Butte - CEC-C STATE OF CALIFORNIA

COUNTY OF BUTTE HEALTH AND WELFARE AGENCY

PO BOX 1709
CALIFORNIA DEPARTMENT OF SOCIAL
OROVILLE, CA 95965-1709
SERVICES

NOTICE DATE: August 10, 2023

CASE NAME: Sara Lopez
CALHEERS CASE NUMBER: 5010711933
SAWS CASE NUMBER: 2063604
WORKER NAME: Maria Gonzalez-Krueger
WORKER ID: 04LS03140A
TELEPHONE NUMBER: (530) 552-6469
CUSTOMER ID:

NOTICE OF ACTION
MEDI-CAL APPROVAL
Sara B Lopez
PO BOX 387
FOREST RANCH, CA 95942-0387

Dear Sara Bersave Lopez, State Hearing: If you think this action is wrong, you can ask
We have reviewed your eligibility for health coverage. for a hearing. The back page tells you how. Your benefits
We used the information you gave us and state and may not be changed if you ask for a hearing before this
action takes place. You have only 90 days to ask for a
federal data to make this decision.
hearing. The 90 days started the day after the county sent
you this notice.
Sara Bersave Lopez

You qualify for pregnancy related Medi-Cal because you

Over the next year, you must report any life changes
are pregnant and your household income is below the
that affect your eligibility for Medi-Cal. You must report
Medi-Cal limit. Your eligibility for pregnancy related
within 10 days after the change happened. For example,
Medi-Cal begins 07/01/2023. Your Medi-Cal coverage
you must contact us if:
will continue unless you are found no longer eligible.
• Your income changes.
This could happen at the time your eligibility is renewed
• Your household changes, such as you marry,
or when your situation changes.
divorce, become pregnant, or have or adopt a child;
Pregnancy related Medi-Cal covers any medical a person moves into or out of your home; or you
condition that can affect your health during your change who will be on your tax return.
pregnancy or the health of your unborn child, such as • You qualify for other health insurance.
pregnancy related services such as prenatal care, labor, • You move. If you move to a new county, you can
delivery, postpartum care, family planning, emergency report your change to your old or new county.
care, and some dental services.
You may report changes to your local county office in
We counted your household size and income to make person or by mail, fax, phone, or electronically. The
our decision. contact information is on the first page of this notice.
For Medi-Cal, your household size is 3 and your
monthly household income is $3,133.27. The monthly
pregnancy related Medi-Cal income limit for your
household size is $4,414.00. Your income is below this
limit, so you qualify for pregnancy related Medi-Cal.

Title 22, C.C.R §50262; Title 42, C.F.R §§435.116,

435.603; is the regulation or law we relied on for this
decision.

Do you have any changes?

MC-MAGI-A (11/15) Page 1 of 2

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 TO ASK FOR A HEARING:
YOUR HEARING RIGHTS
• Fill out this page.
You have the right to ask for a hearing if you disagree with • Make a copy of the front and back of this page for your
any county action. You have only 90 days to ask for a records. If you ask, your worker will get you a copy of this
hearing. The 90 days started the day after the county gave page.
or mailed you this notice. If you have good cause as to why • Send or take this page to:
you were not able to file for a hearing within the 90 days, California Department of Social Services
State Hearings Division, ACAB
you may still file for a hearing. If you provide good cause, a 744 P Street, MS 9-17-97
hearing may still be scheduled. Sacramento, CA 95814
If you ask for a hearing before an action on Cash Aid, OR Fax to: 1-916-651-2789
Medi-Cal, CalFresh, or Child Care takes place: • Call toll free: 1-855-795-0634 or for hearing or speech impaired
who use TDD, 1-800-952-8349.
• Your Cash Aid or Medi-Cal will stay the same while you wait for a hearing.
To Get Help: You can ask about your hearing rights or for a legal aid
• Your Child Care Services may stay the same while you wait for a hearing.
referral at the toll-free state phone numbers listed above. You may get
• Your CalFresh will stay the same until the hearing or the end of your
free legal help at your local legal aid or welfare rights office.
certification period, whichever is earlier.
Legal Services of Northern California
If the hearing decision says we are right, you will owe us for any extra 541 NORMAL ST
Cash Aid, CalFresh or Child Care Services you got. To let us lower or CHICO, CA 95928
stop your benefits before the hearing check below:
(800) 345-9491 / Fax: (530) 345-6913
Yes, lower or stop: Cash Aid CalFresh Child Care Toll Free: (800) 345-9491

While You Wait for a Hearing Decision for:

Welfare to Work:
You do not have to take part in the activities.
If you do not want to go to the hearing alone, you can bring a friend
or someone with you.
You may receive child care payments for employment and for activities
approved by the county before this notice.
HEARING REQUEST
If we told you your other supportive services payments will stop, you will not I want a hearing due to an action by the Welfare Department of
get any more payments, even if you go to your activity. BUTTE County about my:
Cash Aid CalFresh Medi-Cal
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. Other (List)

• To get those supportive services, you must go to the activity the Here's Why:
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 If you need more space, check here and add a page.
approved activity. I need the state to provide me with an interpreter at no cost to
OTHER INFORMATION me. (A relative or friend cannot interpret for you at the
hearing.)
Medi-Cal Managed Care Plan Members: This action on this notice may
My language or dialect is:
stop you from getting services from your managed care health plan. You
NAME OF PERSON WHOSE BENEFITS WERE DENIED, CHANGED OR STOPPED
may wish to contact your health plan membership services if you have
questions. BIRTH DATE PHONE NUMBER

Child and/or Medical Support: The local child support agency will help STREET ADDRESS
collect support at no cost even if you are not on cash aid. If they now collect CITY STATE ZIP CODE
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 SIGNATURE DATE
due money collected that is owed to the county.
NAME OF PERSON COMPLETING THIS FORM PHONE NUMBER
Family Planning: Your welfare office will give you information when you
ask for it. 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
Hearing File: If you ask for a hearing, the State Hearing Division will set up cannot interpret for you.)
a file. You have the right to see this file before your hearing and to get a
NAME PHONE NUMBER
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 STREET ADDRESS
and the U.S. Departments of Health and Human Services and Agriculture.
(W&I Code Sections 10850 and 10950.) CITY STATE ZIP CODE

NA BACK 9 (ACA/ MEDI-CAL) (11/16) - REQUIRED FORM - NO SUBSTITUTE PERMITTED

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