Homepage Fill Out Your Nc Application Medicaid Form
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Navigating the healthcare system can be daunting, especially when it comes to understanding how to apply for assistance programs like Medicaid. In North Carolina, the Nc Application Medicaid form is your gateway to a range of medical services intended for various populations, including the elderly, blind, disabled individuals, and those seeking family planning services. The form requires you to provide key information about all family members applying for medical assistance and any additional people residing in the home, although you're not required to disclose sensitive details such as Social Security numbers or immigration status for those others. Knowing the specific eligibility requirements can save you time; for instance, children under 21 and adults caring for them may qualify without being disabled or elderly. You will need to ensure that your application is complete before submitting it to your local county Department of Social Services (DSS), where a caseworker will guide you through the process. It's crucial to be aware that applicable medical expenses can be claimed even for bills incurred up to three months prior to your application date. Furthermore, if you have questions or require assistance, local Medicaid caseworkers are ready to help. Whether you’re considering family planning services or medical assistance due to a disability, understanding this form is the first step toward securing the healthcare support you need.

Nc Application Medicaid Example

Application for Medicaid

N.C. Department of Health and Human Services

This application is intended for medical assistance for the Aged, Blind and Disabled or those who want Family Planning services. A different application form is available for children and families who need Medicaid. Children under age 21 and adults with children in their care may be eligible for Medicaid without being blind, disabled or age 65 and older. You will need to list all family members who are applying for medical assistance. In addition, to ensure the applicants receive all possible assistance, list other persons in the home. Do not give us social security numbers, citizenship, or immigration status for these other persons.

If you have questions about Medicaid programs for which you may be eligible, please contact the Department of Social Services in the county where you live and ask to speak with a Medicaid caseworker.

Just mail or drop off the completed application at the department of social services in the county where you live. You can find address and phone number in your phone book under “County Government.”

If you want to apply for Work First Family Assistance, Food Stamps, or Special Assistance (to pay for care in an Adult Care Home,) you must see a worker and complete an application at the Department of Social Services.

IMPORTANT NOTICE

IF YOU CHOOSE TO PICK UP THIS APPLICATION AT THE DSS OFFICE:

You or your representative have the right to make an application and have a face-to-face interview for Medicaid on the day you go into the department of social services requesting medical or financial assistance.

If you cannot stay to see a worker to apply for Medicaid, but you want a face-to-face interview, you can schedule an appointment. Please see the receptionist if you want to schedule an appointment.

If you do not want a face-to-face interview and you complete an application and return it later, there is some information you should know:

The date of your application is the date the Department of Social Services gets your complete application.

Medicaid coverage can be requested for any medical bills incurred up to three months prior to the month of application.

The date your Medicaid is started is based on the date of your application. If you wait until next month to return your complete application, Medicaid may not be able to help pay for medical services you received in earlier months.

If you are unable or need help to complete the application or to obtain requested information, contact the department of social services and speak with a Medicaid caseworker.

You will receive a telephone follow-up call within two workdays.

DMA-5000

Page 1 of 16

Rev. 08/12

 

What is Medicaid?

Medicaid is a health insurance program for those with income below amounts set by the federal and state government or with large unmet medical needs.

Who can get Medicaid?

Individuals or couples who are elderly (age 65 or older)

Individuals who are visually impaired (blind)

Individuals who need help in their home to care for themselves (CAP)

Individuals who need help caring for themselves (nursing home or long-term care assistance)

Individuals or couples who are physically or mentally disabled

Individuals or couples who would like to receive family planning services

Children under age 21 and adults with children in their care

Pregnant Women

See page 3 for what the state of North Carolina considers to be disabled and a description of the CAP program.

What will Medicaid pay for?

Medicaid can help pay for certain medical expenses such as:

Doctor Bills

Hospital Bills

Prescriptions (Excluding prescriptions for Medicare beneficiaries effective 01/01/06)

Vision Care

Dental Care

Medicare Premiums

Nursing Home Care (LTC)

Personal Care Services (PCS), Medical Equipment, and Other Home Health Services

In home care under the Community Alternatives Program (CAP)

Mental Health Care

Most medically necessary services for children under age 21

Who can answer my questions about Medicaid?

You can contact your local county department of social services, call the Medicaid Eligibility Unit through the DHHS Customer Service Center, at 1-800-662-7030 or 1-877-452-2514 for the deaf or hearing impaired. The DHHS Customer Service Center is operational Monday through Friday (except state holidays). You can also visit DMA’s website at http://www.ncdhhs.gov/dma/.

