INCOME SUPPORT DIVISION

CENTRAL ASPEN SCANNING AREA

P.O. BOX 830 3230000093864100000000
BERNALILLO NM 87004
PHONE NUMBER: (800) 283-4465 Case Name: Cheyenne A Munoz
FAX NUMBER: (855) 804-8960 Case Number: 120199385
Date: January 20, 2025
Revision Date: HCA 1210 January 12th, 2025

CHEYENNE A MUNOZ
222 LINDEN ST
HAGERMAN NM 88232

Notice of Case Action

Dear Cheyenne A Munoz Household,

This letter is about your benefits. For questions, call the Health Care Authority's Income Support Division
(ISD) at (800) 283-4465 . Or log on to YESNM at https://yes.nm.gov/. You have right to receive this information and
help in your language at no cost. To speak with an interpreter, call 800-383-2246.

Benefit Case Action

Medicaid is renewed but benefits changed for all members of your household.

To learn more, read "Your Medicaid" section below.

Medicaid

é!õê Page 1 of 12
Each program has its own rules. Some persons may count as household members, but may not qualify for every
program. To learn more, read the rest of this letter.

Notice of Rights
To learn your civil rights and your right to a fair hearing, read the last page of this letter.

Medicaid
Medicaid covers health care for people and families who meet certain federal and state guidelines. Medicaid may
also help people pay their Medicare premiums (monthly cost). To qualify for Medicaid, you must meet citizenship,
residency and income requirements. You may get "Full" or "Limited" coverage, depending on the type of Medicaid.

You may not qualify for Medicaid. If not, we will send your application to the New Mexico Health Insurance Exchange.
That is also known as beWellnm. We also do this if you have limited benefits. That includes Family Planning
Medicaid. You can buy health insurance from beWellnm. You might get financial help to pay for it. They will check to
see if you can get help. That is with monthly costs of insurance. Please go to www.bewellnm.com to enroll. You can
also get free help there. They can help you find health insurance for you and your family. You may also call beWellnm.
Call (833) 862-3935 . You have 60 days to enroll or contact them.

ISD renewed Medicaid for your household members. We did not need more information from you. We counted your
household size and got income from your case file and other data sources. This is called an Administrative Renewal.

If the information in the table at the end of this letter is correct, you do not have to do anything. If the information is
wrong or has changed, tell us in one of these ways:

Income Support Division

Mail this form to: Central ASPEN Scanning Area
P.O. Box 830 Bernalillo, NM 87004-0015

Fax to: (855) 804-8960

Call the Income Support (800) 283-4465

Customer Service Center Toll Monday-Friday, 7 am to 6:30 pm
Free at: The call is free.

Submit online at: https://yes.nm.gov/

Chaves County ISD

In person at the ISD office 1701 S SUNSET AVE ROSWELL, NM
88203

Page 2 of 12
 3230000093864100000000

Approvals

Name Dates Medicaid Type Next Renewal Month

Full Coverage, MAGI Other

Cheyenne A Munoz March 2025 - January 2026 Adults Medicaid (Category January 2026
100)

Denials or Closures or Change in Benefits

Name Month Medicaid Type Reason

You are already covered under another

Full Coverage, MAGI
assistance program. (NMAC 8.292.600.11). You
Parent/Caretaker
Cheyenne A Munoz March 2025 will continue to get Medicaid under a new
Relative Medicaid
category. See the approval section above for
(Category 200)
more information.

Full Medicaid Coverage

Cheyenne A Munoz, you are approved for full Medicaid coverage for the months listed in the Medicaid Approvals table
above.

Full Medicaid coverage is for many types of care. Full Medicaid pays for doctor visits, preventive care, hospital care,
emergency room care, and urgent care. It also pays for specialist visits, lab and x-ray services, mental health and
substance abuse treatment, prescriptions, dental services, and more. The help you can get depends on the Medicaid
category you are approved for.

MAGI Category for Adults

Cheyenne A Munoz, you are covered for medical expenses for the months listed in the Medicaid Approvals table
above. You are approved for 12 months of coverage in this category, as long as you continue to qualify.

