Health Care Renewal Notice Page 32
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46Reset Form
Attachment D
Agency Name
Address Line 1
Address Line 2
City, State Zip
Reference Number:
Select to Enter IC Number.
Case Name
Address Line 1
Address Line 2
City, State Zip
Renewal Change Notice—Medical Assistance
You are getting this notice because we reviewed your renewal form. This notice is for the
members of your household shown below. Based on the information in your renewal form, the
following household members now qualify for Medical Assistance.
Health Care Results
Household member name.
Select to enter ID.
MNsure ID Number:
Effective Date
Action
Coverage Type
Approved
Medical Assistance
Closed
MinnesotaCare
You qualify for Medical Assistance starting on the approved date shown above. You qualify
because your monthly household income is within the limits for your household size. [Code of
Federal Regulations, title 42, sections 435.913 and 431.210]
You no longer qualify for MinnesotaCare, because your monthly household income makes you
eligible for Medical Assistance. This change is effective at the end of the day on the closed date
shown above.
When should I tell you if I have a change?
Report changes within 10 days of the change. Tell us about all changes, including changes in:
•
Where you live
•
Who lives with you
•
Who you list as a dependent on your income taxes
•
Income
•
Starting or stopping other health insurance
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