What is the Community Alternatives Program (CAP)?

The Community Alternatives Program (CAP) allows some Medicaid recipients who require institutional care (placement in a hospital, nursing home, or ICF-MR) to remain at home if their care can be provided safely and at less expense in the community with CAP services. CAP participants must meet all CAP eligibility requirements.

How do I know if I am disabled?

An individual may be eligible for Medicaid if he is disabled according to the Social Security definition of disability. A child must meet Social Security’s childhood disability rules. If you are disabled you:

Are unable to work for at least one year due to your medical problem, or

Have a medical problem that may result in death.

If you receive a Social Security (RSDI) or Supplemental Security Income (SSI) check because you are disabled you are automatically considered to meet the disability requirement for Adult Medicaid. Other individuals who apply for Medicaid and are over age 21, under age 65, and do not have children in their care, must be found to be disabled. This requirement does not apply to Family Planning Services only.

DMA-5000

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How do I apply for assistance?

You will need to:

Answer the questions in sections 1 through 15 in a legible manner.

Sign the application.

Bring or mail this application to your county department of social services (DSS) in the county where you live. If you need help locating your county DSS office, please call the DSS office, or the DHHS Customer Service at 1-800-662-7030.

Provide the needed items to complete your application. If you do not have all of the needed information and need help getting the information, return the application and ask your Medicaid worker at DSS for assistance.

Once your application is received by your county department of social services, a case worker will call you to discuss your application in detail.

What if I need help completing this application?

Visit or call your county DSS. If you do not know where your county DSS is, call the DHHS Customer Service toll-free at 1-800-662-7030 to find your county DSS.

What do I do after I fill out this application?

I fill out the application?

Tear off pages 1 through 8 and keep them for your records.

Be sure that you answer all questions in sections 1 through 15.

Attach any documentation or verifications needed to process your application if you have them.

Remember to sign and date page 18 because your application can not be processed without your signature.

Bring or mail the Medicaid application to your county DSS.

How long will it take to process my application?

Once your application is received, we will begin processing it.

If you are 65 or older, a child, or caretaker of a child, it can take up to 45 days to process your application.

If you are under age 65 and have no child in your care, it can take up to 90 days to process your application.

If we need additional information, we will contact you by telephone or mail. The sooner we get the information, the sooner we can let you know if you can get Medicaid.

What are my rights?

To apply for Medicaid, and, if found ineligible, you may reapply at any time.

To apply for other assistance like Food Stamps or Work First Family Assistance.

To have any person help you with this application or participate in the interview for determination of eligibility.

To be protected against discrimination on the grounds of race, creed, or national origin by Title VI of the Civil Rights Act of 1964.

To have any information given to the agency kept in confidence.

To be given information by Social Services about Medicaid and other available assistance.

To get assistance from the department of social services in completing this application or in getting information needed to process the application.

To withdraw from the Medicaid program at any time.

To receive assistance, if found eligible.

To have your eligibility for Medicaid considered under all categories.

DMA-5000

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What are my responsibilities?

To provide the county department of social services (DSS), as well as state and federal officials, upon request, the information necessary to determine eligibility.

To report to the DSS any change in my situation within 10 calendar days of the change.

To report to the DSS if I receive benefits in error.

To agree, by signing this form, that all information that I have provided is true and a complete statement of fact according to the best of my knowledge and that I understand it is against the law to willfully withhold information or make false statements. I am subject to prosecution if I do.

To understand that any Medicaid ID card I receive is to be used only for the person listed on the ID card. I understand it is against the law to give my ID card to someone whose name is not listed on it and that I may be prosecuted for fraud if I let someone else use my ID card.

To understand if any resources are transferred out of the applicant’s name without receiving fair market value for the resources, it could result in a period of ineligibility for long-term medical care, such as in a nursing facility, or for in-home care. I understand all transfer of resources must be reported when making this application and any new transfers must be reported to my worker within 10 calendar days.

To understand any child or spousal support (money) which is paid directly to me must be reported to the county department of social services and will be counted as income when determining eligibility for Medicaid benefits for the person for whom it is received.

North Carolina must be named remainder beneficiary for annuities purchased after November 1, 2007. Contact the county DSS for more information.

Medical/ Financial Records

I understand that my medical and financial records must be made available to the agency and the State by any provider from whom I have received medical care services. I hereby agree to the release of those records by those providers when requested by the agency and the State. The privacy of this information is protected by law.

