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State of Maryland Medical Assistance Manual Revised April 2014
MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY FOR NON-FINANCIAL REASONS
Date of Notice _____________________________
C.I.D. Number _____________________________ Dear ____________________________________:
This is to notify you that based on the application you filed on _____________________ you have been determined ineligible for the reason(s) checked below:
_____ You are not a resident of the State of Maryland. _____ You do not meet the citizenship or alien requirements. _____ You did not provide the required information or verifications. Specify: ___________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ If you send this information before_____________, you will not have to file another application. This agency will re-activate your application and determine your eligibility.
_____ Other-Specify:_______________________________________________________________________________________
________________________________________________________________________________________
______ The income and assets of
are within scale for long-term care Medical Assistance. However, Medical Assistance payment for long-term care services (e.g., nursing facility) cannot be authorized until a DHMH 257 form certifying an appropriate level of care has been received from the Utilization Control Agent. Once we receive that form, you will receive a notice with the decision about your Medical Assistance eligibility.
This decision is based on COMAR 10.09. ______________________. If you have questions, please contact the case manager at the telephone number below. If you do not agree with this decision, you have the right to request a hearing within 90 days of this notice. The procedures for requesting a hearing are on the back of this letter. You also have the right to reapply.
Sincerely,
__________________________________________
Case Manager
__________________________________________
Department of Social Services
__________________________________________
Telephone Number
DHMH 4210 (LTC) – Revised 7/13