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State of Maryland Medical Assistance Manual Revised April 2014
MARYLAND MEDICAL ASSISTANCE PROGRAM
NOTICE OF INELIGIBILITY DUE TO EXCESS RESOURCES OR DISPOSAL OF RESOURCES
Date:
Re:
CURRENT
Name
RETRO
CID #
Dear
,
This is to notify you that based on the application filed on
, the above named person has been determined ineligible for Medical Assistance for the reason(s) checked below:
Resources exceed the Medical Assistance standard of $
. The amount of excess resources is $_____ ___. When the excess resources have been used for necessary personal or health care needs, you may reapply. When you reapply, you will be required to verify how the resources have been used. Keep all receipts for this purpose.
Resources have been transferred or otherwise disposed of for less than fair market value. This results in a period of ineligibility for cost of care payments from
to
. However, you are eligible for medical services covered under the red & white Medical Care Program Identification Card.
The following resources have been considered:
Type of Resource
Amount
$
__________________
___________________ __________________
___________________
This decision is based on COMAR 10.09.
.
. If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You have the right to reapply.
________________________
Case Manager
________________________
Department of Social Services
________________________
Telephone Number
DHMH 4235 (LTC) Revised 07/13
White–Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy Pink-Case Record Copy