Page 40

State of Maryland Medical Assistance Manual Revised April 2014

Fair Market Value (FMV) at Time of Transfer: _____________

Encumbrances at Time of Transfer:

_____________

Equity Value at Time of Transfer:

_____________

Compensation Received:

_____________

Uncompensated Value:

_____________

Uncompensated Value ÷ _________ (MA-6 Monthly Average Cost of Care) =

Length of Computed Penalty - Month(s): __________________

Partial Month Uncompensated Value ÷ _______ (MA-6 Daily Average Cost of Care) =

Length of Partial Month Penalty – Day(s): _________________

Penalty Begin Date: __________________________

Penalty End Date: ____________________________

Case Manager: _______________________________

If the client has an active penalty period, complete the DES/LTC 813 and fax to the Division of Recipient Eligibility Programs (DREP) at (410) 333-5087 on the same day that the case is finalized on CARES to void the individual’s span on MMIS recipient screen 4 for coverage of nursing facility services or on MMIS recipient screen 8 for HCB Waiver services.

The individual’s Medicaid eligibility (MMIS screen 1) is not affected.

DES/LTC 811 Revised 12/08 (2)