Consumer Notices- ICI Phase 2

List of all Notices and why they are sent

Notice 32, application and FAQ: Opt-In Enrollment Letter, Application

Notice 32 Spanish, Notice 32 Portuguese- Opt-In Enrollment Letter

Notice 31 and FAQ: Passive Enrollment Letter #1

Notice 31 Spanish, Notice 31 Portuguese -Passive Enrollment Letter #1

Notice 5: Passive Enrollment Letter #2

Notice 5 Spanish, Notice 5 Portuguese- Passive Enrollment Letter #2

Notice 4: Receipt of Completed Enrollment Request and Confirm Enrollment

Notice 6: Notice for Requesting Information

Notice 8: Member Has Employer or Union Retiree Drug Subsidy

Notice 9: Denial of Enrollment

Notice 11: Acknowledgement of Request to Cancel Enrollment

Notice 16: Notice to Confirm Voluntary Disenrollment

Notice 17: Denial of Disenrollment

Notice 19: Disenrollment Due to Out of Area Status

Notice 21: Disenrollment Due to Loss of Medicaid Status

Notice 23: Disenrollment Due to Death

Notice 24: Disenrollment Due to Part A or B Ending

Notice 25: Disenrollment Due to Incarceration

Notice 27: Acknowledgement of Reinstatement

Notice 28: Acknowledgement of Request to Opt-Out of MMP

Translation insert (included with all notices)

Appeals Instructions and Form (Eng)

Appeals Instructions and Form (Span)

Appeals Instructions and Form (Port)


Cancelling vs. Disenrollment Fact Sheet, 8/25/16


PACE provides care to frail elders and adults with disabilities over age 55 who have high level of care needs and who want to remain living in the community. The PACE interdisciplinary team works with clients and their families to develop an individualized care plans that are person-centered.  For more information on the PACE program:   Phone: (401) 490-6566 or 1-877-781-7223 toll-free     Website:
PACE Brochure

Background Documents   



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