Assignment of Rights

I understand that by accepting medical assistance, I agree to give back to the State any and all money that is received by me or anyone listed on this application from any insurance company for payment of medical and/or hospital bills for which the medical assistance program has or will make payment. I agree to assign the State of North Carolina as the Remainder Beneficiary of any annuities that I may have. In addition, I agree that all medical payments or medical support paid or owed due to a court order for me or anyone listed on this application must be sent to the State to repay past or current medical expenses paid by the State. This includes insurance settlements resulting from an accident. I further agree to notify the county department of social services if I or anyone listed on this application is involved in an accident. I understand that this assignment of rights continues as long as I or anyone listed on this application receive Medicaid and is based on federal regulations.

Social Security Numbers

I understand that I must furnish all social security numbers used by me to determine my eligibility for assistance if I am applying for myself. I understand that if anyone else wants to apply for assistance their social security number must also be furnished. I also understand these social security numbers will be used in matching information with the Social Security Administration (SSA), Internal Revenue Service (IRS), Employment Security Commission (ESC), Department of Transportation (DOT), out of state welfare and ESC agencies, and any other agencies, when applicable. If I do not want these social security numbers used in the matches, I understand that I have the right to request my assistance to be denied, terminated or withdrawn.

Estate Recovery Notice

I understand that Federal and State laws require the Division of Medical Assistance (DMA) to file a claim against the estate of certain individuals to recover the amount paid by the Medicaid program during the time the individual received assistance with certain medical services. Ask your Medicaid case worker for specific information regarding which services are applicable to estate recovery.

DMA-5000

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Rev. 08/12

 

If You Request A Hearing

If you do not agree with a decision we make about your case, you can request a hearing. You can request this in person, by telephone or in writing. You must ask for this hearing within sixty days of when we tell you in writing of our decision on your application. You have the right to examine your case record and documents used before your hearing.

You can have a household member or someone you ask to represent you, like a friend or relative. You also have the right to have an attorney or other legal representative represent you at the hearing. Free legal aid may be available. Call 1-866-219-5262 for more information.

Citizenship, Identity and Immigration Status

I understand that the county DSS worker will verify citizenship, identity, and immigration status to determine which Medicaid program the applicant may qualify for. Household members listed on the application, but are not applying for Medicaid, will not be subject to this verification. In order to receive services, the applicant’s identity must be confirmed. In order to receive regular Medicaid, the applicant must be a citizen or have a qualified alien status. If citizenship or immigration status makes the applicant not eligible for regular Medicaid, the applicant can apply for Emergency Medicaid services.

If the county DSS worker is unable to verify citizenship, identity, and/or immigration status, the applicant may need to provide additional documentation. If the alien applicant has no documents to establish qualified alien status, contact a county DSS worker for assistance. If not eligible for regular Medicaid, I understand that persons applying for Emergency Medicaid services only are not required to declare or provide documentation of their immigration status or Social Security Number. These individuals must meet all other Medicaid eligibility requirements, and qualify for one of the Medicaid coverage groups.

Residence

I hereby certify under penalty of perjury that I and all the persons for whom I am making an application are living in North Carolina with the intention of remaining permanently or for an indefinite period, in the state seeking employment, or have a job commitment.

To verify North Carolina residency, provide two different documents from the following list:

A valid North Carolina driver license or other identification card issued by the North Carolina Division of Motor Vehicles.

A current North Carolina rent, lease, mortgage payment receipt, or current utility bill in the name of the applicant or the applicant’s legal spouse, showing a North Carolina address.

A current North Carolina motor vehicle registration in the applicant’s name and showing the applicant’s current North Carolina address.

A document verifying that the applicant is employed in North Carolina.

One or more documents proving that the applicant’s home in the applicant’s prior state of residence has ended, such as closing of a bank account, termination of employment, or sale of a home.

The tax records of the applicant or the applicant’s legal spouse, showing a current North Carolina address.

A document showing that the applicant has registered with a public or private employment service in North Carolina.

A document showing that the applicant has enrolled his children in a public or private school or a child care facility located in North Carolina.

A document showing that the applicant is receiving public assistance (such as Food Stamps) or other services which require proof of residence in North Carolina. Work First and Energy Assistance do not currently require proof of NC residency.

Records from a health department or other health care provider located in North Carolina which shows the applicant’s current North Carolina address.

