Form DSS-8110 "Notice of Modification, Termination, or Continuation of Public Assistance" - North Carolina

What Is Form DSS-8110?

This is a legal form that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2019;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DSS-8110 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Form DSS-8110 "Notice of Modification, Termination, or Continuation of Public Assistance" - North Carolina

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North Carolina
County Department of Social Services
Notice of Modification, Termination, or Continuation of Public Assistance
Date Mailed
Name
A change is about to take place in your
benefits. Please read all pages of this
Address
form carefully.
__________________________________________________
What The Change Is:
If this block is checked, you will receive a separate notice about your Medicaid.
Why The Change Will Be Made:
When The Change Will Happen:
Medicaid Payment of Your Medicare Premium Will
If you receive Medicare, Medicare is responsible for your prescriptions.
The State Regulations Requiring This Change Are Found In
Individuals who are ineligible for Medicaid or NC Health Choice or individuals who are eligible for a Medicaid
program that is not considered minimal essential coverage, may be eligible for assistance in purchasing
insurance on the Federal Marketplace. Application information is sent to the Federal Marketplace via secure
electronic transfer for those who may be eligible for assistance and will be contacted by someone at the
Federal Marketplace if further information is needed. For more information, visit Healthcare.gov or call 1-800-
318-2596
HEARING RIGHTS: If you disagree with this decision, you have a right to a hearing to review this decision. Call your
th
worker at the number below within 60 days to ask for a hearing. The 60
day is _________________________. If
you do not ask for a hearing by this date, you cannot have a hearing unless you have a good reason for missing this
deadline. You may reapply for benefits at any time. To protect your rights, you may BOTH reapply AND ask for a
hearing.
FREE LEGAL HELP: Free Legal Aid may be available to help you. Contact your nearest Legal Aid or Legal Services
office or call 1-866-219-5262 toll free.
In some cases, you may choose to get your benefits until your hearing. If you want a hearing, read the instructions
included on this form.
If this block is checked, your benefits will be changed without further notice. You may request a hearing by the
date above.
If this block is checked, and if you contact your caseworker by ______________________________________ to
ask for a hearing, your benefits will continue at the present level until the first hearing decision, unless you waive
this right. If your benefits continue and the hearing shows the changes were correct, you may have to repay the
benefits you received while waiting for the hearing decision. Continuation of benefits DOES NOT apply to North
Carolina Health Choice.
FOR OFFICE USE ONLY:
County Case # _____________________
Caseworker Name and Phone Number
Case ID # _________________________
Aid Program/Category _______________
Address
DSS-8110 (rev. 9-19)
Economic and Family Services
DHB/Eligibility Services
North Carolina
County Department of Social Services
Notice of Modification, Termination, or Continuation of Public Assistance
Date Mailed
Name
A change is about to take place in your
benefits. Please read all pages of this
Address
form carefully.
__________________________________________________
What The Change Is:
If this block is checked, you will receive a separate notice about your Medicaid.
Why The Change Will Be Made:
When The Change Will Happen:
Medicaid Payment of Your Medicare Premium Will
If you receive Medicare, Medicare is responsible for your prescriptions.
The State Regulations Requiring This Change Are Found In
Individuals who are ineligible for Medicaid or NC Health Choice or individuals who are eligible for a Medicaid
program that is not considered minimal essential coverage, may be eligible for assistance in purchasing
insurance on the Federal Marketplace. Application information is sent to the Federal Marketplace via secure
electronic transfer for those who may be eligible for assistance and will be contacted by someone at the
Federal Marketplace if further information is needed. For more information, visit Healthcare.gov or call 1-800-
318-2596
HEARING RIGHTS: If you disagree with this decision, you have a right to a hearing to review this decision. Call your
th
worker at the number below within 60 days to ask for a hearing. The 60
day is _________________________. If
you do not ask for a hearing by this date, you cannot have a hearing unless you have a good reason for missing this
deadline. You may reapply for benefits at any time. To protect your rights, you may BOTH reapply AND ask for a
hearing.
FREE LEGAL HELP: Free Legal Aid may be available to help you. Contact your nearest Legal Aid or Legal Services
office or call 1-866-219-5262 toll free.
In some cases, you may choose to get your benefits until your hearing. If you want a hearing, read the instructions
included on this form.
If this block is checked, your benefits will be changed without further notice. You may request a hearing by the
date above.
If this block is checked, and if you contact your caseworker by ______________________________________ to
ask for a hearing, your benefits will continue at the present level until the first hearing decision, unless you waive
this right. If your benefits continue and the hearing shows the changes were correct, you may have to repay the
benefits you received while waiting for the hearing decision. Continuation of benefits DOES NOT apply to North
Carolina Health Choice.
FOR OFFICE USE ONLY:
