Form Dma-5002 - Approval Notice - North Carolina Department Of Social Services
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1
2PLEASE READ THIS IMPORTANT NOTICE ABOUT YOUR MEDICAID OR SPECIAL ASSISTANCE
APPROVAL NOTICE
NORTH CAROLINA
_________________________________ County Department of Social Services
__________________________________________________ Date Mailed: ____________________________
__________________________________________________
__________________________________________________
APPROVALS
The application for ____________________________________ for ________________________________________ is approved.
Medicaid Identification number (MID) is: _______________________________________________________________________
Eligibility for ____________________________________ for ________________________________________
continues from __________________________________to __________________________________.
Medicaid Identification number (MID) is: ____________________________________________________________________________
Your patient monthly liability for long-term care is:
Your Special Assistance/In-home payment is: ______
Month: ________ Amount: ________
Your Special Assistance/Adult Care Home payment is: ______.
Month: ________ Amount: ________
Month: ________ Amount: ________
Month: ________ Amount: ________
Medicaid is approved starting _________________________ and ending _________________________.
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: _________________________.
Medicaid pays only Medicare Part A and B premiums and Medicare cost sharing for Medicare and Medicaid covered services.
Medicaid pays only your Medicare Part B premium.
Medicaid pays for only limited services related to Family Planning. Your partner may be potentially eligible also.
Retroactive Medicaid coverage is approved for the month(s) of _______________, _______________, _______________.
If you receive Medicare, Medicare is responsible for your prescriptions.
The State rules used to make this decision are in ____________________________ of the Aged, Blind and Disabled Medicaid Manual,
which states that: _________________________________________________________________________________________.
DENIALS
Medicaid
Special Assistance/Adult Care Home
Special Assistance/In-home
is denied from _____________ to _______________ because: _____________________________________________________
____________________________________________________________________________________________________________.
The State rules used to make this decision are in ____________________________, which says that: __________________________
_________________________________________________________________________________________.
HEARING RIGHTS: If you disagree with this decision, you have a right to a hearing to review this decision. Call your worker at the
th
number 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 1-877-
694-2464 toll free.
_______________________________________________________
FOR OFFICE USE ONLY:
Caseworker Name and Phone
County Case # __________________________
Address ________________________________________
Case ID # ___________________________ __
Aid Program/Category ___________________
____________________________________
____________________________________
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.
DMA-5002 10/01/09
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