Policies & Guidance

Note: The following is a template of the letter to be used in this process. All letters used will contain the required CMS disclaimers, materials ID, and appropriate CMS submission approval prior to use.





<City>, <State> <ZIP>

IMPORTANT: Your health and drug plan coverage is changing.

Dear <Name of Member>:

We are writing to let you know about important changes to your medical and prescription drug coverage. As your Medicaid plan, we´d like to thank you for your membership in <Medicaid MCO Plan Name>, offered by <Parent Organization Name>.

Because you will be eligible for Medicare soon, <Parent Organization Name> will automatically enroll you into <D-SNP Name> for your Medicare benefits. This coverage will start on <insert effective date = Part A and B effective date>, the same day your Medicare benefits start.

You currently have <state-specific name for Medicaid program> (Medicaid). <D-SNP name>, offered by <parent organization name>, helps your Medicare and <Medicaid or state-specific Medicaid name> benefits work together.

If you don´t want <D-SNP name> to provide your Medicare coverage, you can choose to get your Medicare coverage through another plan or Original Medicare. However, by enrolling with <D-SNP name>, your Medicaid and Medicare services will be coordinated by one organization. If you don´t make another choice by <insert date before effective date>, you´ll be enrolled with <D-SNP name> starting <insert effective date>.

Your <state-specific name for Medicaid program> coverage won´t change [Insert as applicable: <due to enrollment in <D-SNP name>, Original Medicare or another Medicare health plan>. You will continue to get your <state-specific name for Medicaid program> coverage through <Medicaid MCO Plan Name>.

You don´t have to do anything unless you don´t want to be automatically enrolled in <D-SNP name>. If you don´t make another choice by <insert day before effective date>, your new coverage will start on <insert effective date>.

For more information about your <D-SNP name> and the benefits and services your new plan covers, or to find out if you can still see your current providers in your new plan and whether your new plan covers all of your prescription drugs, call <D-SNP name> at <phone number>. TTY users should call <TTY number>. We are open <days/hours of operation and, if different, TTY hours of operation>.

Frequently Asked Questions

What is <D-SNP name>?

<D-SNP Name> is a Medicare Advantage health plan that includes prescription drug coverage <if applicable, insert "and other supplemental benefits">. Enrolling in <D-SNP Name> will allow us to coordinate all of your Medicare and <State Medicaid Program> benefits, including your hospital, medical, prescription drug, and long term care needs. You will be eligible for <D-SNP Name> as long as you have both Medicare and <State Medicaid Program> coverage and continue to live within the approved plan service area.

How much will I pay for <D-SNP name>?

Like with <Medicaid MCO name>, you won´t have any monthly premium in <D-SNP name>.

Your costs for prescription drugs in Medicare, including in <D-SNP name> will be no more than:

  • $0/$X.xx/ $X.xx for each prescription of generic/preferred multi source drugs and $0/$X.xx/ $X.xx for each prescription for all other drugs. This is a little [insert as appropriate: <more> <less>] than what you pay now under <Medicaid MCO name>, which is <insert per prescriptions costs>.
  • [If there are costs in either Medicaid MCO or D-SNP, insert the following (for Qualified Medicare Beneficiaries always use $0 for the costs below. For Dual Eligible beneficiaries subject to cost-sharing, include applicable cost-sharing or range in cost-sharing.): Your costs for doctor visits <D-SNP name> will be <insert costs>. Right now, you pay <insert costs> for doctor visits in < Medicaid MCO name>.
  • For hospital stays, you will pay <insert costs> in <D-SNP name>. You now pay <insert costs> for hospital visits in <Medicaid MCO name>.]
  • [If there are zero costs under either the Medicaid MCO and the D-SNP, insert the following: Like with <Medicaid MCO name>, you won´t pay to see a doctor or for hospital visits with <D-SNP name>.]
How do I get Medicare services through <D-SNP Name>?

[If true, insert <You can continue to see your current Primary Care Physician (PCP) for your health care needs with <D-SNP Name>].

[If true, insert <You will need to choose a new Primary Care Physician for your health care needs with <D-SNP Name>, Your current Primary Care Physician is not in our network.]

Beginning on the date your <D-SNP Name> coverage begins, you must get all of your Medicare health care services from <D-SNP Name>, except for emergency or urgently needed services or out-of-area dialysis services.

Services authorized by <D-SNP Name> and other services contained in the Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. If you go to a provider not in <D-SNP Name> without authorization, neither Medicare nor <D-SNP Name> will pay for Medicare-covered services.

Once you are a member of <D-SNP Name>, you have the right to appeal plan decisions about payment or services if you disagree. Read the Evidence of Coverage from <D-SNP Name> when you get it to know which plan rules you must follow to get coverage with this plan.

What if Medicaid pays for my prescription drugs now?