If you are Native American, you will get services through the Medicaid fee-for-service program unless you chose a
Turquoise Care Managed Care Organization (MCO) on your application. If you did not choose an MCO on your
application, you may choose to enroll in an MCO any time.

You are in the Medicaid Expansion Alternative Benefit Plan (ABP). The Medicaid ABP pays for doctor visits, preventive
care, hospital care, emergency room care, urgent care, specialist visits, lab and x-ray services, mental health and
substance abuse treatment, prescriptions, certain dental services, and more. To see a list online of services covered
under the Medicaid ABP, go to https://hca.nm.gov/LookingForInformation/abpvstateplan/.

You might qualify for more services through the New Mexico Medicaid program if you have special health care needs
such as:
• Serious or complex medical condition
• Terminal illness
• Chronic substance use disorder
• Serious mental illness

é!õê Page 3 of 12
 • Physical, intellectual or developmental disability that keeps you from doing one or more activities of daily
living
If you think you have special health care needs, call your Turquoise Care MCO. If you are Native American and are not
in Turquoise Care, call the Third Party Assessor toll-free at (866) 962-2180. They will help find out if you have special
health care needs and qualify for other services through the New Mexico Medicaid program.

If you have special health care needs, you can choose to get services under the Medicaid ABP or through standard
Medicaid. To compare the Medicaid ABP to standard Medicaid, go to
https://hca.nm.gov/LookingForInformation/abpvstateplan/ . Or call (800) 283-4465 and ask for the comparison.

Other Important Information About Medicaid

What does Medicaid give me?

In New Mexico, different Medicaid types may cover different care. To see if you or someone in your home can get
Medicaid, we look at each person. We find the Medicaid that covers the most care. Some people can get "Full"
Medicaid. It covers many services. Or there is "Limited" Medicaid. That covers only some types of care. Some people
may not be able to get any type of Medicaid.

How do people with Full Medicaid get care?

Most people with Full Medicaid get their care from New Mexico Turquoise Care. This is New Mexico's managed care
program. Turquoise Care uses Managed Care Organizations (MCOs) to give care to Turquoise Care members. A MCO is
an insurance company. The MCO works with doctors, hospitals, pharmacies, and health care providers.

To learn more about the Medicaid you get, call the Medicaid Call Center at (800) 283-4465. Or go to
https://yes.nm.gov/. If you need a new Medicaid card, you can call this number or go to this website. You do not need
a Turquoise Care MCO to get a new card. If you have a Turquoise Care MCO, you can get a new Medicaid card by
calling your MCO.

When do I have to renew my Medicaid?

Most Medicaid types must be renewed every year. We will try to renew your Medicaid with what we know about you. If
we need to know more, we will mail a letter that tells you how to renew. To keep getting Medicaid, you must renew by
the renewal date in the letter.

Your Medicaid coverage is based on your total household income and some expenses. Expenses do not lower your
income dollar for dollar. For some Medicaid programs, we also count resources. We used these amounts to figure out
your Medicaid benefits.

MAGI Other Adults Medicaid Income Test for Cheyenne A Munoz

How we figured your financial eligibility for Medicaid.

Type of Income Description +/-/=/: Amount

Unearned Income This is the money you get each month that is not from work. = $0.00

Page 4 of 12
 3230000093864100000000

This is the money you get each month from working, before
Earned Income + $0.00
taxes and deductions.

This is the money you get each month from working for
Self Employment Income + $0.00
yourself.

Countable Income Total money that is counted. = $0.00

This is money deducted from your countable income because

Federal Deductions - $0.00
of federal deductions.

This disregard is applied only if your income was above the

5% Disregard - $0.00
net income limit.

Net Income This is your countable income after all deductions. = $0.00

Household size (including The household size is identified by tax filer rules and includes
: 1
unborn) unborn.

This is the money a household the size of yours can have in a

Income Limit month after deductions have been applied and still get : $1,670.00
benefits.

Pass: This means your net income is less than the income
Result limit for your household size. This means you are eligible to : Pass
get Medicaid benefits.

