The DMA-5199 form is a crucial document issued by the County Department of Social Services (DSS) that requests information necessary for the renewal of Medicaid or N.C. Health Choice coverage. It serves as a thorough check to verify if individuals and their family members still qualify for these health insurance programs, requiring details about income, living situations, and any changes in personal details since the last renewal. For individuals looking to maintain their health coverage without interruption, completing and submitting this form on time is imperative.
To ensure your health coverage continues without a hitch, click the button below to fill out your DMA-5199 form today.
The DMA-5199 form serves as a crucial tool for those seeking to renew their Medicaid or N.C. Health Choice coverage, ensuring that individuals and their families continue to receive essential healthcare services without interruption. Dispatched by the County Department of Social Services (DSS), this form, accompanied by a specific deadline (30 days from the notice date), must be submitted promptly to avoid the potential loss of benefits. It seeks detailed information about the applicant and their family members, including tax filing status, dependency, pregnancy status, existing Medicaid coverage, and income. Furthermore, the form inquires about living situations and whether any listed individuals were in foster care at age 18. Applicants are required to answer under penalty of perjury, stressing the importance of providing truthful information to avoid federal penalties. Completion can occur via several methods: in-person visits, phone calls, or mail, offering flexibility to applicants. Additional sections of the form assist in applying for Medicaid for persons not currently covered, requiring data on citizenship, relationship to the applicant, and immigration status where applicable. This form not only facilitates the renewal process but also underscores the broader commitment to maintaining accessible healthcare coverage for vulnerable populations within North Carolina.
Print Form
Medicaid Renewal Request for Information Notice
COUNTY DEPARTMENT OF SOCIAL SERVICES (DSS)
Date: _____________________
To: ______________________________________
Address: __________________________________
__________________________________
Case ID No: _______________________________
Worker: ____________________
*THIS FORM MUST BE SENT IN BY ____________________________ (30 DAYS FROM ABOVE DATE) OR YOU MAY LOSE YOUR N.C. MEDICAID OR N.C. HEALTH CHOICE *
Why You Need to Complete This Form
In order to be considered for Medicaid or N.C. Health Choice, you must complete this form. The information will be used to verify that you and your family still qualify. The information is necessary to process your review.
In addition to helping yourself, you can use this form to apply for health insurance coverage for other family members in your house.
Contact __________________ County DSS at ________________ if you have any questions about filling out
this form.
SECTION 1
TELL US ABOUT YOURSELF
Do you expect to file a tax return? Yes
No
Are you a dependent on someone else’s tax return? Yes
If yes – who?
SECTION 2
TELL US ABOUT YOUR FAMILY
(include family members and tax dependents living in your house)
PERSON 1:
Name:
Does this person expect to file a tax return? Yes No
Does this person expect to be a dependent on someone else’s tax return? Yes No
Is this person pregnant? Yes No
If so, what is the expected due date?
Does this person have Medicaid? Yes No
DMA-5199 (3/30/16)
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If this person does not have Medicaid, complete Attachment A to apply for Medicaid.
PERSON 2:
To apply for Medicaid for this person complete Attachment A.
PERSON 3:
PERSON 4:
Name
If more space is needed, please attach a separate sheet.
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SECTION 3
TELL US MORE ABOUT THE PEOPLE LISTED ON THIS FORM
A.Income: Does anyone listed on this form have an income? Yes No If yes, complete Attachment B.
B.Living Situation: Does anyone listed on this form live in a:
Long‐term care facility, group home, or nursing home
Private home, but gets at‐home medical, personal or health services
Private home, but gets medical, personal or health services in the community (such as adult day care)
If so, please list their names:
Name(s):
C.Foster Care: Is anyone listed on this form between the ages of 18 and 26 and was in foster care at
age 18? Yes No
SECTION 4
SIGNATURE
I am signing this renewal form under penalty of perjury which means I have provided true answers to all the questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide untrue information.
Beneficiary/Authorized Representative*
Date
*The person who completed the form or their legal representative.
WHERE TO SEND THE INFORMATION
You can complete the form:
• In‐person at the
County DSS Office (street address)
•By phone at:
• By mail at:
County DSS Office, (mailing address)
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ATTACHMENT A
TO APPLY FOR MEDICAID FOR ANYONE LISTED IN SECTION 2.
Person 1:
A.Name:
B.Social Security Number:
C.Date of Birth:
D.How is this person related to you?
E.This person is : Male Female
F.This person is a U.S. citizen or U.S. national Yes No
If yes, skip to “additional information” below.