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A written declaration from an individual who has a social, family, or economic relationship with the applicant, and who has personal knowledge of the applicant’s intent to live in North Carolina permanently, for an indefinite period of time, or residing in North Carolina in order to seek employment or with a job commitment.

A current North Carolina voter registration card.

A document from the U.S. Department of Veteran’s Affairs, U.S. Military or the U.S. Department of Homeland Security, verifying the applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing in North Carolina to seek employment or has a job commitment.

Official North Carolina school records, signed by school officials, or diplomas issued by North Carolina schools (including secondary schools, colleges, universities, community colleges), verifying the applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing in North Carolina to seek employment or has a job commitment.

A document issued by the Mexican consular or other foreign consulate verifying the applicant’s intent to live in North Carolina permanently or for an indefinite period of time, or that the applicant is residing in North Carolina to seek employment or has a job commitment.

*If you do not have two of these documents, contact the county DSS for assistance.

MEDICAL TRANSPORTATION ASSISTANCE

NOTICE OF RIGHTS

The following information regarding medical transportation was explained to me. I understand that:

If I receive Medicaid or have presumptive eligibility and do not have a way to get to the doctor or to other medical services, social services will help me arrange suitable transportation.

I can receive transportation assistance only after I am authorized for Medicaid or found to be presumptively eligible.

Medical transportation expenses that I am responsible for paying can be used to meet a deductible, including transportation expenses for anyone who is financially responsible for me.

I have the right to ask for help with transportation. I understand that if transportation is provided, it will be to the nearest appropriate medical provider of my choice, by the least expensive method suitable to my individual needs.

I, or someone acting on my behalf, may contact DSS by mail, phone, or in person to ask for help with transportation to the doctor or other medical services.

Except for emergencies, I must request transportation assistance as far in advance of my appointments as possible. Otherwise, my appointment(s) may have to be rescheduled.

I understand that I am not eligible for transportation assistance:

if I am authorized for Medicare-Aid (M-QB);

while my application is pending (before a decision is made) while I am on a deductible for Medicaid; OR

while I am authorized for NC Health Choice.

I have the right to a written notice of decision on my request within 10 work days, and I have the right to have a local hearing to appeal the decision if I disagree.

NOTE: You will need 2 first class stamps to mail this application. If you include additional information (pay stubs, bank statements, etc.) with the Medicaid application, additional postage may be needed. It is recommended that you contact the post office to verify the amount of postage needed.

*Tear off pages 1 through 6 and keep them for your records.

DMA-5000

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Application for Adult Medicaid

North Carolina Department of Health and Human Services

For Official Use Only

County DSS: ________________________

Date Received:_______________________

Case #: _____________________________

DSS _______

Aging _______

Mail In________

I am applying for Medicaid for myself.

 

 

 

 

Yes

No

I am applying for Medicaid for my spouse.

 

 

 

 

Yes

No

I am age 65 or older.

 

 

 

 

 

 

 

Yes

No

My spouse is age 65 or older.

 

 

 

 

 

 

 

Yes

No

I am blind.

 

 

 

 

 

 

 

Yes

No

My spouse is blind.

 

 

 

 

 

 

 

Yes

No

I am disabled.

 

 

 

 

 

 

 

Yes

No

My spouse is disabled

 

 

 

 

 

 

 

Yes

No

My child is disabled.

 

 

 

 

 

 

 

Yes

No

I am applying for Medicaid for a child or children in my care. List children below:

Yes

No

 

 

 

 

 

 

 

 

 

Citizen?

Yes

No

Name

DOB

Sex

 

Social Security

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizen?

Yes

No

Name

DOB

Sex

 

Social Security

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I need help with nursing home care.

 

 

 

 

Yes

No

My spouse needs help with nursing home care.

 

 

 

 

Yes

No

I am applying for the Community Alternatives Program (CAP).

Yes

No

My spouse is applying for the Community Alternatives Program (CAP).

Yes

No

My child is applying for the Community Alternatives Program (CAP).

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

Medicaid Family Planning Waiver Services

To be eligible for Medicaid Family Planning Waiver services, you must be a woman age 19 through 55 or a man age 19 through 60 and have not had a medical procedure that would prevent you from having a baby or fathering a baby.

Do you wish to apply for the Medicaid Family Planning Waiver?

 

Yes

No

If yes, for whom

 

 

Social Security #

 

 

 

DMA-5000

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1. Tell us about you.

