Notice of eligibility review



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ES-3820 NOTICE OF ELIGIBILITY REVIEW 10-11
Label

Your eligibility ends for Food Assistance Cash Assistance Medical Assistance

Child Care If you want your benefits to continue, you must complete the enclosed review form and return it not later than .
Please return the review form to: , KS. .
If an interview is required, you will be notified of a time and date. A phone interview may be scheduled. You may opt to have a face to face interview.
This action is based on the Kansas Economic and Employment Services Manual Section(s) 1412 and 9300 and subsections.
Please make sure the following is included when returning the reapplication form:


  1. The enclosed application form will be accepted if it is signed and has a readable name and address, however, the reapplication form must be completed in order for your benefits to continue. If you need help in completing the enclosed review form, we will help you.




  1. Include a telephone number at which you can be reached during the day or a message can be left for you.



  1. If you are employed include your pay stubs for the past 30 days for each job.



  1. If you are paying child support provide proof of payment for the past three months.



  1. If you are reapplying for Medical Assistance include your most recent bank statements for your checking and savings accounts.

You may return the review form by mail, in person or through a medical or authorized representative. If everyone in your household is receiving SSI benefits, you may apply for food assistance at a Social Security Administration (SSA) Office.


Failure to return the enclosed review form, complete an interview, if required, and provide required verification will cause your benefits to be delayed or ended. You have the right to request a fair hearing.

Local Office: Signature/Date


11RIGHT TO REQUEST A FAIR HEARING You have the right to ask for a fair hearing if you do not agree with a decision made on your case. For cash, child care and medical programs, you must request an appeal in writing within 33 days of the date of this notice. If your written request is received prior to the effective date of the adverse action, you may continue receiving benefits at the current level if you request to do so. For food assistance, you may ask for a fair hearing in writing, in person, or by calling your DCF Service Center anytime within 90 days of the date of this notice. If your request is received within 10 days of the date of this notice, your benefits may continue at the current level while waiting for the fair hearing. In addition, you may request a pre-hearing conference to discuss your fair hearing request. This pre-hearing shall in no way delay or replace the fair hearing process. Contact your caseworker if you want a pre-hearing. For any program, if you request to continue receiving benefits at the current level while awaiting the fair hearing, you may have to pay back any benefits you receive if the fair hearing decision is not in your favor.


CIVIL RIGHTS PROVISION If you feel you have been discriminated against on the basis of age, race, color, sex, sexual orientation, religion, national origin, or political belief in any program or activity of DCF/KanCare, call 1-888-369-4777 for information on filing a complaint.
PENALTY FOR FRAUD Persons found guilty of intentionally obtaining benefits for which they are not entitled will be barred from receiving assistance in accordance with program guidelines and may also be subject to a fine or imprisonment or both.
REPORTING CHANGES You are required to report changes to DCF. We will tell you which changes you are required to report. If you have questions about your reporting requirements, please contact your worker.
HEALTH INSURANCE You must report to DCF/KanCare all changes in your health insurance coverage, health insurance coverage available through your employer, and insurance settlements due to accident or injury. You must notify your medical providers of all health insurance, including Medicaid, at the time of treatment.
CASH ASSISTANCE You may not use your cash benefits to purchase alcohol, tobacco or lottery tickets.
TOLL FREE NUMBERS: KanCare/Family Medical 1-800-792-4884

All other DCF services 1-888-369-4777


DERECHO A SOLICITAR UNA AUDIENCIA IMPARCIAL Usted tiene derecho a solicitar una audiencia imparcial si no está de acuerdo con una decisión tomada en su caso. Para los programas medicos, asistencia para cuidado de niños y de dinero en efectivo, debe solicitar por escrito una apelación dentro de los 33 días posteriores a la fecha del presente aviso. Si su solicitud por escrito es recibida antes de la fecha efectiva de la acción adversa, si así lo requiere puede continuar recibiendo beneficios al nivel actual. Para cupones de alimentos, puede solicitar una audiencia imparcial por escrito, en persona o llamando a su centro de servicios de DCF en cualquier momento dentro de los 90 días posteriores a la fecha del presente aviso. Si se recibe su solicitud dentro de los 10 días posteriores a la fecha del presente aviso, sus beneficios pueden continuar en el nivel actual mientras espera la realización de la audiencia imparcial. {0>In addition, you may request a pre-hearing conference to discuss your fair hearing request.<}0{>Además, usted puede solicitar una conferencia previa a la audiencia para discutir su solicitud de audiencia justa.<0} {0>This pre-hearing shall in no way delay or replace the fair hearing process.<}0{>Esta reunión previa a la audiencia no debe de ninguna manera demorar ni reemplazar el proceso de audiencia justa.<0} {0>Contact your caseworker if you want a pre-hearing.  <}57{>Comuníquese con su trabajador de caso si usted desea una reunión previa a la audiencia.<0} Para cualquier programa, si solicita continuar recibiendo beneficios al nivel actual mientras espera la realización de la audiencia imparcial, puede que deba devolver los beneficios recibidos en caso de que la decisión de la audiencia imparcial no le resulte favorable.
CLÁUSULA DE DERECHOS CIVILES Si considera que ha sido discriminado/a por causa de su edad, raza, color, sexo, orientación sexual, religión, nacionalidad o creencias políticas en cualquiera de los programas o actividades de DCF/KanCare, llame al 1-888-369-4777 para obtener información sobre cómo presentar un reclamo.
PENALIDADES POR FRAUDE Las personas culpables de obtener de forma intencional beneficios a los cuales no tienen derecho quedarán excluidas de recibir asistencia, de conformidad con los lineamientos del programa; podrán también ser condenadas al pago de multas, prisión o ambas.
INFORMACIÓN DE CAMBIOS Deberá informar los cambios a DCF. Le informaremos cuáles son los cambios que debe informar. Si tiene alguna consulta respecto a los requisitos de información, póngase en contacto con su trabajador(a) de caso.

SEGURO DE SALUD Deberá informar a DCF/KanCare todo cambio en su cobertura de seguro de salud, en la cobertura de seguro disponible a través de su empleador, y todo pago de seguro debido a un accidente o lesión. En el momento del tratamiento, deberá notificar a sus proveedores de servicios médicos todo seguro de salud, incluido Medicaid.
ASISTENCIA EN EFECTIVO Usted no puede utilizar sus beneficios en efectivo para comprar alcohol, tabaco, o boletos de lotería.
NÚMEROS PARA LLAMADA GRATUITA: KanCare/Family Medical 1-800-792-4884

Demás servicios DCF 1-888-369-4777


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