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Get NC DMA-5003 2017-2024

Caseworker Name and Phone Number Address FOR OFFICE USE ONLY County Case Case ID Aid Program/Category YOU WILL RECEIVE A RE-ENROLLMENT NOTICE WHEN IT IS TIME TO REVIEW YOUR ELIGIBILITY FOR MEDICAID OR NC HEALTH CHOICE. IT IS IMPORTANT TO RE-ENROLL TO CONTINUE YOUR HEALTH COVERAGE. PLEASE CONTINUE READING FOR IMPORTANT INFORMATION ABOUT YOUR RIGHT TO A HEARING. DMA-5003 10/01/09 Is there a problem You can ask for a hearing. PLEASE READ THIS IMPORTANT NOTICE ABOUT YOUR MEDICAID OR NC HEALTH CHOICE APPROVAL NOTICE NORTH CAROLINA County Department of Social Services APPROVALS The application for for is approved* Medicaid Identification number MID is Eligibility for for continues from to Medicaid is approved starting and ending. Medicaid covers all necessary medical services Medicaid pays only for services related to pregnancy and for conditions that may complicate pregnancy Retroactive Medicaid coverage is approved for the month s of. If you receive Medicare Medicare is responsible for your prescriptions. NC Health Choice for Children is approved starting and ending. The State rules used to make this decision are in of the Family and Children s Medicaid Manual which says that DENIALS Medicaid is denied from to because HEARING RIGHTS If you disagree with this decision you have a right to a hearing to review this decision* Call your worker at the number th below within 60 days to ask for a hearing. The 60 day is. If you do not ask for a hearing by this date you cannot have a hearing unless you have a good reason for missing this deadline. You may reapply for benefits at any time. To protect your rights you may BOTH reapply AND ask for a hearing. FREE LEGAL HELP Free Legal Aid may be available to you. Contact your nearest Legal Aid or Legal Services office or call 1-877694-2464 toll free. If you think we are wrong or you have new information you have the right to a hearing. You must ask for this hearing within 60 days or 90 days if you have a good reason for delay. This hearing is a meeting to review your case and give you the correct benefits if it was wrong. Call or write your caseworker to ask for a hearing. A local hearing will be held within 5 days of your request unless you ask for it to be postponed* The hearing can be postponed for good reasons for as much as 10 calendar days. Then if you think the decision in the local hearing is wrong call or write your caseworker WITHIN 15 DAYS to ask for a second hearing. The second hearing is before a state hearing official* Did you know you have the right to see your record If you ask your caseworker will show you or the person speaking for you your benefits record before your hearing. If you ask you may also see other information to be used at the hearing. You can get free copies of this information* You may see this information again at your hearing. Do you understand your rights If you have any questions please contact Don t forget to report all changes to your county If you are requesting a hearing about disability call or write department of social services within 10 calendar days 5 whether a change is important ask your caseworker.

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