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State of Maryland Medical Assistance Manual Revised April 2014

35. DHMH 4343- Declaration of Joint Bank Account Ownership Interest

This form is completed and signed by the recipient A/R and any co-owners who have a bank account(s) or other liquid assets in common. The owners must also indicate their ownership interest in each account (see MA Manual Section 800).

36. DHMH 4354 - Resource Evaluation for Married Applicants Institutionalized

The worksheet is used to assess the resources of a married applicant and the spouse for: the month of institutionalization, the month of application and the post-eligibility transfer period.

37. DHR/FIA 1052-LTC- Long Term Care Request for Information to Verify Eligibility

This form is used by the Medical Assistance LTC CM to request information necessary to determine Medical Assistance eligibility for the applicant or recipient.

38. 206-C -Interface Correction Report

This form is sent to the Division of Recipient Eligibility Program (DREP) to correct changes on MMIS that were unable to be transmitted from CARES:

• for multiple transactions; • for changes to income or resources; • to report a death; • when an individual is discharged from a LTCF or is transferred from one facility to another; • to report provider changes; and • to document multiple spans for MMIS screen 4 (Long-Term Care Spans), etc.

39. C-TAD- Certification/Turnabout Document

This form is sent to the Division of Recipient Eligibility Program (DREP) to establish MA eligibility on MMIS screen 1 or to change the eligibility data on screen 1.

40. OES 001 (Revised 05/12) - Request for Non-Covered Services Pre/Post-Eligibility Deductions

This form is completed by the CM and sent to the Office of Eligibility Services to request a pre/post-eligibility deduction and/or a non-covered service deduction.

41. OES 011 (LTC) -Notice of Eligibility for the Post-Eligibility Medical Expense Deduction

This manual notice is used to advise the recipient, representative, and nursing facility of the amounts that have been approved and disapproved. The CM will receive a printout with the decision from the Office of Eligibility Services stating each medical service, the amount approved, and the amount disapproved (if any). This printout needs to be attached to this letter and sent to the recipient, representative, and nursing facility. In addition, this letter also informs the recipients, representative, and nursing facility how long the deduction will continue to be subtracted from the cost of care.