Applicant’s Name

 

 

 

First

 

 

 

 

 

 

Middle

 

 

 

 

 

 

Maiden

 

 

 

 

Last

 

 

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

Sex

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Not required if you are not applying for Medicaid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

Month

Date

 

Year

for yourself, you are applying for Medicaid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

someone else, or you are applying for Emergency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicaid.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please indicate your race(s)

 

 

 

 

 

 

 

Hispanic/Latino?

Do you speak English?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

Yes

 

 

No

Asian= A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

White or Caucasian = W

 

 

 

 

 

 

 

If yes, specify by circling

What language do you prefer to

Black or African American = B

 

 

 

 

 

 

 

the code below:

 

 

speak if not English?

 

 

 

 

 

American Indian or Alaska Native = I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian or

 

 

 

 

 

 

 

 

 

 

Hispanic Cuban= C

 

 

 

 

 

 

 

 

 

 

 

Other Pacific Islander = P

 

 

 

 

 

 

 

Hispanic Mexican= M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hispanic Puerto Rican= P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hispanic Other= H

 

 

 

 

 

 

 

 

 

 

 

Are you a Veteran?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am a U.S. Citizen.

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

Have you served in the armed forces?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ARE YOU:

 

 

 

 

 

 

 

 

 

 

If you live with your spouse:

 

 

 

 

 

 

 

 

 

 

Married

 

 

 

 

 

 

 

 

 

 

Spouse’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

Middle

Maiden

Last

 

 

 

 

 

 

 

 

Single

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separated (When?

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you live with your spouse?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Complete section 2 on the next page, only if you want to apply for Adult Medicaid for your spouse.

DMA-5000

Page 8 of 16

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2. Tell us about your spouse.

 

 

 

First

 

 

Middle

Maiden

 

Last

Social Security Number

Sex

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Not required if your spouse does not

 

 

Female

 

Month

Date

 

 

Year

want Medicaid.)

 

 

 

 

 

 

 

 

 

 

Please indicate your spouse’s race(s) ______

Asian= A

White or Caucasian = W Black or African American= B American Indian or Alaska Native= I

Native Hawaiian or Other Pacific Islander= P

Is your spouse a Veteran?

Yes

No

Has the spouse served in the armed forces?

Yes

No

Hispanic/Latino?

Yes No

If yes, specify by circling the code below:

Hispanic Cuban= C

Hispanic Mexican= M

Hispanic Puerto Rican=P

Hispanic Other= H

Does your spouse speak English?

Yes

No

What language does your

spouse prefer to speak if not English?

My spouse is a U.S. Citizen.

Yes

No

(Not required if your spouse does not want regular Medicaid or if applying for emergency Medicaid.)

*Please provide documentation of citizenship, identity and/or qualified immigration status for any person applying for Medicaid. Persons applying for Emergency Medicaid services only are not required to provide documentation of citizenship or immigration status.

First

Middle

Last

Alien Registration Number

Applicant Only

Does anyone live with you other than your spouse?

Yes

No

If YES,

Who?Relationship:

If YES,

Who?Relationship:

If YES,

Who?Relationship:

DMA-5000

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3. Tell us where you live.

Mailing Address (include apartment number, in care of, etc.)

City, State, County, Zip Code

Home Phone (or number where you can be reached between 8am – 5pm)

Give the address where you actually live, if different than your mailing address:

Do you live in a nursing home? If yes, please indicate the name of the home, city and phone number.

Name:

City:

Phone Number:

Do you and your spouse intend to remain in North Carolina?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Tell us about your dependents.

 

 

 

 

Does anyone live with you and depend on you (or your spouse)

 

 

 

to provide at least one-half of their financial support?

 

Yes

 

No

If YES, Who?

 

 

 

 

 

 

 

Date of

 

 

 

Relationship:

 

 

Birth

 

 

 

5. Tell us if you or your spouse have any unpaid medical bills.

Do you, your spouse, or children need help paying medical bills

 

 

for services received during the last three calendar months?

Yes

No

If YES, please provide a copy of the medical bills from the last three months or fill out the information below.

Do you, your spouse, or children have any old, unpaid (medical bills you have not paid yet) medical bills?

The medical bills must be less than 2 years old, or

If the medical bills are over 2 years old, you must have

Yes

 

No

made a payment on them within the past 2 years.