If no, answer question “G”:
G.If this person has eligible immigration status: Document Type:
ID Number:
Check here, if this person has lived in the U.S. since 1996
Check here, if this person, his or her spouse, or a parent is a veteran or an active duty member in the U.S. military
Additional Information
Check here, if this person lives with at least one child under the age of 19 and is the person taking care of this child.
Check here, if this person is 18 years or younger and has a parent living outside of the house
Check here, if this person wants help paying for medical bills from the last three months
Person 2:
A.Name
B.Social Security Number
C.Date of Birth
F.This person a U.S. citizen or U.S. national Yes No If yes, skip to “additional information” below.
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If no, answer question “G”
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ATTACHMENT B
INCOME
Person Receiving Income
Income Type *
Amount
Before Taxes
How Often
Received
Start Date
If more space is needed to report changes, attach a separate sheet.
Include income from:
Jobs
Foreign Income
Self‐Employment
Investment Income or Interest
Alimony
Farming or Fishing Income
Unemployment
Rental or Royal Income
Social Security Benefits
Capital Gains
Retirement / Pension
Scholarship
Title
Alien Sponsor
Lump Sum Amount
American Indian / Alaskan Native Income
Do not include:
Child Support
Workers Compensation
Supplemental Security Income (SSI)
Veterans Administration (VA) Benefits
C. Loss of Income: Was anyone listed on this form receiving income in the last 12 months but no longer is?
Yes No
If yes, who, when and what type?
D. Expenses: Is there anyone in the family deducting expenses from their taxes? Yes No If yes, complete Expenses (Deductions) below.
EXPENSES (DEDUCTIONS)
Person Paying Deduction
Deduction Type
If more space is needed to report changes, please attach a separate sheet.
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Allowable deductions include:
Alimony Paid
Health Savings Acct Contributions
Educator Expenses
IRA Contributions
Tuition / Fees
Moving Expenses
Student Loan Interest
Penalty on Early Withdrawals of savings
For those who are self‐employed, allowable deductions also include:
Rent / Royalty Expenses
Certain Business Expenses of Reservists, Performing Artists and Fee Basis Government Officials Deductible Part of Self‐Employment Tax
Domestic Production Activities Deduction Health Insurance Deduction
SEP, SIMPLE and Qualified Plans
E. Health Insurance: Does anyone listed on this form have other health insurance besides Medicaid and
N.C. Health Choice? Yes No
If so, complete Health Insurance below.
HEALTH INSURANCE
Person Covered
Policy Holder
Policy
Number
Insurance Company
Type of
Coverage
Voter Registration:
If you are not registered to vote where you live now, would you like to apply to register to vote here today? __ yes __ no
If you want to register to vote, you can complete a voter registration form at http://www.ncsbe.gov/.
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Filling out the DMA 5199 form is essential for those seeking to renew their Medicaid or N.C. Health Choice coverage. This step-by-step guide is designed to assist you in completing the form accurately and effectively, ensuring your continued access to healthcare services without interruption. Given the importance of this process, it's crucial to adhere to the deadline mentioned in the form to avoid the potential loss of benefits. Follow the instructions carefully to provide all the necessary information regarding your and your family's eligibility.
After submitting this form, your renewal request will be processed. It is vital to ensure that all information is accurate and complete to prevent any delays or issues in maintaining your Medicaid or N.C. Health Choice coverage. Keep a copy of the completed form for your records and note the submission date. Should you have any questions or require assistance during this process, do not hesitate to contact your County DSS office.
What is the DMA 5199 form?
The DMA 5199 form is a Medicaid Renewal Request for Information Notice. It is used by individuals who are currently receiving Medicaid or N.C. Health Choice benefits to provide necessary information for the renewal of their coverage. The form helps verify eligibility for continued health insurance coverage under these programs.
Why do I need to complete the DMA 5199 form?
Completing the DMA 5199 form is essential to determine if you and your family still qualify for Medicaid or N.C. Health Choice benefits. The information you provide allows the County Department of Social Services to process your review and ensure that the benefits can continue without interruption.
What happens if I do not send in the DMA 5199 form within 30 days?
If the DMA 5199 form is not submitted within 30 days from the date indicated on the form, you may lose your North Carolina Medicaid or N.C. Health Choice coverage. It is crucial to respond in a timely manner to avoid any gaps in your health insurance coverage.
How do I complete the section about my family on the DMA 5199 form?
