Medi Cal Customer Service
Resume:
NOTICE DATE:
CASE NAME:
CALHEERS CASE NUMBER:
SAWS CASE NUMBER:
WORKER NAME:
WORKER ID:
TELEPHONE NUMBER:
CUSTOMER ID:
October 10, 2023
ALISA CARNES ARNOLD
SE7301F
Brooke Moon
19DPZFA302
65482783
DPSS Customer Service Center IV
3400 AERO JET AVE
EL MONTE, CA 91731-2803
COUNTY OF LOS ANGELES STATE OF CALIFORNIA
HEALTH AND WELFARE AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL
SERVICES
Alisa Carnes
13015 HAAS AVE
GARDENA, CA 90249-1712
MC-MAGI-A (11/15) Page 1 of 2
NOTICE OF ACTION
MEDI-CAL APPROVAL
State Hearing: If you think this action is wrong, you can ask for a hearing. The back page tells you how. Your benefits may not be changed if you ask for a hearing before this action takes place. You have only 90 days to ask for a hearing. The 90 days started the day after the county sent you this notice.
Dear Alisa Carnes,
We have reviewed your eligibility for health coverage. We used the information you gave us and state and
federal data to make this decision.
Alisa Carnes
You qualify for Medi-Cal because your household
income is below the Medi-Cal limit. Your eligibility for Medi-Cal begins 10/01/2023. Your Medi-Cal coverage will continue unless you are found no longer eligible. This could happen at the time your eligibility is renewed or when your situation changes.
We counted your household size and income to make
our decision. For Medi-Cal, your household size is 1 and your monthly household income is $1,108.01. The monthly Medi-Cal income limit for your household size is $1,677.00. Your income is below this limit, so you qualify for Medi-Cal.
Title 42, C.F.R. §§435.119, 435.603; is the regulation or law we relied on for this decision.
Do you have any changes?
Over the next year, you must report any life changes that affect your eligibility for Medi-Cal. You must report within 10 days after the change happened. For example, you must contact us if:
• Your income changes.
• Your household changes, such as you marry,
divorce, become pregnant, or have or adopt a child; a person moves into or out of your home; or you
change who will be on your tax return.
• You qualify for other health insurance.
• You move. If you move to a new county, you can
report your change to your old or new county.
You may report changes to your local county office in person or by mail, fax, phone, or electronically. The contact information is on the first page of this notice. 0000000430692484
YOUR HEARING RIGHTS
You have the right to ask for a hearing if you disagree with any county action. You have only 90 days to ask for a hearing. The 90 days started the day after the county gave or mailed you this notice. If you have good cause as to why you were not able to file for a hearing within the 90 days, you may still file for a hearing. If you provide good cause, a hearing may still be scheduled.
TO ASK FOR A HEARING:
• Fill out this page.
• Make a copy of the front and back of this page for your records. If you ask, your worker will get you a copy of this page.
• Send or take this page to:
California Department of Social Services
State Hearings Division, ACAB
744 P Street, MS 9-17-97
Sacramento, CA 95814
OR Fax to: 1-916-***-****
• Call toll free: 1-855-***-**** or for hearing or speech impaired who use TDD, 1-800-***-****.
If you do not want to go to the hearing alone, you can bring a friend or someone with you.
HEARING REQUEST
I want a hearing due to an action by the Welfare Department of LOS ANGELES County about my:
Cash Aid
Other (List)
Here's Why:
If you need more space, check here and add a page. I need the state to provide me with an interpreter at no cost to me. (A relative or friend cannot interpret for you at the hearing.)
My language or dialect is:
BIRTH DATE PHONE NUMBER
STREET ADDRESS
CITY STATE ZIP CODE
SIGNATURE DATE
NAME OF PERSON COMPLETING THIS FORM PHONE NUMBER
I want the person named below to represent me at this hearing. I give my permission for this person to see my records or go to the hearing for me. (This person can be a friend or relative but cannot interpret for you.)
NAME
CITY STATE ZIP CODE
NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED STREET ADDRESS
PHONE NUMBER
OTHER INFORMATION
Medi-Cal Managed Care Plan Members: This action on this notice may stop you from getting services from your managed care health plan. You may wish to contact your health plan membership services if you have questions.
Child and/or Medical Support: The local child support agency will help collect support at no cost even if you are not on cash aid. If they now collect support for you, they will keep doing so unless you tell them in writing to stop. They will send you current support money collected but will keep past due money collected that is owed to the county.
Family Planning: Your welfare office will give you information when you ask for it.
Hearing File: If you ask for a hearing, the State Hearing Division will set up a file. You have the right to see this file before your hearing and to get a copy of the county's written position on your case at least two days before the hearing. The state may give you hearing file to the Welfare Department and the U.S. Departments of Health and Human Services and Agriculture.
(W&I Code Sections 10850 and 10950.)
If you ask for a hearing before an action on Cash Aid, Medi-Cal, CalFresh, or Child Care takes place:
• Your Cash Aid or Medi-Cal will stay the same while you wait for a hearing.
• Your Child Care Services may stay the same while you wait for a hearing.
• Your CalFresh will stay the same until the hearing or the end of your certification period, whichever is earlier.
If the hearing decision says we are right, you will owe us for any extra Cash Aid, CalFresh or Child Care Services you got. To let us lower or stop your benefits before the hearing check below: While You Wait for a Hearing Decision for:
Welfare to Work:
You do not have to take part in the activities.
You may receive child care payments for employment and for activities approved by the county before this notice.
If we told you your other supportive services payments will stop, you will not get any more payments, even if you go to your activity. If we told you we will pay your other supportive services, they will be paid in the amount and in the way we told you in this notice.
• To get those supportive services, you must go to the activity the county told you to attend.
• If the amount of supportive services the county pays while you wait for a hearing decision is not enough to allow you to participate, you can stop going to the activity.
Cal-Learn:
• You cannot participate in the Cal-Learn Program if we told you we cannot serve you.
• We will only pay for Cal-Learn supportive services for an approved activity.
Yes, lower or stop: Child Care
CalFresh Medi-Cal
Cash Aid CalFresh
To Get Help: You can ask about your hearing rights or for a legal aid referral at the toll-free state phone numbers listed above. You may get free legal help at your local legal aid or welfare rights office. NA BACK 9 (ACA/ MEDI-CAL) (11/16) - REQUIRED FORM - NO SUBSTITUTE PERMITTED Legal Aid Foundation of Los Angeles (LAFLA)
Neighborhood Legal Services of Los Angeles County
(NLSLA)
0000000430692484
Contact this candidate