TSAB NTAWV TSHAJ TAWM COV LUS QHIA
Tshawb Xyuas Tsis Tau Tias Yog Neeg Xam Xaj Mis Kas (U.S.)/
Keeb Neeg (Identity) Los Ntawm Social Security Administraton
State of California - Health and Human Services Agency
Department of Health Care Services
MC 239 DRA-6 Hmong (2/10)
Notice Date: _________________________________
Case Number: ________________________________
Worker Name: ________________________________
Worker Number: ______________________________
Worker Telephone Number: _____________________
Oce Hours: _________________________________
TSAB NTAWV TSHAJ TAWM NO YOG QHIA RAU KOJ TIAS PEB TSHAWB XYUAS TSIS TAU TIAS KOJ YOG NEEG XAM XAJ MIS KAS THIAB
KOJ LI KEEB NEEG NROG RAU SOCIAL SECURITY ADMINISTRATION (SSA). QHOV NO MUAJ FEEM CUAM TSHUAM RAU COV NEEG
NRAM QAB NO:
Muab Lub (Cov) Npe Tso Rau Ntawm No
Tsoom fwv teb chaws txoj cai kom cov neeg thov kev pab Medi-Cal uas tsis muaj kev zam (non-exempt) thiab cov neeg tau kev pab
uas nws hais tias nws yog ib tug neeg Xam Xaj Hauv Teb Chaws Mis Kas los sis yog Neeg Hauv Teb Chaws (Nationals), muab pov thawj
tias lawv yog Neeg Xam Xaj Mis Kas/Neeg Hauv Teb Chaws thiab lawv li keeb neeg (identity). Rau cov neeg feem ntau, qhov no yog
ua los ntawm kev tshawb xyuas cov lus qhia txog koj nrog rau SSA. Tiam sis, SSA tshawb xyuas tsis tau tias koj yog ib tug Neeg Xam
Xaj Hauv Teb Chaws Mis Kas los sis Neeg Hauv Teb Chaws.
Hauv 90 hnub, koj yuav tau muab cov ntaub ntawv zoo txaus uas qhia txog qhov tias koj yog Neeg Xam Xaj Mis Kas thiab koj li keeb
neeg mus rau koj tus neeg tuav txooj xwm hauv koj lub cheeb nroog (case worker). Qhov no yuav tsum tau muaj thiaj li tau Medi-Cal
cov kev pab txhua yam (full scope).
• Lub sij hawm 90-hnub no pib xya hnub hauv daim ntawv teev caij nyoog (calendar days) tom qab ntawm hnub tim hauv
tsab ntawv tshaj tawm no.
• Tsab ntawv tshaj tawm no muaj ib co lus qhia nrog uas qhia seb cov ntaub ntawv twg yog cov uas zoo txaus. Thov saib daim
“Cov Neeg Xam Xaj Mis Kas thiab Cov Neeg Hauv Teb Chaws Uas Thov Kev Pab Medi-Cal Yuav Tsum Tau Muab Pov Thawj
Tias Yog Neeg Xam Xaj thiab Keeb Neeg (Identity) (DHCS 0001)” los sis “Pov Thawj Tias Yog Neeg Xam Xaj thiab Keeb Neeg
(Identity) – Cov Uas Yuav Tsum Tau Muaj (Requirements) Tshiab rau Cov Neeg Tau Medi-Cal Uas Yog Neeg Xam Xaj Mis Kas los
sis Neeg Hauv Teb Chaws (DHCS 0002).”
• Yog hais tias tsis yog li ntawd es koj tsim nyog rau Medi-Cal cov kev pab txhua yam, koj yuav tau cov kev pab no thaum lub
sij hawm 90-hnub.
• Yog hais tias lub cheeb nroog tsis tau txais cov ntaub ntawv zoo txaus los ntawm koj, koj cov kev pab yuav txo mus rau kev
pab qee yam (limited scope) tom qab lub sij hawm 90-hnub xaus. Peb yuav TSIS txo koj cov kev pab tam sim no. Yog hais tias
koj cov kev pab raug txo yav tom ntej no, yuav xa ib tsab ntawv tshaj tawm ntxiv tuaj rau koj txog qhov ntawd.
Cov kev pab qee yam tsuas them rau cov kev pab thaum muaj xwm ceev, muaj feem rau cev xeeb tub, thiab cov kev pab kho mob
mus ntev. Yog hais tias koj tsis paub seb tej yam puas yog xwm ceev, muaj feem rau cev xeeb tub, los sis cov kev pab kho mob mus
ntev, hu rau koj qhov chaw muab kev pab kho mob.
Koj tseem tham tau rau SSA qhov chaw ua hauj lwm es daws qhov teeb meem no. Yog hais tias SSA pom zoo kho cov ntaub ntawv
kom qhia tias koj yog neeg Xam Xaj Mis Kas thiab koj li keeb neeg, koj yuav tsum tau qhia rau koj tus neeg tuav txooj xwm hauv
cheeb nroog. Lub cheeb nroog mam li rov xa lawv qhov kev thov mus tshawb xyuas qhov koj yog neeg Xam Xaj Mis Kas thiab koj li
keeb neeg.
Yuav tsum tau muaj tsab ntawv tshaj tawm no raws li hauv Welfare and Institutions Code section 14011.2