In the section about your family, you will need to include information for each family member or tax dependent living in your house. This includes whether they expect to file a tax return, are a dependent on someone else’s tax return, their Medicaid status, and other relevant details. If someone does not have Medicaid, you'll be prompted to complete Attachment A for that individual.
What if someone listed on the form is pregnant?
If any person listed on the DMA 5199 form is pregnant, you should indicate this by checking 'Yes' next to the question about pregnancy and provide the expected due date. This information is crucial for determining eligibility for additional benefits or services.
What information about income is needed?
If anyone listed on the DMA 5199 form has an income, you must indicate 'Yes' in Section 3 under income and complete Attachment B. This includes all types of income to ensure an accurate assessment of eligibility for continued Medicaid or N.C. Health Choice coverage.
How do I report my living situation on the DMA 5199 form?
You will need to specify your living situation by selecting one of the options provided on the form, whether it's a long-term care facility, group home, nursing home, a private home with at-home medical, personal, or health services, or a private home with community-based services. Be sure to list the names of individuals in these situations as requested.
What if a listed individual was in foster care?
If anyone between the ages of 18 and 26 listed on the form was in foster care at age 18, you should indicate 'Yes' in the relevant section and list their names. This may affect their eligibility for certain benefits.
Where do I send the completed DMA 5199 form?
Once completed, you can submit the DMA 5199 form in person at the County Department of Social Services (DSS) Office, by phone, or by mail at the given DSS office address. Contact information and address details should be provided on the form or by the DSS office.
What if I need additional space to complete the DMA 5199 form?
If you need more space to provide all required information, you are allowed to attach a separate sheet to the DMA 5199 form. Ensure that any additional information is clearly marked and associated with the correct section of the form.
Filling out the DMA-5199 form, a crucial step for Medicaid or N.C. Health Choice renewal, often poses challenges for applicants, leading to common mistakes that can jeopardize their eligibility. One significant error is overlooking the deadline stated at the top of the form. Recipients must return the completed form within 30 days from the date mentioned, or they risk losing their benefits. This critical timeframe is intended to ensure timely processing of the renewal request, yet it's frequently missed due to misinterpretation or oversight.
Another common pitfall involves inaccurately reporting income and household composition in Sections 1 and 2. Applicants sometimes fail to include all required family members or misstate their income, which can lead to incorrect eligibility assessments. It's essential to provide comprehensive and accurate information about every person living in the household, their relationship, their income status, and whether they expect to file a tax return or be claimed as dependents. This information directly affects the determination of one's eligibility and the amount of benefit received.
Incorrect or incomplete responses in Section 3, which asks about the living situation and specialized circumstances like foster care, can also derail the application process. For instance, neglecting to mention that a family member is residing in a long-term care facility or has received foster care between the ages of 18 and 26 might result in the omission of crucial considerations for one’s eligibility and potential benefits.
Many applicants struggle with Attachment A, which requires detailed information for those seeking Medicaid. Essential details like social security numbers, dates of birth, and immigration status are sometimes entered incorrectly or left blank. The precise documentation of each applicant’s demographic and legal status is fundamental for processing the Medicaid request efficiently and accurately.
People often misunderstand the significance of checking the appropriate boxes in the "Additional Information" section of Attachment A, which could lead to missing out on potential benefits—such as assistance with medical bills from the past three months. This oversight underscores the importance of thoroughly reviewing each section and question to ensure all applicable options are considered and selected.
Lastly, failing to utilize all available resources for assistance with the form, such as contacting the county DSS office, is a recurrent oversight. Many applicants are unaware of the support available to them, leading to unnecessary errors on the form from simply not asking for help or clarification. Engaging with these resources can provide crucial guidance and significantly mitigate the risk of mistakes.
When applying for Medicaid or renewing Medicaid coverage through the DMA 5199 form, individuals and families often need to provide additional information to verify eligibility and ensure the accurate processing of their application. This verification process is crucial for both new applicants and those seeking to renew their Medicaid or N.C. Health Choice coverage. Understanding the forms and documents that are commonly required alongside the DMA 5199 can help applicants prepare for a smoother application process.
Collecting and preparing the necessary documents before applying or renewing Medicaid can significantly ease the process. Applicants are encouraged to reach out to their local Department of Social Services (DSS) with any questions or for assistance with their application. By understanding what is required and proactively gathering these documents, individuals and families can navigate the Medicaid application process with greater confidence and efficiency.
The SSA-820-BK form, used for documenting work activity for Social Security Disability Insurance, shares similarities with the DMA-5199 form. Both forms gather detailed personal information and require reporting on the individual's current living situation, dependents, and additional specific circumstances such as income or health coverage status. The key similarity lies in their shared objective to determine eligibility for governmental assistance based on provided information.
