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EXAMPLE: DOM-304 NON-MAGI LETTER
Regional Office Name Address City, State, Zip
Phone: (RO Phone) Fax: (RO Fax)
Name of Potential Applicant Mailing Address City, State, Zip
(DATE)
The Mississippi Division of Medicaid received a referral from the Health Insurance Marketplace, telling us that you would like to apply for Medicaid. On the application you submitted to the federal Health Insurance Marketplace, you said one or more of the following:
• You said you want to apply for Medicaid based on a disability. • You said y o u have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.). • You said you live in a medical facility or nursing home.
Please read this letter to see what you need to do and the kind of additional information we will ask for to see if you are eligible for Medicaid.
If you want to apply for Medicaid, we will need other information, such as your income and resources. Resources are things that you own and are available to help meet your needs, such as: money in the bank, property that you own other than your home, stocks, bonds and other types of resources. We will use the information you provide to see if you are eligible for Medicaid.
If you are applying for Medicaid based on a disability, and the Social Security Administration has already determined that you have a disability, we can use the decision they made. If not, we will ask you to tell us about your disability and how it affects what you do every day. We also need you to tell us about your medical history. The Disability Determination Services (DDS) makes disability decisions for the Division of Medicaid. DDS will determine if you meet disability medical requirements.
If you want to continue with an application for Medicaid because you meet one or more of the conditions above, sign this letter and return it to us by mail, in person, fax or e-mail at application@medicaid.ms.gov. You can also call the local regional office at the telephone number listed above or the Office of Eligibility toll-free at 800-421-2408.
Signature Date
APPENDIX PAGE A-13