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State of Maryland Medical Assistance Manual Revised April 2014

Maryland Medical Assistance Program

MANUAL MMIS INSTRUCTIONS FOR SCREEN 4/ SCREEN 8

When a penalty has been calculated using the DES/LTC 811, please complete this document and fax a copy to the Division of Recipient Eligibility Programs (DREP) at (410) 333-5087.

Timely submission of this form will ensure that MMIS recipient screen 4 (LTC) or MMIS recipient screen 8 (Waiver) is closed during the client’s penalty period.

Client’s Name ___________________________ Client ID_______________________ AU ID:_____________________

Social Security Number ___________________ Date of Birth ______________________

Penalty Begin Date ___________________ Penalty End Date __________________

[FOR MMIS USE ONLY] Closing/Termination Code: __I__

_______________________________________________________________________________________________________

MANUAL HOME EQUITY INSTRUCTIONS FOR SCREEN 4/SCREEN 8

When the total equity value exceeds the current home equity limit in Schedule MA-10 by any amount, after completing the DES/LTC 812, fax this form to DREP at (410) 333-5087 to void Screen 4/Screen 8.

Client’s Name: ____________________________ Client ID: _____________________________ AU ID: __________________

Social Security Number: __________________ Date of Birth: ____________________ Date of

Ineligibility:_________________

[FOR MMIS USE ONLY] Closing/Termination Code: __I__

Case Manager ___________________________ District Office __________________ Telephone Number ___________

YOU MUST RETAIN A COPY OF THIS FORM IN THE CLIENT’S CASE RECORD

DES/LTC 813 Revised 12/08