County Case # _____________________
Caseworker Name and Phone Number
Case ID # _________________________
Aid Program/Category _______________
Address
DSS-8110 (rev. 9-19)
Economic and Family Services
DHB/Eligibility Services
YOUR RIGHT TO A HEARING: If you think we’re wrong, you
Free legal services may be available in your community.
have until
, which is 60
Contact your nearest Legal Aid or the Legal Aid Helpline at 1-
days from the date of this notice, to ask for a hearing.
866-219-5262, toll free.
Calling your worker may fix the problem!
If you have additional questions or concerns, contact your
Did you miss an appointment or fail to return a
caseworker for information, or call DHHS Customer Service
form or other information? You can:
Center, toll free at 1-800-662-7030. TDD/Voice for the
hearing impaired is also available through the number. The
hours are 8:00am-5:00pm, Monday – Friday, excluding State
1.
Call your caseworker to reschedule your appointment or
see what you can do.
holidays.
2.
Return the form or other information immediately. Be
sure you answer every question. Be sure you provide
Did you know you have the right to see your record?
any proof of income.
If you ask, your caseworker will show you (or the person
3.
If your case has already been closed, call your
speaking for you) your benefits record before your hearing. If
caseworker to see what you can do.
you ask, you may also see other information to be used at the
hearing. You can get free copies of this information. You
Did you not do something your caseworker asked you to
may see this information again at your hearing.
do? You can call your caseworker to explain why and try to
solve the problem.
Do you understand your rights? Do you understand how to
get a hearing? If you have any questions, please contact your
Did your caseworker make a mistake or has your
caseworker as soon as possible.
situation changed? Call your caseworker right away.
Medicare Medicaid Recipients
Prescription drug coverage for Medicare individuals who also
Is there still a problem? You can ask for a
have Medicaid is only covered through a Prescription Drug
hearing. If you think we are wrong, or you
Plan (PDP). You must be enrolled in a PDP to receive
have new information, you have the right to a
prescription drug coverage. PDP co-payments differ from
hearing. You must ask for this hearing within
Medicaid co-payments. For questions about a PDP, co-
60 days (or 90 days if you have a good reason for delay).
payment, or assistance with enrolling, you may call 1-800-
This hearing is a meeting to review your case and give you
MEDICARE.
the correct benefits if it was wrong. Call, write or contact via
ePass (Medicaid Only) your caseworker to ask for a hearing.
Beware of Fraud!
A local hearing will be held within 5 days of your request
Don’t forget to report all changes to your county department of
unless you ask for it to be postponed. The hearing can be
social services within 10 calendar days (5
postponed, for good reasons, for as much as 10 calendar
calendar days for Special Assistance). If you
days. Then, if you think the decision in the local hearing is
don’t know whether a change is important, ask
wrong, call or write your caseworker WITHIN 15 DAYS to ask
your caseworker. If you do not truthfully report
for a second hearing. The second hearing is before a state
information and changes, you may be guilty of a misdemeanor
hearing official.
or felony.
NC Medicaid Hearing Information
Notice to Work First Cash Assistance Clients Whose
If you believe a standard hearing could seriously jeopardize
Benefits Have Stopped: Unless you ask the Child Support
your life or health or could threaten your ability to attain,
Services office to stop the child support services, you will
maintain or regain maximum function, you may request an
continue to receive them. If you choose to stop services, but
expediated hearing. An expedited hearing will be held within
later reapply for services within thirty (30) days, you will not be
3 days unless you ask for it to be postponed. You will be
charged an application fee. Contact your county
required to provide documentation from a person who has
social/human services agency for the telephone number of the
knowledge of your situation (such as a doctor, nurse or social
Child Support Services office.
worker) to support your request. If you do not provide
documentation, your appeal will be held on a standard
North Carolina Division of Social Services (NC DSS)
schedule.
complies with applicable Federal civil rights laws and
does not discriminate on the basis of race, color, national
If you are requesting a hearing about a medical disability
origin, sex, religion, creed, disability, age, political
determination, call, write or contact via ePass your
beliefs, or reprisal or retaliation for prior civil rights
caseworker for a hearing. There is no local hearing. A state
activity in any program or activity conducted or funded
hearing officer holds the medical disability hearing. If you
by U.S. Health and Human Services
believe a standard hearing could seriously jeopardize your life
or health or could threaten your ability to attain, maintain or
regain maximum function, you may request an expedited
medical disability hearing if you have medical records (such
as physical examination, laboratory findings, etc.) to support
your request. A doctor’s note providing an opinion about your
health without submission of supporting medical records is not
sufficient to justify an expedited fair hearing. If you do not
provide medical records, your appeal will be handled on a
standard schedule.
Did you know you have the right to be represented?
You may have someone speak for you at your hearing, such
as a relative, paralegal or attorney obtained at your expense.
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