 

 

 

If YES, please provide us with a copy of the medical bills you are being billed for or fill out the information below. Bills used to meet a deductible will not be paid by Medicaid.

*If you do not have copies of your medical bills, please fill out the chart below.

Who owes the bill(s) Please give us the Patient’s name

List the name of the doctor, clinic, hospital, telephone number and city where treated.

Date of medical treatment

DMA-5000

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Form Characteristics

Fact Name Description
Purpose of Form This form is used to apply for Medicaid benefits specifically for the Aged, Blind, and Disabled, as well as for individuals seeking Family Planning services. A separate application is required for children and families.
Eligibility Criteria Individuals including those aged 65 and older, disabled individuals, and children under 21 may qualify. Adults with children in their care may also be eligible without needing to meet blindness or disability criteria.
Application Processing Time Once submitted, applications from those aged 65 or older or children can take up to 45 days to process. Applications for individuals under 65 without children may take up to 90 days.
Governing Laws The Medicaid program in North Carolina operates under both federal and state laws, which dictate eligibility requirements and benefits provided. Specifically, 42 U.S.C. § 1396 et seq. governs the federal Medicaid program.

Guidelines on Utilizing Nc Application Medicaid

Filling out the NC Application for Medicaid can be a straightforward process when you take it step by step. Keeping organized and having the necessary information at hand will make this task much easier. Once you've submitted the form, the local Department of Social Services will review your application, and a caseworker will reach out to discuss the next steps.

  1. Gather Necessary Information: Before starting, collect personal details such as income, household members, and relevant documents like identification and proof of residence.
  2. Complete the Application: Answer all questions in sections 1 through 15. Use clear, legible writing to ensure your answers are easy to read.
  3. List All Family Members: Include everyone applying for assistance, as well as other persons living in the home (without providing their social security numbers or immigration status).
  4. Sign the Application: Don’t forget to sign and date page 18, as your application will not be processed without it.
  5. Attach Required Documentation: If you have any supporting documentation, attach it to your application to help with the review process.
  6. Submit Your Application: You can either mail or deliver the application in person to your county's Department of Social Services office. Make sure you have the correct address.
  7. Keep Copies: Tear off pages 1 through 8 and keep them for your records. This documentation may be useful for future reference.
  8. Expect a Follow-Up: Once submitted, a caseworker will contact you within two business days to discuss your application and any further steps.

Following these steps will help ensure that your application is complete and ready for processing. Remember, if you encounter any difficulties or have questions, don't hesitate to reach out to your local Department of Social Services for assistance. They are there to help you through the process.

What You Should Know About This Form

What is the purpose of the North Carolina Medicaid Application?

The North Carolina Medicaid Application serves to determine eligibility for medical assistance provided by the North Carolina Department of Health and Human Services. This application is specifically intended for qualified individuals, including those who are aged, blind, or disabled. Additionally, it also covers individuals seeking family planning services. It is important to note that a different application exists for children and families; thus, applicants should ensure they are using the appropriate form based on their circumstances.

Who is eligible to apply for Medicaid through this application?

Eligibility for Medicaid in North Carolina includes a wide range of individuals. Those who meet the qualifications include elderly individuals aged 65 or older, visually impaired persons, and individuals requiring assistance in home care or who need support in nursing homes. Additionally, individuals or couples with physical or mental disabilities can apply. Importantly, children under 21 and adults with children in their care are also eligible, regardless of their status as aged, blind, or disabled. Pregnant women can also receive consideration for Medicaid services.

What should I do after I complete the Medicaid Application?

Upon completion of the Medicaid Application, applicants should first tear off pages 1 through 8 for their records. It is crucial to ensure that all questions in sections 1 through 15 are answered completely and accurately. Additionally, any necessary documentation or verifications should be attached to facilitate the processing of the application. Lastly, it is essential to sign and date page 18, as the application cannot be processed without this signature. Following this, applicants should either bring the application to their county department of social services (DSS) or mail it to the appropriate office.

How long does it take for the Medicaid application to be processed?

The processing time for Medicaid applications varies based on the applicant's status. For individuals who are 65 or older, children, or caretakers of children, the processing can take up to 45 days. For those under age 65 who do not have children in their care, the time frame extends to a maximum of 90 days. If additional information is required during this process, the caseworker will reach out via telephone or mail to request the necessary details. Prompt submission of any requested information can expedite the processing timeline.

Who can I contact for assistance with my Medicaid questions?