IRS Form 1040, the U.S. Individual Income Tax Return, though primarily for tax purposes, aligns with the DMA-5199 form in querying about dependents and taxable income. Both forms seek information on household composition and financial status, which ultimately influences qualification for tax benefits or health coverage programs like Medicaid.
The Medicaid Application form, distinct yet directly linked to the DMA-5199, is designed specifically for new applicants, whereas the DMA-5199 targets current beneficiaries undergoing renewal. Despite their different audiences, both forms collect comprehensive data on family composition, income, living situation, and other eligibility criteria for Medicaid.
The Health Insurance Marketplace application parallels the DMA-5199 form as it assesses eligibility for health insurance subsidies or programs like Medicaid. It scrutinizes household size, income, and specific health coverage needs, echoing the DMA-5199’s objective of ensuring applicants meet the criteria for continued or new health assistance.
The SNAP benefits application form, while focusing on food assistance, reflects the DMA-5199 form's structure in collecting information on household composition, income, and expenses. Both forms meticulously assess the applicant's financial situation to establish eligibility for governmental aid programs.
The Free Application for Federal Student Aid (FAFSA) showcases another facet of federal assistance, evaluating a family's financial capacity to contribute to education costs. Although its primary focus diverges, the FAFSA, like the DMA-5199, seeks detailed financial and dependent information to ascertain qualification for aid.
The CHIP application, specifically designed for the Children’s Health Insurance Program, similarly requires detailed household and financial information to the DMA-5199 form. Both applications are crucial for families seeking assistance, be it for child-specific health coverage or broader Medicaid benefits, ensuring no eligible individual goes without necessary health services.
When it comes to ensuring continued coverage under the North Carolina Medicaid or N.C. Health Choice programs, the accuracy and completeness of the DMA-5199 form are paramount. Below are detailed instructions aimed at guiding individuals through the process effectively.
Do:
Don't:
When dealing with matters as important as Medicaid and N.C. Health Choice, understanding the documentation involved is critical. One such document, the DMA-5199 form, often results in confusion due to misinformation or misunderstandings. Let's clear up some common misconceptions people may have about the DMA-5199 form.
Misconception #1: The DMA-5199 form is optional for Medicaid renewal. In truth, completing this form is a crucial step in the Medicaid or N.C. Health Choice renewal process. It gathers necessary information to verify continued eligibility.
Misconception #2: You need to fill out the DMA-5199 form for each family member separately. Actually, this form allows the applicant to include information about all relevant family members and tax dependents living in the household, streamlining the process.
Misconception #3: There's no rush to submit the form. The form clearly states a deadline — 30 days from the date issued. Failing to send it by the specified deadline may result in losing coverage.
Misconception #4: The form is comprehensive enough for all Medicaid applications. While the DMA-5199 form is thorough, certain situations, such as applying for Medicaid for someone who doesn't currently have it, require completing additional attachments.
Misconception #5: If someone isn't a U.S. citizen or U.S. national, they can't be included on the form. The form accommodates individuals with eligible immigration status, requiring relevant documentation details to be provided.
Misconception #6: Only financial information is required for renewal. The form asks for much more than financial details, including household composition, income, living situation, and even if anyone listed was in foster care after turning 18.
Misconception #7: Completing the form doesn't require a signature. A signature under penalty of perjury is mandatory, affirming that all provided information is true and accurate. This can be the beneficiary’s or an authorized representative’s signature.
Misconception #8: Information about prenatal care or expectancy isn’t relevant. The form explicitly asks about pregnancies, due dates, and whether Medicaid application for prenatal care is needed, making it relevant information.
Misconception #9: The form can only be submitted by mail. There are multiple submission options available, including in-person at the County DSS Office and by phone, ensuring accessibility for everyone involved.
Understanding these aspects of the DMA-5199 form can significantly streamline the Medicaid renewal or application process, ensuring that you or your loved ones continue to receive necessary healthcare coverage without unnecessary interruptions.
When filling out and using the DMA 5199 form for Medicaid or N.C. Health Choice renewal, it's important to keep a few key points in mind to ensure the process goes smoothly. Understanding these points can help you complete the form accurately and increase your chances of retaining your health coverage.
Completing the DMA 5199 form accurately and on time plays a pivotal role in maintaining your Medicaid or N.C. Health Choice benefits. Always verify your information before submission and reach out to your county's Department of Social Services if you encounter any issues or have questions.
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