é!õê Page 5 of 12
If you think we made a mistake in how we counted your income or resources, please call the Customer Service Center
at (800) 283-4465. Or go to your local ISD office.

Page 6 of 12
 3230000093864100000000

Notice of Rights

Special Needs Information If you are a person with a disability and you require this information
in an alternative format, or require a special accommodation to participate in any public hearing,
program or services, please contact the Health Care Authority, American Disabilities Act (ADA)
coordinator at 1-505-709-7588 or by dialing 711. The HCA requests at least 10 days advance notice
to provide requested alternative formats and special accommodations. (Revised 4/22/24)

Your Civil Rights Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and
policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex
(including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or
retaliation for prior civil rights activity. Program information may be made available in languages other than
English.
Persons with disabilities who require alternative means of communication to obtain program information (e.g.,
Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they
applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA
through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program
Discrimination Complaint Form which can be obtained online at:
https://www.usda.gov/sites/default/files/documents/ad-3027.pdf , from any USDA office, by calling (833)
620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address,
telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the
Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation.
The completed AD-3027 form or letter must be submitted to:

(1) mail: Food and Nutrition Service, (2) fax: (833) 256-1665 or (202) 690-7442 ; or
USDA 1320 Braddock Place, (3) email: FNSCIVILRIGHTSCOMPLAINTS@usda.gov
Room 334 Alexandria,

VA 22314; or This institution is an equal opportunity provider.

(Revised 02/15/23)

To file a complaint through HCA of discrimination and/or rude treatment regarding a program receiving Federal
or State financial assistance, a complaint form is available at the ISD office or you may write to: NM Health Care
Authority, ISD Civil Rights Director, P.O. Box 2348, Santa Fe, NM 87504-2348 or by fax (505) 827-7241.

Confidentiality
All information you give to HCA is confidential. This information will be given to HCA employees who need it to
manage the programs for which you have applied. Confidential information may also be released to other federal
and state agencies. All information will be used to determine eligibility and/or to provide services. (Revised
07/15/14)
This information may be given to other Federal and State agencies for official examination, and to law
enforcement officials for the purpose of picking up persons fleeing to avoid the law. If you get benefits that you
were not eligible for and have to pay them back, this is called a claim. If your household gets a claim against it,
the information on this application including all Social Security Numbers, may be given to Federal and State
agencies, as well as private claims collection agencies for claims collection action. You only have to give U.S.

é!õê Page 7 of 12
Citizenship and Social Security Numbers for those household members that you are applying for. You do not need
to be a U.S. Citizen to apply.
Non-citizen immigrants not requesting assistance for themselves, do not need to give immigration status
information, Social Security Numbers, or other similar proofs; however, they must give proof of income and things
they own because part of their income and things they own may count towards the household's eligibility for
assistance. Certain benefits may be available for people without a Social Security Number; ask ISD.
We also check with other agencies, the federal Income and Eligibility Verification Service (IEVS) and The Public
Assistance Reporting Information System (PARIS) about the information that you give us. This information may
affect your household eligibility and benefit amount.

Page 8 of 12
 Revision Date: June 30th, 2024

YOUR RIGHT TO A FAIR HEARING

IF YOU WANT TO SIGN UP FOR A FAIR HEARING, PLEASE FILL OUT THE BACK OF THIS PAGE

What is a Fair Hearing A Fair Hearing gives you the chance to explain why you think there has been a
and why should I ask wrong decision made about your benefits, or if you think that your benefits were
for one? not processed in a timely manner. Hearings are held over the phone with a
hearing officer. The hearing officer will hear information from you and from the
Income Support Division and decide whether the decision was right or wrong.

Can I get help with my You can have a friend or family member participate in the hearing with you. You
hearing? may also be able to get free legal help. To learn more about free legal help, call
NM Legal Aid at (833) LGL-HELP (833) 545-4357.

How long do I have to You must request a hearing within 90 days from the date of the adverse action
ask for a hearing? you are appealing. You may be able to get more time to ask for a hearing if you
have a good reason, like illness or another circumstance beyond your control.

