Attachment 1: Draft New York Medicaid Choice Member Notice

  • Letter is also available in Portable Document Format

New York
Medicaid Choice           New York State´s Medicaid managed care enrollment program


1–888–401–6582           P.O. Box 5009, New York, NY 10274–5009
Ask • Choose • Enroll

New Reason Code Indicator= C                               [Date]

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

Dear [Member Name]:                                              [CIN]

New York State changed the way your nursing home benefit is covered under Medicaid. Because of this change, you will be disenrolled from [Old Health Plan] on [Plan Disenrollment Effective Date]. After [Plan Disenrollment Effective Date], you will continue to receive your nursing home services through regular Medicaid if you are eligible.

Why you can no longer stay in [Old Health Plan]

The plan coverage for this benefit is limited to three months. Our records indicate you have been receiving long–term nursing home services for more than three months. You can receive coverage for your nursing home care through regular Medicaid if you are eligible for Medicaid´s nursing home coverage.

The Department of Health sent you a letter about the Medicaid program changes that required the plan to change your nursing home benefits.

What happens next
  • If you have not already applied, you will need to apply for coverage of your nursing home stay with the Local Department of Social Services (LDSS). The LDSS will make your eligibility determination. While you are waiting for your eligibility determination, you should continue to pay your income contribution to the nursing home. You can stay in your nursing home.
  • Your local Department of Social Services will send you a letter that has information about your Medicaid benefits. Call the phone number on that letter if you have questions about your Medicaid services.
Questions?

If you have questions about this letter, call [Old Health Plan] at [Medical Plan Phone]. You may also call New York Medicaid Choice at the phone number listed at the end of this letter.

(FH#299 A)
_______________________________________________________________________________________________

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.

DU–MLTC NH Disenrollment 05–2018 _v01


This action has been taken in accordance with Public Health Law 4403–f. If you would like to talk to someone about this decision, you may have a conference to review these actions. If you believe this decision is wrong, you may ask for a State fair hearing. Please read the back of this notice to find out how to arrange a conference and/or a fair hearing.

FH#299A–NYC–0613

NOTICE OF DISENROLLMENT FROM
<MLTC PLAN NAME>

RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one as soon as possible. At the conference, if we discover that we made the wrong decision, or if, because of information you provide, we determine to change our decision, we will take corrective action and give you a new notice. You may ask for a conference by calling New York Medicaid Choice at 1–888–401–6582, TTY: 1–888–329–1541. You can also send a written request by fax: 917–228–8899, or mail it to: Conference Unit, New York Medicaid Choice, P.O. Box 5016, New York, NY 10274. These phone numbers and address are only to ask for a conference. It is not the way you request a fair hearing. If you ask for a conference, you are still entitled to a fair hearing. If you want to have your benefits continue unchanged, you must request a fair hearing in the way described below. A request for a conference alone will not result in continuation of benefits. Read below for fair hearing information.

RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by:

  1. TELEPHONE: Statewide Toll Free 1–800–342–3334. Please have this notice with you when you call.
  2. FAX: Fax a copy of all the pages of this notice to (518) 473–6735.
  3. WALK–IN: Bring a copy of all the pages of this notice to the Office of Administrative Hearings, of the Office of Temporary & Disability Assistance, 14 Boerum Place, 1st floor, Brooklyn, New York.
  4. TO WRITE FOR A FAIR HEARING: Fill in the space below and send a copy of all pages of this notice to:
    • Fair Hearing Section
      New York State Office of Temporary and Disability Assistance
      P.O. Box 22023,
      Albany, New York, 12201–2023
    Please keep a copy for yourself.
  5. OR ONLINE ON THE INTERNET. Complete the online request form at the following Web page:
    https://www.otda.state.ny.gov/oah/FHReq.asp

    I want a fair hearing. The Agency´s action is wrong because: __________________________

_____________________________________________________________________________________

Print Name of Client: _______________________________ Name of Plan: ________________________

Signature of Client: _______________________________________ Date: _________________________

Address: __________________________________________ Phone #: ____________________________

Case #: __________________________________________ CIN #: _______________________________

TP/MM/NOTICE-DU-E/1                                                                                                                                                   REV J


If you do NOT want your aid to continue while waiting for the decision of the fair hearing, check the box below and send this page to the Fair Hearing Section, New York State Office of Temporary and Disability Assistance, P.O. Box 22023, Albany, New York, 12201.

  • I do NOT want my aid to continue while waiting for the decision of the fair hearing. I understand if I lose the fair hearing I may be responsible for the cost of any Medical Assistance benefits that the fair hearing determines I should not have received.

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under "Lawyers" or by calling the number indicated on the first page of this notice.

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you call or write us, we will provide you with free copies of the documents from your file which we will give to the hearing officer at the fair hearing. Also, if you call or write us, we will provide you with free copies of other documents from your file which you think you may need to prepare for your fair hearing. To ask for documents or to find out how to look at your file, contact New York Medicaid Choice at 1–888–401–6582, TTY: 1–888–329–1541, or write to us. You can send your request by fax: 917–228–8899, or mail it to: Record Access Unit, New York Medicaid Choice, P.O. Box 5016, New York, NY 10274.

