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State of Maryland Medical Assistance Manual Revised April 2014

Maryland Medical Assistance Program HOME EQUITY VALUE WORKSHEET

Client’s Name:

Client ID:

Local Department of Social Services/DEWS:

Application/Redetermination Date:

Date of Evaluation:

Owner(s):

Fair Market Value:

Encumbrances:

Total Encumbrances:

Equity Value:

(=FMV minus Encumbrances)

When the equity value exceeds the current home equity limit in Schedule MA-10 by any amount, complete and fax the DES/LTC 813 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 screen 8 for HCB Waiver services.

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

DES/LTC 812 Revised 12/08