help understanding this letter, if you have questions about differences between various Medicare and Medicaid programs, 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

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.