If you want copies of documents from your case file, you should ask for them ahead of time. Usually, they will be sent to you within three working days of when you ask for them. If your hearing is within three working days of when you ask for them, your case file documents may be given to you at the fair hearing.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get additional copies of documents, call New York Medicaid Choice at 1–888–401–6582, TTY: 1–888–329–1541, or write to us. You can send your request by fax: 917–228–8899, or by mail it to: Record Access Unit, New York Medicaid Choice, P.O. Box 5016, New York, NY 10274.

_______________________________________________________________________________________________

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.

DU–MLTC NH Disenrollment 05–2018 _v01


FH#299A–NYC–0613

NOTICE OF DISENROLLMENT FROM
<MLTC PLAN NAME>

RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one as soon as possible. At the conference, if we discover that we made the wrong decision, or if, because of information you provide, we determine to change our decision, we will take corrective action and give you a new notice. You may ask for a conference by calling New York Medicaid Choice at 1–888–401–6582, TTY: 1–888–329–1541. You can also send a written request by fax: 917–228–8899, or mail it to: Conference Unit, New York Medicaid Choice, P.O. Box 5016, New York, NY 10274. These phone numbers and address are only to ask for a conference. It is not the way you request a fair hearing. If you ask for a conference, you are still entitled to a fair hearing. If you want to have your benefits continue unchanged, you must request a fair hearing in the way described below. A request for a conference alone will not result in continuation of benefits. Read below for fair hearing information.

RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by:

  1. TELEPHONE: Statewide Toll Free 1–800–342–3334. Please have this notice with you when you call.
  2. FAX: Fax a copy of all the pages of this notice to (518) 473–6735.
  3. TO WRITE FOR A FAIR HEARING: Fill in the space below and send a copy of all pages of this notice to:
    • Fair Hearing Section
      New York State Office of Temporary and Disability Assistance
      P.O. Box 22023,
      Albany, New York, 12201–2023
    Please keep a copy for yourself.
  4. OR ONLINE ON THE INTERNET. Complete the online request form at the following Web page:
    https://www.otda.state.ny.gov/oah/FHReq.asp

    I want a fair hearing. The Agency´s action is wrong because: __________________________

_____________________________________________________________________________________

Print Name of Client: _______________________________ Name of Plan: ________________________

Signature of Client: _______________________________________ Date: _________________________

Address: __________________________________________ Phone #: ____________________________

Case #: __________________________________________ CIN #: _______________________________

TP/MM/NOTICE-DU-E/1                                                                                                                                                   REV J


IF YOU REQUEST A FAIR HEARING, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by a legal counsel, a relative, a friend or other person, or represent yourself. At the hearing you, your attorney or other representative will have the opportunity to present written or oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, pay stubs, receipts, medical bills, medical verification, letters, etc. that may be helpful in presenting your case.

CONTINUING YOUR BENEFITS: If you request a fair hearing before the effective date stated in this notice, you will continue to receive care through your managed care provider until the fair hearing decision is issued. However, if you lose the fair hearing, New York State may recover the cost of any Medical Assistance benefits that you should not have received.

If you do NOT want your aid to continue while waiting for the decision of the fair hearing, check the box below and send this page to the Fair Hearing Section, New York State Office of Temporary and Disability Assistance, P.O. Box 22023, Albany, New York, 12201.

  • I do NOT want my aid to continue while waiting for the decision of the fair hearing. I understand if I lose the fair hearing I may be responsible for the cost of any Medical Assistance benefits that the fair hearing determines I should not have received.

LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under "Lawyers" or by calling the number indicated on the first page of this notice.

ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you call or write us, we will provide you with free copies of the documents from your file which we will give to the hearing officer at the fair hearing. Also, if you call or write us, we will provide you with free copies of other documents from your file which you think you may need to prepare for your fair hearing. To ask for documents or to find out how to look at your file, contact New York Medicaid Choice at 1–888–401–6582, TTY: 1–888–329–1541, or write to us. You can send your request by fax: 917–228–8899, or mail it to: Record Access Unit, New York Medicaid Choice, P.O. Box 5016, New York, NY 10274.

If you want copies of documents from your case file, you should ask for them ahead of time. Usually, they will be sent to you within three working days of when you ask for them. If your hearing is within three working days of when you ask for them, your case file documents may be given to you at the fair hearing.

INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get additional copies of documents, call New York Medicaid Choice at 1–888–401–6582, TTY: 1–888–329–1541, or write to us. You can send your request by fax: 917–228–8899, or by mail it to: Record Access Unit, New York Medicaid Choice, P.O. Box 5016, New York, NY 10274.

_______________________________________________________________________________________________

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.

DU–MLTC NH Disenrollment 05–2018 _v01