Page 31

State of Maryland Medical Assistance Manual Revised April 2014

21. DHMH 4233 (LTC)- Notice of Eligibility

Use this manual eligibility approval notice and suppress the CARES notice when it is difficult to get CARES to put the correct information on the system-generated notice.

22. DHMH 4235 (LTC)-Notice of Ineligibility Due to Excess Resources

This manual notice is used to advise the applicant/recipient (A/R), representative, and LTCF of the A/R’s ineligibility for MA because the A/R’s resources exceed the allowable resource standard. The CM enters the amount of excess resources, checks off whether the individual is denied eligibility or terminated and, if terminated, enters the effective date of termination. The DHMH 4235 notice informs the A/R and the representative of their appeal rights and the process to request a hearing. This notice is to be used until the appropriate LTC notice is available through CARES. If terminated, the DHMH 4235, DES 100, and DHMH 4342 must be issued together.

23. DES 100 (LTC) Attachment to DHMH 4235- Explanation of Ineligibility Due to Excess Resources

This is an attachment to the DHMH 4235 notice. It indicates that the A/R is ineligible for MA due to excess resources, gives the amount of over scale resources, and advises that benefits may be restored for a recipient if the excess amount of the resources is used to reimburse the Medicaid program for its payments.

24. DHMH 4235A (LTC)- Notice of Non-Coverage of Nursing Facility Services Due to Disposal of Assets for Less Than Fair Market Value

This manual notice is used to advise the A/R, representative, and nursing facility of a penalty period for non-coverage of nursing facility services because the applicant/recipient/spouse transferred or otherwise disposed of assets for less than fair market value. The notice also informed the A/R and representative of their appeal rights and the process to request a hearing. This notice is to be used until the appropriate LTC notice is available through CARES.

25. DHMH 4235B (LTC)- Notice of Non-Coverage of Nursing Facility Services Due to Substantial Home Equity

This manual notice is used to advise the A/R, representative, and nursing facility of a penalty period for non-coverage of nursing facility services because the applicant/recipient owns equity interest in home property (after deducting any encumbrances) that exceeds the current home equity limit. The notice also informs the A/R and representative of their appeal rights and the process to request a hearing. This notice is to be used until the appropriate LTC notice is available through CARES.

26. DHMH 4235C (LTC)- Notice of Non-Coverage of Nursing Facility Services Due to Annuity

This manual notice is used to advise the A/R, representative, and nursing facility of a penalty period of non-coverage of nursing facility services because certain specified requirements related to an annuity owned by the A/R or spouse were not met. The notice informs the A/R and representative of their right to contact the case worker and request an “Undue Hardship Waiver”. The notice and attachment also inform the A/R and representative of their appeal rights and the process to request a hearing. This notice is to be used until the appropriate LTC notice is available through CARES.