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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM WORKSHEET FOR ISTIUTIONALIZED PERSONS Cost of Care/Available Income

Cost of Care Determination

Effective

Effective

Effective

Private Per Diem $

$

$

Days Per Month

×

×

×

Monthly C.O.C.

$

$

$

Available Income Determination

Effective

Effective

Effective

Monthly Income: Social Security

$

$

$

V.A.

Pension

Other

Other

Total Monthly Income $

$

$

Deductions: Personal Needs

$

$

$

Health Insurance

Medicare

Other

Total Deductions -

-

-

Available Income $

$

$

Eligibility Decision Available income less than cost of care. Eligible for MA and cost of care. Issue 206N-showing income. Complete 1159C, LIEN WORKSHEET, if the institutionalized person has income home property.

Available income is equal to cost of care. Eligible for MA card only. Issue 206N showing available income. Complete 1159C, LIEN WORKSHEET, if the institutionalized person has home property.

Available income greater than cost of care. For applications, proceed to side 2. For recipients close case.

DHMH 1159D 7/13 (LTC) (1 of 2)