Voluntary Enrollment Pended

Employer, Union, or Retiree Member 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]

Please confirm that you want to join a FIDA plan.

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

We got your application to join a FIDA plan. Before we process your application, we need you to confirm that you want to join the plan.

We learned from Medicare that you get your medicines through your employer/union health insurance.

If you join FIDA, you, your spouse, and your other dependents could lose this and other benefits.

Please contact the benefits administrator at your former employer or union and tell them that:

  • You are thinking about joining a FIDA plan
  • The FIDA plan will provide both your Medicare and Medicaid benefits
  • The FIDA plan will cover your medicines (and serve as your Medicare prescription drug plan)

Ask the benefits administrator what will happen to your current healthcare benefits if you join a FIDA Plan.

Call New York Medicaid Choice at the phone number on the last page of this letter to say if you still want to join a FIDA plan. If we do not hear from you by [ResponseDate; A-16], New York Medicaid Choice will not process your application.

If you need help understanding this letter 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 addional information.