If assistance is needed regarding Medicaid questions, individuals can reach out to their local county department of social services (DSS). Another viable option is to call the Medicaid Eligibility Unit through the DHHS Customer Service Center at 1-800-662-7030. For the deaf or hearing impaired, a service is available at 1-877-452-2514. The DHHS Customer Service Center operates Monday through Friday, excluding state holidays. For additional information, visiting the DMA's website at http://www.ncdhhs.gov/dma/ can also be beneficial.

Common mistakes

Filling out the North Carolina Medicaid application is a crucial step in securing health coverage. However, many individuals make mistakes that can delay the process or result in application denial. One common mistake is not providing complete family information. Applicants often forget to list all family members who are applying for assistance. Failing to include everyone can lead to confusion and delays as caseworkers seek missing information.

Another frequent error involves missing signatures. It’s vital to ensure that the application is signed and dated. Without a signature, the application cannot be processed. Some applicants may overlook this simple step in their eagerness to submit the form, thus jeopardizing their eligibility for Medicaid. Always check at the end of the application to confirm all necessary signatures are collected.

Inaccurate or illegible responses to application questions present another hurdle. Applicants may rush through the sections or fail to write clearly, leading to misunderstandings. If sections 1 through 15 are not answered legibly, delays can occur as caseworkers attempt to decipher the information. Thus, taking extra care to ensure clarity and accuracy can smooth the review process significantly.

Furthermore, many people fail to attach the required documentation. While some applicants bring the necessary items, others assume that verbal confirmation will suffice. This lapse can stall the processing of the application. To avoid this, it’s essential to review the required documents checklist and ensure that all necessary attachments are included before submission.

Finally, individuals often misunderstand the importance of timely application submission. The date that Medicaid starts hinges on when a complete application is received by the Department of Social Services. If an applicant waits too long to submit their form, they risk missing out on benefits for any medical expenses incurred earlier. Acting promptly not only prevents these complications but also ensures that applicants receive the help they need without unnecessary delays.

Documents used along the form

When applying for Medicaid in North Carolina, the NC Application Medicaid form is just the starting point. Applicants often need to provide additional documentation to ensure their application is complete and correctly processed. Below are several other forms and documents commonly used in conjunction with the Medicaid application.

  • Proof of Income: This document includes pay stubs, tax returns, and other forms that demonstrate your income level. This information helps determine your eligibility for Medicaid.
  • Proof of Residency: To verify that you reside in North Carolina, you may need to submit documents like a driver's license, utility bills, or rental agreements that list your North Carolina address.
  • Social Security Numbers: You must provide the Social Security numbers for all individuals listed on the application. This information is crucial for verifying eligibility and matching records.
  • Medical Records: If you have ongoing medical conditions or disabilities, including related medical documentation can help support your case for Medicaid assistance.
  • Disability Verification: If applying based on a disability, documentation from a healthcare provider confirming your condition may be required to prove eligibility.
  • Asset Documentation: Bank statements, property deeds, and other financial documents will help assess your current assets and ensure they align with Medicaid eligibility requirements.
  • Citizenship Verification: Documents such as a birth certificate, passport, or naturalization certificate may be necessary to establish your citizenship or qualified alien status.
  • Release of Information Form: This form allows healthcare providers to share necessary medical and financial records with the Medicaid office, facilitating the evaluation of your application.
  • Previous Medicaid Denial Letter (if applicable): If you have previously applied for Medicaid and were denied, submitting the denial letter could provide context for your current application.

Gathering these documents can help prevent delays and ensure that your application for Medicaid is thoroughly considered. Contact your local Department of Social Services if you have questions or need assistance with the required documentation.

Similar forms

The North Carolina Application for Medicaid shares similarities with several other important documents related to health and social services. Below is a list of documents that serve functions similar to the NC Application for Medicaid, along with descriptions of their similarities.

