Form Dma-5099 - North Carolina Department Of Social Services (Page 2 of 2) in pdf

How can you meet your deductible?

You can use only medical bills that are your responsibility to pay. You cannot use bills that

someone else pays for you or that insurance pays. If insurance pays only part of the bill and you

have to pay the rest, you can use the part you have to pay to help meet your deductible.

Take your bills or receipts to your caseworker. If you don’t have the bill or receipt, you can send a

statement from the medical provider or send the medical provider’s name, address and phone

number. Ask your caseworker about any medical expenses not listed here.

The following medical expenses can be used to meet your Medicaid deductible:

• Hospital charges

• Clinic and laboratory charges

• Charges for doctors, dentists and therapy

• Prescription drugs

• Over-the-counter medicines and medical supplies from the drug store like aspirin, cold medicines,

gauze, bandages, needles, and absorbent pads for the incontinent. If you want to use these to

help meet your deductible you must have a receipt that clearly shows the item purchased, the

date and the cost. If your cash register receipt does not have this information, ask for a written

receipt.

• Other medical expenses like medically related transportation, eyeglasses, dentures, hearing aids,

walkers, wheelchairs, crutches, braces and other medical equipment and dietary supplements if

your doctor prescribes it.

• Premiums you pay for private health insurance.

Call your worker if you have questions or a change in situation.

You can ask for a hearing.

If you think we’re 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 the delay). This hearing is a meeting to review your case and give you the correct benefits if the decision we made was wrong.

Call or write your caseworker to ask for a hearing. A local hearing will be held within 5 days of your request. 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 be represented?

You may have someone speak for you at your hearing, such as a relative or attorney obtained at your expense.

Free legal services may be available in your community.

Contact your caseworker for information, or call the CARE-LINE, Information and Referral Service, toll free at 1-800-662-7030. If you live in the Raleigh area, call

919-855-4400. TDD/Voice for the hearing impaired is also available through CARE-LINE at 1-877-452-2514. 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. If needed, free copies of this case information will be provided. 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.

DMA-5099 (04-2007)