Form Na 791 - Notice Of Action - Approval/denial/change
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3STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND HUMAN SERVICES AGENCY
Page ____ of ____
Notice of Action
If you have questions or want more information
Case Name:
Case Number:
about this action, please contact your adoption
Adoption/Post Adoption Worker:
worker.
Phone:
Email:
•
•
Date:
•
•
Description of the Action. Effective ______________________ , the following action will be taken regarding your child’s Adoption
DATE
Assistance Program (AAP) benefits:
A.
I
Monthly negotiated rate of $ ______________ is approved.
B.
Your child’s Medi-Cal/Medicaid benefit is approved.
I
C.
I
Your child does not meet AAP eligibility criteria to receive AAP benefits. (refer to comments section)
D.
Your child is not eligible to receive the requested benefits. (refer to comments section)
I
I
Monthly negotiated rate is increased to $ ______________.
A.
I
You have signed an amended AAP Agreement
B.
Due to the California Necessities Index (CNI) Increase Fiscal Year ______________.
I
I
Monthly negotiated rate is decreased to $ _____________.
A.
You have signed an amended AAP agreement.
I
B.
I
You have requested Medi-Cal/Medicaid only benefits.
C.
I
The rate is greater than what your child would be eligible to receive had they not been placed for adoption.
D.
Your child’s out of home placement has ended.
I
E.
I
Your child’s Wraparound services have ended.
You have signed a deferred AAP agreement. If your child requires AAP benefits in the future, contact Post Adoptions Services
I
at _______________________________________________________________________________________________________________.
I
Your child’s AAP benefits, including Medi-Cal coverage will be terminated:
A.
Your child will be age 18.
I
Your child may be eligible for the extention of AAP benefits to age 21. Contact Post Adoption Services at ___________________
TELEPHONE
to request the extention of benefits prior to your child’s 18th birthday if:
They have a mental or physical disability.
I
O R
I
The initial AAP agreement was signed on or after your child’s 16th birthday and one of the five participation criteria are met:
1. Completing high school or an equivalency program.
2. Enrolling in post-secondary or vocational school.
3. Participating in a program or activity that promotes or removes barriers to employment.
4. Employed at least 80 hours per month.
5. Is incapable of participating in 1 through 4 above, due to a documented physical or mental condition.
B.
Your child will be age 21
I
C.
I
You are no longer legally responsible for your child.
a.
I
Your child has married.
b.
I
Your child has enlisted and is on active duty in the military.
c.
I
Your parental rights have been terminated.
D.
You are no longer supporting your child.
I
NA 791 (11/16)– REQUIRED FORM
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