  • Application for Food and Nutrition Services: This document assists individuals and families in applying for food assistance. Like the Medicaid application, it requires detailed information about household members and their financial situations.
  • Application for Work First Family Assistance: This form is used to request financial help for families in need. Similar to the Medicaid form, it focuses on gathering information about household members and income eligibility.
  • Supplemental Security Income (SSI) Application: This application is for individuals seeking financial support for disability. It requires personal information and documentation about income and living arrangements, much like the detail needed for Medicaid.
  • Health Insurance Marketplace Application: This document allows individuals to apply for health insurance through the federal marketplace. It collects information related to household income and members, similar to how Medicaid gathers data for eligibility.
  • North Carolina Adult Care Home Application: This application is for those seeking to enter an adult care home and requires family details and medical history, paralleling the Medicaid application's focus on health and family information.
  • Medicaid Waiver Application: This document is used for applying for waivers that provide additional services to those who qualify. It also collects detailed personal and financial information similar to that required by the Medicaid application.
  • Children's Health Insurance Program (CHIP) Application: This application is aimed at helping families with children obtain health insurance. It needs family and financial information, which mirrors the Medicaid application process for children and families.
  • Emergency Medicaid Application: This application is specifically for individuals needing urgent medical care but who may not meet traditional Medicaid qualifications. Like the NC Medicaid application, it requires personal information and quick processing to offer immediate assistance.

Understanding these similarities is crucial for individuals navigating health and social support systems. Prompt and accurate completion of these applications can facilitate timely access to essential services.

Dos and Don'ts

Things to Do:

  • Fill out all sections of the application thoroughly and legibly, ensuring clarity in your responses.
  • Include all family members applying for assistance, as well as any other individuals living in the home, without disclosing their Social Security numbers or immigration status.
  • Sign and date the application before submission, as it cannot be processed without your signature.
  • Attach any necessary documentation or verification relevant to your application.
  • Submit the completed application to your local Department of Social Services in person or by mail.
  • Contact a Medicaid caseworker for assistance if you have questions or require help completing the application.

Things to Avoid:

  • Do not leave any sections of the application blank; incomplete applications may cause delays.
  • Avoid including Social Security numbers, citizenship, or immigration status for individuals not applying for Medicaid.
  • Do not wait to submit your application, as delays may impact your Medicaid coverage start date.
  • Do not provide false information or omit facts, as this may lead to prosecution for fraud.
  • Do not assume that all required information is understood; ask for clarifications if needed.
  • Do not forget to keep copies of all submitted documents for your records.

Misconceptions

Misconceptions about the North Carolina Application for Medicaid can lead to confusion and hinder individuals from receiving the assistance they need. Here are nine common misconceptions and their clarifications:

  1. Only elderly individuals can apply for Medicaid. Many people think Medicaid is only for those aged 65 and older. In fact, children under 21, pregnant women, and individuals with disabilities also qualify.
  2. You need to be blind or disabled to qualify for Medicaid. While being blind or disabled can qualify a person, individuals with low income or large unmet medical needs may also be eligible.
  3. You must provide Social Security numbers for everyone in your household. This is not true. When applying, you only need to provide Social Security numbers for those applying for Medicaid, not for other household members.
  4. Medicaid will only cover future medical expenses. Medicaid can help pay for eligible medical bills incurred up to three months before your application date, not just for future services.
  5. It takes a long time to get approved for Medicaid. Approval times vary. For some applicants, it can take up to 45 days, while others may wait up to 90 days, based on their specific situations.
  6. You cannot receive help if you don’t have all your documents in order. If you’re missing some documents, you can still submit your application. The county department of social services can help you complete the application process.
  7. Applying for Medicaid will negatively affect your immigration status. This is a misconception. Eligible non-citizens can apply for Medicaid without affecting their immigration status, as long as they meet the program's requirements.
  8. All Medicaid assistance requests are the same. Medicaid has different programs tailored to various needs. Family planning services, nursing home care, and disability assistance can have different criteria and coverage.
  9. You have to apply in person to submit a Medicaid application. While in-person assistance is available, you can also mail or drop off your completed application at your local department of social services.

Understanding the accurate information about the Medicaid application process is essential for those seeking assistance. If there are any questions or uncertainties, it's beneficial to reach out to a Medicaid caseworker for personalized guidance.

Key takeaways

When filling out the NC Application Medicaid form, it is essential to consider the following key points:

  • Eligibility Criteria: This application is specifically designed for seniors, those who are blind or disabled, and individuals seeking family planning services. Different forms exist for children and families.
  • Required Information: Ensure to list all family members applying for assistance. It is important to include information about other individuals living in the household, without disclosing their social security numbers or immigration status.
  • Application Submission: After completing the application, it can be mailed or delivered directly to the local Department of Social Services (DSS). If you prefer a face-to-face interview, it can be scheduled on the same day as your visit to the DSS office.
  • Processing Timeline: The application may take up to 45 days for seniors and those with children, and up to 90 days for others. Speeding up this process depends on providing all required information promptly.