<Plan Letterhead>

  • Attachment B is also available in Portable Document Format

[Date; A-15]

<Name>
<In Care Of>
<Address>
<City>, <State>, <Zip>

PACE Direct Eligibility Disclosure Letter

Dear (first and last name):

Thank you for your interest in joining [Plan Name] Plan, a Program of All-inclusive Care for the Elderly (PACE). PACE is one of several types of health plans available to New York Medicaid recipients.

To know if you are eligible for PACE you need to have an assessment. There are two ways you can choose to have your assessment:

  • Direct Eligibility: You can have [Plan Name] complete your assessment, which will see if you are eligible to join our plan. If you select Direct Eligibility our Plan will conduct your assessment. We will let you know if you are eligible for PACE. If you are found eligible, we can work with you to join our Plan. All Direct Eligibility assessments will be reviewed by the New York Independent Assessor (NYIA) to see if you can remain in the Plan. You should note that our Direct Eligibility assessment only applies towards enrollment into [Plan Name].

    OR
  • New York Independent Assessor (NYIA): You can contact NYIA to schedule an assessment. NYIA is the state-contracted independent assessor, that oversees and conducts assessments for individuals seeking personal care services, consumer directed personal assistance services, or Managed Long Term Care (MLTC), including PACE. If you choose to have a NYIA assessment and you are found eligible for PACE enrollment, there will be no further review. If you are not eligible for PACE enrollment, the NYIA assessment can also be used to see if you are eligible for other MLTC programs.
Do Direct Eligibility and NYIA use the same assessment?

Yes, Direct Eligibility and NYIA use the same assessment tool to help see if you are eligible for PACE. Our staff can assist you with both Direct Eligibility and contacting NYIA.

What if Direct Eligibility finds I am not eligible for PACE?

If our Plan's Direct Eligibility assessment finds that you are NOT eligible for PACE, you may contact NYIA to have another assessment completed to see if you are eligible for PACE or other services. NYIA will provide you the results of their assessment and let you know your available options.

How does NYIA review my Direct Eligibility assessment?

If you choose a Direct Eligibility assessment, within 30 days of PACE enrollment, NYIA will conduct a quality review of the Direct Eligibility assessment. In most cases, you will not be involved in this review, and you will not need to take any action. In a small number of cases, NYIA may contact you to repeat the assessment.If you are contacted by NYIA, you are required to have another assessment by NYIA.

What happens if the NYIA repeat assessment finds that I am not eligible for PACE?

If NYIA's repeat assessment finds that you are not eligible for PACE, you will receive a notice from our Plan and a Disenrollment Notice from New York Medicaid Choice (NYMC). If you receive a Disenrollment Notice, contact a New York Medicaid Choice counselor immediately to go over your next steps and tell you your options.The Disenrollment Notice will also include information about your rights to a Conference and Fair Hearing if the assessment finds that you are not eligible for PACE.

What happens if I am disenrolled from PACE?

The Plan will work with you to ensure a safe and smooth transition. You may contact New York Medicaid Choice, the New York State Enrollment Broker, at the phone number below to assist you with next steps.

How do I choose between NYIA and Direct Eligibility?

Choosing between the two ways is up to you. Both ways will use the same assessment tool to help see if you are eligible for PACE. You may select whichever one works best for you and our staff is available to assist you.

Questions?

Please feel free to reach out to [Insert Plan Name], [Insert Plan Phone Number], [Insert Plan Hours of Operation]. [Insert TTY/TDD Information].

You can also call, New York Independent Assessor at 1-855-222-8350 (TTY: 1888-329-1541). You can call Monday - Friday, from 8:30 a.m. - 8:00 p.m. and Saturday, from 10:00 a.m. - 6:00 p.m.

You may also contact the Independent Consumer Advocacy Network.

The Independent Consumer Advocacy Network (ICAN) is the ombudsman program for health plan members. ICAN can answer your questions and give you free, independent advice about your coverage, complaints, and appeal options. To learn more about ICAN, go to www.icannys.org, or call 1-844-614-8800. TTY: 711. All services are free.

Thank you,

[Plan Name]