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State of Maryland Medical Assistance Manual Revised April 2014

27. DHMH 4236 (LTC)- Notice of Ineligibility Due to Excess Income

This manual notice is used to advise the applicant/recipient of his/her ineligibility for Medical Assistance due to excess income. It also advises them that they may submit non covered medical expenses to meet spend down. The CM must also include the form, DHMH 4200 (Record of Medical Expenses), for the individual to track his/her medical expenses.

28. DHMH 4239 (LTC)- Discharge From Long Term Care

This manual notice is used when the recipient is discharged from a long-term care facility. The notice is sent to the recipient/representative and the LTCF to show the income calculation for the portion of available income to be paid to the LTCF for the month of discharge. It also advises the recipient/representative if Medical Assistance will continue or be terminated due a redetermination of eligibility based on the changes in the living arrangements. This notice is to be used until the appropriate LTC notice is available through CARES.

29. DHMH 4240 (LTC) - Notice of Change in Available Income

This manual notice is used to inform the recipient and the LTCF of a change in the recipient’s available income for the cost of care. The CARES notice is suppressed if CARES is unable to put the correct information on the system generated notice.

30. DHMH 4241- Notice to Review Medical Assistance Eligibility for SSI-LTC

This manual notice is sent to SSI recipients to advise the recipient that their Medical Assistance eligibility under SSI needs to be reviewed and that they have 10 business days to report any changes in their circumstances.

31. DHMH 4245- Physician Report

This form is completed by the applicant/recipient’s physician to indicate how long the physician anticipates the individual will remain in the LTCF.

32. DHMH 4246 (LTC) -Notice of Medical Review Decision-Home Property

This form is completed by the Utilization Control Agent (UCA). The UCA determines if an individual is able to resume living in his/her home property in order to determine if the home property is an excludable resource.

33. DHMH 4255 (LTC)- Exclusion- Statement of Intent

This form is completed whenever a person has home property, to indicate the institutionalized person’s intent to return to the home property (see MA Manual Section 800). It is used to evaluate the consideration of home property and the residential maintenance allowance.

34. DHMH 4342- Excess Resources Reimbursement Form

This manual notice is used to advise the A/R of the exact amount of excess resources. This form is completed by the A/R when they opt to pay the excess amount to the Division of Recoveries.