Medicaid Family Planning Services - Ending Waiver Notice

This is to notify you that on 00/00/200X your extended Medicaid benefits for FAMILY PLANNING will end. Family Planning benefits were extended for an additional two-year period and that period has ended.

You have the right to ask for a hearing within 90 days of the mailing date of this notice. If you ask for a hearing before a state hearing officer within 10 days of the date of this notice, you may continue to receive your family planning benefits. You can bring with you or be represented at the hearing by anyone you choose, such as a lawyer, relative or friend. You can ask for a hearing by writing, calling or going into your local Agency for Health Care Administration office.

If you think that you may be eligible for Medicaid based on your family income, you can apply at your nearest Department of Children and Families office.