<p>NWD Transitional Medical Assistance - Letter Report Layout Oklahoma Health Care Authority Case Number: XXXXXXXXX P.O. Box 548804 ATN: XX-XXXXX-XXX-XXX Oklahoma City, OK 73154-1200 PIN: XXXXXXXXXX</p><p>The TMA letter is for: 1)TMA due to earned income: new TMA, first notice, second notice, third</p><p> notice 2) TMA due to child support: new TMA</p><p>Applicant Name Applicant mailing address 1 Applicant mailing address 2 Applicant City, St 99999-9999</p><p>MM/DD/CCYY </p><p>Dear Applicant Name,</p><p>This letter is to notify you of changes in your SoonerCare health benefits. Because of an increase in your household’s <reason>, your SoonerCare benefits would normally be stopped. However, your household qualifies for an extension of your health benefits for up to <time period> months under Transitional Medical Assistance (TMA). TMA allows you to still receive SoonerCare benefits for this period of time after your income goes above the SoonerCare limit. </p><p>Variable Paragraph only if new TMA due to earned income During this <time period> months that your household is on TMA, you must periodically report specific information about your household. If you do not, your benefits will end.</p><p>In both of the above paragraphs <reason> and <time period> are variable depending on removal reason. If earned income, then <reason> equals “earnings” <time period> equals “twelve” and include the second paragraph. If child support, then <reason> equals “child or spousal support” <time period> equals “four” and do NOT include second paragraph.</p><p>If TMA is due to child support, then they will only get this letter and will not get any of the future TMA notices. Only TMA from earned income will get the notices in the 3rd, 6th, and 9th months.</p><p>Variable Paragraph for TMA due to earned income Notice #1. (Notice #1 is issued in the third month of the TMA period)</p><p>Notice #3. (Notice #3 is issued in the ninth month of the TMA period)</p><p>You must provide the information requested below by MM/DD/CCYY to be considered for continued Transitional Medical Assistance or your benefits will end on that day without any further notice. Information requested: (A) gross earned income of the people in your household (B) child care expenses necessary to continue employment</p><p>(C) changes in household size- who all lives with you (D) where you live (E) insurance coverage of the people in your household Notice #3 Important other information! The information you send in above will only extend your health coverage through the end of your original Transitional Medical benefits period, which expires on MM/DD/CCYY. If you believe you may still be eligible for benefits after that date, you will need to re-apply, even if you have turned in the information above. </p><p>Variable Paragraph for TMA due to earned income</p><p>Notice #2. (Notice #2 is issued in the sixth month of the TMA period)</p><p>You may be eligible for another six-month period if you provide the information requested below by MM/DD/CCYY to be considered for continued Transitional Medical Assistance or your benefits will end on that day without any further notice.</p><p>Information requested: (A) gross earned income of the people in your household (B) child care expenses necessary to continue employment</p><p>(C) changes in household size- who all lives with you (D) where you live (E) insurance coverage of the people in your household</p><p>To make changes online: 1. Go to our Web site at www.apply.okhca.org to log on.</p><p>2. Click on the link you prefer under Manage my Account</p><p>- If you have not created a logon, use the PIN number provided at the top of this letter to</p><p> create a User ID and Password to access your account.</p><p>- If you have created a User ID and Password online you will need to log on using the</p><p>PIN provided at the top of this letter to confirm your User ID and Password within 30</p><p> days.</p><p>3. Follow the instructions to complete the application. </p><p>If you would like to report changes by paper please contact the Oklahoma Health Care Authority at the number listed at the bottom of this letter to request an application.</p><p>Some adults in the household may qualify for health insurance through the Insure Oklahoma/O- EPIC program. For more information call 1-888-365-3742.</p><p>For additional information about the SoonerCare Program, apply online, or to report changes online, refer to our Web site at www.apply.okhca.org. For questions about this letter, call the Oklahoma Health Care Authority toll-free at 1-800-987-7767 or for the hearing impaired, call the TDD/TTY line at (800) 757-5979. Please refer to letter DET-9009-D and the Application Tracking Number (ATN) listed at the top of this letter when you call. </p><p>Sincerely, Oklahoma Health Care Authority</p>