Medicaid won´t cover drugs after <effective date for Medicare coverage.> Now you must get drug coverage from Medicare. [Insert if applicable <State Medicaid Program> may cover a few prescriptions that won´t be covered under your Medicare prescription drug coverage]. To continue to have prescription drug coverage, you must be enrolled in a Medicare prescription drug plan. By enrolling in <D-SNP Name>, you will get this coverage.

Do I have to join <D-SNP Name>?

No. You can decide to join a different Medicare plan or Original Medicare. If you do not want to get your Medicare benefits through <D-SNP Name>, please call us at <phone number(s)> by <insert date before effective date>. TTY/TDD users should call <phone number>. Our hours of operation are <insert days and hours of operation>.

[Insert if applicable <You can also return the enclosed opt-out form to:

<Insert Address>]

If you choose not to enroll in <D-SNP Name> at this time, you will still keep your <Medicaid MCO Plan Name> membership.

Do I have other choices for how I get my Medicare?

Yes. If you don´t want to be enrolled in <D-SNP name>, you have other choices in how you get your Medicare coverage, including:

Option 1: You can join another Medicare health plan, sometimes called a Medicare Advantage plan. You will want to check whether your providers and prescription drugs are covered by the plan.

A Medicare health plan is offered by a private company that contracts with Medicare to provide benefits. Medicare health plans cover all services that Original Medicare covers and most also include your prescription drug coverage. They may also offer extra coverage such as vision, hearing, or dental services.

Make sure the plan you want to join receives your enrollment request before <insert effective date>.

If you don´t join another Medicare health plan during this time, you´ll only be able to change plans during certain times of the year or in certain situations.

Option 2: You can change to Original Medicare and join a Medicare drug plan. Original Medicare is coverage managed directly by the Federal government.

  • To change to Original Medicare, call <plan name> at <toll-free phone number>. Call <TTY number> if you use TTY. We are open <days/hours of operation and, if different, TTY hours of operation>. Tell them you don´t want to be in <plan name> (you want to "opt-out").
  • If you change to Original Medicare, you need to enroll in a separate Medicare prescription drug plan. You should pick a plan that covers the drugs you take. (See the question below for help in choosing.) If you don´t enroll in a drug plan yourself, Medicare will enroll you in a Medicare prescription drug plan and send you a letter telling you the name of your new drug plan.
How can I get help comparing my Medicare plan choices?

It´s important to find a plan that covers your doctor visits and prescription drugs.

You can get help comparing your plan choices if you:

  • Call the <name of SHIP program> at <phone number and TTY number if available>. Representatives provide free, personalized health insurance counseling. <SHIP Program name> counselors are not affiliated with any health plan.
  • Visit Medicare.gov. Medicare´s web site has tools that can help you compare plans and answer your questions. Click "Find health & drug plans" to compare plans in your area.
  • Call 1-800-MEDICARE (1-800-633-4227). Tell them you got a letter saying you have Medicaid now and are going to be eligible for Medicare. Say that you want help with your Medicare choices. This toll-free helpline is available 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
  • Refer to your Medicare & You Handbook for a list of all Medicare health and prescription drug plans in your area. If you want to join one of these plans, you can call the plan to get information about their costs, rules, and coverage.
Why am I being offered this option?

As an individual eligible for both Medicaid and Medicare coverage (i.e., dually eligible) this assisted enrollment into a Medicare D-SNP will allow for better coordination of care and services with your Medicaid and Medicare benefits.

If you have questions about your <name of state Medicaid program> coverage, please call <Medicaid phone number>. This includes questions about staying enrolled in <plan name parent organization> for your <Medicaid or state-specific Medicaid name> benefits. Call <TTY number> if you use TTY. We are open <days/hours of operation and, if different, TTY hours of operation>.

Additionally, you may call the following to assist you with any questions about your Medicare and Medicaid coverage options:

New York Medicaid Choice

Call: 1-888-401-6582
TTY users: 1-888-329-1541
A free interpreter: 1-888-401-6582

Monday-Friday, 8:30 am - 8:00 pm
Saturday, 10:00 am - 6:00 pm

Website: www.nymedicaidchoice.com

Medicare Rights Center

Call: 1-800-333-4114 and (TTY #711)

Monday - Friday, 10:00am - 3:00pm

Website: www.medicarerights.org

What´s next? [Provide a roadmap of mailings and actions expected in the next few weeks, for example:

We <insert as applicable: will send, have already sent> you a membership card to show when you use health services or go the pharmacy after <effective date.>

We will send you an Evidence of Coverage to explain the benefits of our plan.

We will call you to welcome you and answer any questions you have.

If you have any other questions, call <plan name> at <phone number>. Call <TTY number> if you use TTY. We are open <days/hours of operation and, if different, TTY hours of operation>.

Keep a copy of this letter for your records.



[Plans must include all applicable disclaimers as required in the Medicare Communications and Marketing Guidelines.]