Can I keep my If you are already getting benefits, you may be able to continue receiving
benefits if I request a benefits while you wait for your hearing if you request your hearing within 13
hearing? days of the adverse action date.
For SNAP or CASH: If the hearing decision is not in your favor, you may have to
pay back the benefits you received while waiting for your hearing.

How do I ask for a You can request a hearing by filling out the information on the other side of this
hearing? form and mailing or faxing it to:
HEALTH CARE AUTHORITY - OFFICE OF FAIR HEARINGS, HCA
PO BOX 2348
SANTA FE, NM 87504-2348
FAX # (505) 476-6215

You can request a hearing over the phone by calling (800) 283-4465. You can also
request a hearing in person at any Income Support Division office.

é!õê Page 9 of 12
Special Needs If you are a person with a disability and you require this information in an
Information alternative format, or require a special accommodation to participate in any
public hearing, program or services, please contact the Health Care Authority,
American Disabilities Act (ADA) coordinator at 1-505-709-7588 or by dialing 711.
The HCA requests at least 10 days advance notice to provide requested
alternative formats and special accommodations. (Revised 4/22/24)

If you need an You have a right to a free interpreter. Let the Health Care Authority (HCA) know if
interpreter you need an interpreter before or during the hearing by calling: (800) 283-4465.

Page 10 of 12
 FAIR HEARING REQUEST
IF YOU DO NOT AGREE WITH AN ACTION ON YOUR CASE, USE THIS FORM TO ASK FOR A FAIR
HEARING.
THIS FORM IS NOT REQUIRED UNLESS YOU WANT TO ASK FOR A FAIR HEARING.

YOU DO NOT NEED TO SEND THIS FORM IF YOU AGREE WITH WHAT HAS HAPPENED ON YOUR CASE.

THIS FORM IS NOT REQUIRED TO RENEW YOUR BENEFITS.

Mailing Address:222 Linden St Date: JANUARY 20, 2025

Hagerman Name:Cheyenne A Munoz

NM 88232 Case Number: 120199385

Q1. I DISAGREE with the decision made on my case Yes No

Q2. I would like to ask for a fair hearing and appeal the decision Yes No

If you answered "Yes" to Q1 and Q2, please complete the information below and send it to us.
If you did not answer "yes" to both questions, you do not need to complete this form.
I am asking for a fair hearing for the following program(s).

SNAP or E&T Cash Assistance or NM Works LIHEAP

(TANF)

General Assistance The Water Program Medicaid

(Unrelated Child & Disabled
Adult)

If my benefits were lowered or stopped because of the action on my case:

I want to keep getting the same amount of benefits while I wait for a fair hearing
decision. I understand if the hearing decision is not in my favor, I may have to pay back any
benefits I received while waiting for the hearing and the decision.

I do not want to keep getting the same amount of benefits while I wait for a fair hearing
decision.
(For more information on the fair hearing process see the other side of this form.)

Please write down your reason(s) for asking for a fair hearing and why you think the action taken was
wrong. Give as much information as you can. You can still have a fair hearing even if you don't fill this
section out.

é"‚ê Page 11 of 12
By signing this form, you are requesting a Fair Hearing.
You do not need to sign or return this form unless you are asking for a Fair Hearing.

Client or Authorized Representative Signature: Date: Phone:

You can leave this form at any Income Support Division and it will be delivered to the Office of Fair
Hearings, or you may send it or fax it to:

HEALTH CARE AUTHORITY - OFFICE OF FAIR HEARINGS, HCA

PO BOX 2348
SANTA FE, NM 87504-2348
FAX # (505) 476-6215

A notice will be sent to you when the Office of Fair Hearings gets your hearing request. You will get a
second notice with the phone number to call and the date and time of your hearing. It will be sent when
your hearing has been set. You will need to call in at the number and the date and time of your hearing. If
you have any questions about your hearing rights, call Law NM Legal Aid at (833) LGL-HELP (833) 545-4357.

Page 12 of 12