Fillable Dma 5002 Ia.pdf (North Carolina)

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Dma 5002 Ia.pdf (North Carolina)

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__________________________________________________ Date Mailed: ____________________________
PLEASE READ THIS IMPORTANT NOTICE ABOUT YOUR MEDICAID OR SPECIAL ASSISTANCE
APPROVAL NOTICE
NORTH CAROLINA _________________________________ County Department of Social Services
Medicaid Identification number (MID) is: ____________________________________________________________________________
APPROVALS
The application for _________________________________ for ________________________________________________is approved.
____________________________
continues from _______________________________ to __________________________________.
Medicaid Identification number (MID) is: ____________________________________________________________________________
Your patient monthly liability for long-term care is: Your Special Assistance/Adult Care Home payment is:
____________________________
Month: _____________________________ Amount: ___________________________
Month: _____________________________ Amount: ___________________________
Your Special Assistance/In-home payment is: _____________
Eligibility for _________________________________ for______________________________________________________
Month: _____________________________ Amount: ___________________________
If you receive Medicare, Medicare is responsible for your prescriptions.
The State rules used to make this decision are in ____________________________, which says that:
_________________________________________________________________________________________.
DENIALS
Medicaid Special Assistance/Adult
Care Home
Special Assistance/In-home
YOU WILL RECEIVE A NOTICE WHEN IT IS TIME TO REVIEW YOUR CONTINUED ELIGIBILITY FOR
BENEFITS. IT IS IMPORTANT TO COMPLETE THIS PROCESS TO CONTINUE YOUR HEALTH COVERAGE.
PLEASE CONTINUE
READING FOR IMPORTANT INFORMATION ABOUT YOUR RIGHT TO A HEARING.
DHB-5002 Revised 09/2021
Aid Program/Category ___________________
Case ID # ___________________________ __
County Case # __________________________
FOR OFFICE USE ONLY:
HEARING RIGHTS: If you disa
gree with this decision, you have a right to a hearing to review this decision. Call your worker at the
number below within 60 days to ask for a hearing. The 60
th
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
1-866-219-5262 toll free.
The State rules used to make this decision are in ____________________________, which says that: __________________________
_________________________________________________________________________________________.
is denied from ___________________________________ to _______________________________________ because:
____________________________________________________________________________________________________________.
Retroactive Medicaid coverage is approved for the period(s) of
______________________________________________
Medicaid pays for limited services related to Family Planning. (See notice on pg. 2)
Medicaid pays only your Medicare Part B premium.
Medicaid pays only Medicare Part A and B premiums and Medicare cost sharing for Medicare and Medicaid covered
services.
Medicaid covers all necessary medical services. If you get Medicare from the Social Security Administration, Medicaid
will pay your Medicare A and B premiums, deductible, and coinsurance beginning:
Month: _____________________________ Amount: ___________________________
Medicaid is approved starting ____________________________________ and ending _____________________________________.
Name:
Address:
Caseworker Name and Phone Number:
Address:
Is there a problem?
You can ask for a hearing
.
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. You may call, write,
send electronically, or via ePASS to your caseworker a request
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 15 calendar
days. Then, if you think the decision in the local hearing is
wrong, you may call, write, send electronically, or via ePASS
WITHIN 15 calendar DAYS to ask for a second hearing. The
second hearing is before a state hearing official.
If you believe a standard hearing could seriously jeopardize
your life or health or could threaten your ability to attain,
maintain, or regain maximum function, you may request an
expedited hearing. An expedited hearing will be held within 3
days unless you ask for it to be postponed. You will be required
to provide documentation from a person who has knowledge of
your situation (such as a doctor, nurse, or social worker) to
support your request. If you do not provide documentation,
your appeal will be handled on a standard schedule.
If you are requesting a hearing about a medical disability
determination, call, write, send electronically, or via ePASS to
your caseworker a request for a hearing. There is no local
hearing. A state hearing officer holds the medical disability
hearing. If you believe a standard hearing could seriously
jeopardize your life or health or could threaten your ability to
attain, maintain, or regain maximum function. You may request
an expedited medical disability hearing if you have medical
records (such as physical examination, laboratory findings, etc.)
to support your request. A doctor’s note providing an opinion
about your health without the submission of supporting medical
records is not sufficient to justify an expedited fair hearing. If
you do not provide medical records, your appeal will be
handled on a standard schedule.
Did you know you have the right to be represented?
You may have someone speak for you at your hearing, such as
a relative or a paralegal or attorney obtained at your expense.
Free legal services may be available in your community.
Contact your nearest Legal Aid or Legal Services office or call
1-866-219-5262 toll free.
If you have additional questions or concerns, contact your
caseworker for information, or call the DHHS Customer
Service Center, Information and Referral Service, toll free at 1-
888-245-0179. TDD/Voice for the hearing impaired is also
available through the DHHS Customer Service Center number
1-888-835-5322. Their hours of operation are 8 am to 5 pm,
Monday through Friday.
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?
Do you understand how to get a hearing?
If you have any questions, please contact
your
caseworker as soon as possible.
Don’t forget to report all changes to your county
department of social services within 10 calendar days (5
calendar days for Special Assistance). If you don’t know
whether a change is important, ask your caseworker. If
you do not truthfully report information and changes, you
may be guilty of a misdemeanor or felony.
NOTICE: Your coverage is limited to Family Planning
Medicaid services. Family planning services include one
annual physical exam per 365 days, which should be scheduled
as your first appointment and six family planning visits per 365
days. Services include contraceptive services and supplies,
permanent sterilization, and screening for sexually transmitted
infections (STDs)and HIV screening. You can access these
services through a health department, community health or
rural health clinic, or by any provider in your community who
accepts your Family Planning Medicaid coverage. If a
beneficiary chooses permanent sterilization and the necessary
post-surgical follow-up testing has occurred, or if a beneficiary
has no medical need for family planning services, there are no
other services available under Family Planning Medicaid.
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Dma 5002 Ia.pdf (North Carolina)

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Completed 1 February 2022

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