MLTC Policy 23.02: Attachment F

  • Attachment F is also available in Portable Document Format

<Date>

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

Dear <Consumer Name>:                     <CIN>

We are writing because <Plan> told you that you must leave their Plan.
New York Medicaid Choice reviewed the Plan's decision to end your enrollment. After a review of your case, we agree with the Plan. Starting
<Effective date>, you will no longer be in <Plan Name> because:

You do not qualify to remain enrolled in a Program of All-Inclusive Care for the Elderly (PACE) plan. A PACE plan is a type of Managed Long Term Care (MLTC) plan. To get long term services and support in a PACE plan, you must require both nursing home level of care and one or more of the services below for more than 120 days:

  • Nursing services in the home
  • Home health aide services
  • Private duty nursing
  • Personal care services in the home
  • Adult day health care
  • Consumer Directed Personal Assistance Services (CDPAS)
  • Therapies in the home (physical, occupational, respiratory and speech pathology)
What happens next:
  • Please call New York Medicaid Choice. A Medicaid Choice counselor will go over your next steps and tell you your options.
  • If you are seeking personal care or Consumer Directed Personal Assistance Services (CDPAS), our counselors can tell you how to find out if you qualify to receive these services in another type of MLTC plan.

LL - MLTC Involuntary Confirmation Notice - E - 3/22

Please turn this page for more information

You may want to share this letter with your family or someone who knows about your health care needs. Please call New York Medicaid Choice if you have trouble reading or understanding this letter or if you have any questions.

Our counselors can also help you choose a Plan.

Call: 1-888-401-MLTC or 1-888-401-6582, Monday - Friday, from 8:30 am - 8:00 pm and Saturday, from 10:00 am - 6:00 pm. TTY Services: 1-888-329-1541.

Information for people in New York State's managed care plans

The Independent Consumer Advocacy Network (ICAN) is the ombudsman program for health plan members. If you have a problem with your health plan, doctor or other care provider - ICAN can help. To learn more about ICAN, go to www.icannys.org, or call 1-844-614-8800. TTY: 711. All services are free.

(FH#299 A)

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.