Form Dma-5099 - North Carolina Department Of Social Services
ADVERTISEMENT
1
2North Carolina ________________________________________ County Department of Social Services
*YOUR APPLICATION FOR MEDICAID IS PENDING FOR A DEDUCTIBLE*
Date Mailed______________________
_______________________________________________
Your application for Medicaid
Name
cannot be completed until you
_______________________________________________
meet your Medicaid deductible.
Address
Please read all pages of this form
_______________________________________________
carefully.
Dear
________________________________________:
Your application for Medicaid cannot be completed because your income is too high. Before we can approve your application, you
must meet a Medicaid deductible. Send in your medical bills as you get them. You can use the pre-addressed envelope that is
included with this letter. Once your bills are equal to your deductible we will approve your Medicaid.
You will be responsible for medical bills used to meet your deductible. Medicaid will begin the day your bills equal the deductible
amount. You will be responsible for medical bills equal to the deductible amount.
The amount of your deductible for the months of _____________________________________________________ through
is $___________________________________
_____________________________________________________________________________
The amount of your deductible has changed because _________________________________________________________
____________________________________________________________________________________________________________________________
The new amount of your deductible for the months of _________________________________________________ through
is $_______________________________________________________
___________________________________________________
You sent in some bills to use to meet your deductible. We used $ ___________________________________ of those bills
toward your deductible. The balance of your deductible is now $______________________________________________.
What can you use to meet your Medicaid deductible?
•
Do you have current medical bills paid or unpaid, for the months of _____________________________________
through ____________________________________?
If you have medical bills that you still owe, send the bills in to your caseworker. We can use unpaid bills from the last
two years or older bills on which you are currently making payments, to help meet your deductible.
•
Do you still owe money on old medical bills for visits you made or services you received from
______________________________________ through _______________________________________________?
If you have medical bills that you still owe, send the bills in to your caseworker. We can use unpaid bills from the last
two years or older bills on which you are currently making payments, to help meet your deductible.
HEARING RIGHTS:
You have the right to a hearing if you disagree with the amount of your deductible. 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. Free legal advice may
.
be available. Contact your nearest Legal Aid or Legal Services office or call 1-877-694-2464
_________________________________________________________________________________________
Caseworker
Phone
______________________ ________________________________________________________________________________________________________________
Address
Please continue reading for important information about your deductible and your hearing rights.
DMA-5099 (04-2007)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dma-5095 - Medicaid/work First Notice Of Inquiry - North Carolina Department Of Social Services
Legal
Form Dma-5125b - Medicaid Transportation Suspension Notice - North Carolina Department Of Social Services
Legal
Form Dma-5124 - Medicaid Transportation Provider Documentation - North Carolina Department Of Social Services
Legal
Form Dss 5120a - Redetermination Of Foster Care Assistance Benefits And/or Medical Assistance - North Carolina Department Of Social Services
Legal
Related Categories
Parent category: Legal