Voluntary Enrollment

Denial 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 cannot accept your application to join the FIDA program

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

Thank you for applying to the Fully Integrated Duals Advantage (FIDA) program. We cannot accept your application to join the FIDA program for the following reason:

  • Print Reason text
  • [Reason(s); B-9]

    • This action has been taken in accordance with Public Health Law 4403-f.

    What you should know about this decision:

    You will keep getting your benefits from the Medicare/Medicaid plan(s) you have now. The way you get benefits such as medicines, doctor and hospital visits, home care and nursing home care will stay the same.

    You have the right to ask us to review our decision. If you still disagree, you have the right to appeal our decision.

    You may ask New York Medicaid Choice and/or the State of New York to review this decision.

    • If you disagree and would like to talk to someone about this decision, you may ask for a "conference." A conference is an informal meeting in person or on the phone. At the conference, you may ask why New York Medicaid Choice made the decision. You may also provide more information and ask New York Medicaid Choice to look again at the decision.
    • If you still disagree, you may "appeal," or formally ask the state of New York to review the decision. To do that, you can ask for a State fair hearing.

    Please read "How to Ask New York Medicaid Choice and/or the State of New York to Review This Decision" included with this notice. It has more information on how to ask for a conference and/or a State fair hearing.

    If you decide to ask for a State fair hearing, please read, for more information, "You May Ask for a Fair Hearing within 60 Days from the Date of This Notice", also included with this notice.

    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.