Eligibility Requirements

Am I eligible to enroll?

You may be eligible to enroll in our MetroPlus FIDA Plan. Are you 21 years or older and reside in a participating New York City county? Are you entitled to benefits under Medicare? Are you receiving full Medicaid benefits? Do you demonstrate the need for community-based long-term care services? You may qualify for our MetroPlus FIDA Plan. Read more about our eligibility requirements and find out more.

Eligible requirements include:

  • Age 21 or older at the time of enrollment;
  • Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; and
  • Reside in a FIDA Demonstration county: the Bronx, Kings (Brooklyn), New York (Manhattan), and Queens;
  • Individuals must also meet one of the three following criteria:
  1. Are Nursing Facility Clinically Eligible and receiving facility-based long-term services and supports (LTSS), which are subsequently referred to as individuals eligible for facility-based LTSS. These individuals are eligible contingent upon submission and approval of an amendment to the existing Partnership Plan demonstration under Social Security Act Section 1115(a);
  2. Are eligible for the Nursing Home Transition & Diversion (NHTD) 1915(c) waiver contingent upon submission and approval of an amendment to the existing Partnership Plan demonstration under Social Security Act Section 1115(a) and an amendment to the NHTD Section 1915(c) waiver; or
  3. Require community-based long term-care services for more than 120 days. Assessments to identify an individual’s need for 120 days or more of community based long-term care services shall be conducted in accordance with Special Term and Condition 28 of the Partnership Plan Demonstration under Social Security Act Section 1115(a).
The following populations are not eligible for the FIDA Demonstration:
  • Residents of a New York State Office of Mental Health (OMH) facility;
  • Those receiving services from the New York State Office for People with Developmental Disabilities (OPWDD) system;
  • Individuals under the age of 21;
  • Residents of psychiatric facilities;
  • Individuals expected to be Medicaid eligible for less than six months;
  • Individuals eligible for Medicaid benefits only with respect to tuberculosis-related services;
  • Individuals with a "county of fiscal responsibility" code 99 in MMIS (individuals eligible only for breast and cervical cancer services);
  • Individuals receiving hospice services (at time of enrollment);
  • Individuals with a "county of fiscal responsibility" code of 97 (individuals residing in a State Office of Mental Health facility);
  • Individuals with a “county of fiscal responsibility” code of 98 (individuals in an OPWDD facility or treatment center);
  • Individuals eligible for the family planning expansion program;
  • Individuals under 65 years of age (screened and require treatment) in the Centers for Disease Control and Prevention breast and/or cervical cancer early detection program and need treatment for breast or cervical cancer, and are not otherwise covered under creditable health coverage;
  • Residents of intermediate care facilities for individuals with intellectual/developmental disabilities (ICF/IIDD);
  • Individuals who could otherwise reside in an ICF/IIDD, but choose not to;
  • Residents of alcohol/substance abuse long-term residential treatment programs;
  • Individuals eligible for Emergency Medicaid;
  • Individuals in the OPWDD Home- and Community-Based Services (OPWDD HCBS) section 1915(c) waiver program;
  • Individuals in the following section 1915(c) waiver program: Traumatic Brain Injury (TBI); 
  • Residents of Assisted Living Programs; and
  • Individuals in the Foster Family Care Demonstration.
To see if you qualify, call the State Enrollment Broker, New York Medicaid Choice 'MAXIMUS' at 1.855.600.FIDA, TTY users: 1.888.329.1541, from Monday through Friday, 8:30 am to 8 pm, and Saturday from 10 am to 6 pm or at their website.

Rights and Responsibilities Upon Disenrollment

Your participation will end in certain situations. These are the cases when the FIDA Program rules require that your participation must end:
  • If there is a break in your in Medicare Part A and Part B coverage.
  • If you no longer qualify for Medicaid.
  • If you permanently move out of our service area.
  • If you are away from our service area for more than six consecutive months.
    • ‚ÄčIf you move or take a long trip, you need to call Participant Services to find out if the place you are moving or traveling to is in MetroPlus FIDA Plan’s service area.
  • If you go to jail, prison, or a correctional facility.
  • If you lie about or withhold information about other insurance you have for health care or prescription drugs.
In any of the above situations, the Enrollment Broker (New York Medicaid Choice) will send you a disenrollment notice and will be available to explain your other coverage options.
 
In addition, we can request that the FIDA Program remove you from MetroPlus FIDA Plan for the following reasons:
 
If you intentionally give us incorrect information when you are enrolling in MetroPlus FIDA Plan and that information affects your eligibility for our plan.
 
If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other Participants of MetroPlus FIDA Plan even after we make and document our efforts to resolve any problems you may have.
 
If you knowingly fail to complete and submit any necessary consent or release form allowing MetroPlus FIDA Plan and providers to access health care and service information that is necessary for us to deliver care to you.
 
If you let someone else use your ID card to get medical care.
 
If we end your participation because of this reason, Medicare may have your case investigated by the Inspector General.
 
In any of the above situations, we will notify you of our concern before we request FIDA Program approval to have you disenrolled from MetroPlus FIDA Plan. We will do this so that you have the opportunity to resolve the problems first. If the problems aren’t resolved, we will notify you again once we have submitted the request. If the FIDA Program approves our request, you will receive a disenrollment notice. The Enrollment Broker will be available to explain your other coverage options.
 
For more information, review chapter 10 in your Participant Handbook.