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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF ELIGIBILITY

Re: _________________________________

Date: _____________

Name

Client Identification Number: ____________

LTC Facility: _____________

Dear _______________________________:

This is to notify you that the individual identified above has been determined eligible for Medical Assistance (MA) for the period __________________through__________________. The MA card will be sent to the Long Term Care Facility. A portion of the patient’s income must be paid directly to the Facility, and you must contact the Facility to establish the time and manner of payment.

(NOTE: The Department of Social Services and the LTC facility must be notified of any increase in the patient’s current income benefits and/or any new benefits received. The increased amount must be paid to the facility when received, whether or not a notice of increased payment requirement is received from the Department of Social Services or the facility has billed for it.)

The portion of income to be paid to the Long Term Care Facility has been calculated as follows:

Effective _____ Effective ___________ Effective_____ Social Security $

$

$ ___________ Veterans Benefits

___________ Pension

___________ Other

Total Income $

$

$___________

Personal Needs

____________

Health Insurance

Medicare

Other

Total Deductions -

-

-

Cost of Care $

$

$

If these amounts are not correct, you must contact the Department of Social Services immediately and, if necessary, the Department will adjust these amounts.

Any change in income, resources, health insurance premiums, medical expenses, living arrangements, persons living in the home, etc., must be reported within 10 working days to the Department of Social Services. The recipient, representative, and Long Term Care Facility are responsible for reporting such changes. Any of these changes could affect eligibility and income paid for the cost of care. This decision is based on COMAR 10.09.24__. If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting a hearing are attached.

Sincerely,

Case Manager

Department of Social Services

Telephone

DHMH 4233 (LTC) - Revised 3/08

White-Customer/Authorized Representative Copy Yellow- Long Term Care Facility Copy Pink- Case Record Copy