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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM

NOTICE OF NON-COVERAGE OF NURSING FACILITY SERVICES DUE TO DISPOSAL OF ASSETS FOR LESS THAN FAIR MARKET VALUE

Date

Re:

Name

CID #

Dear

,

This is to notify you that based on the application/redetermination filed on

, you are determined ineligible for Medical Assistance coverage of nursing facility services. This is because income and/or assets have been transferred or otherwise disposed for less than fair market value. However, you are eligible for medical services covered under the red and white Medical Care Program Identification Card. Your eligibility for Medical Assistance:

 began effective

.  will continue unless you receive a cancellation notice.

The transfers considered are listed below: Asset

Date Transferred

Value

Amount Transferred

$

$

$

$

The total amount transferred for less than fair market value was $

.

This results in a penalty period of

months and

days, which begins on

and expires on

____ .

You are not covered by Medical Assistance for nursing facility services until the penalty period expires, at which time you may have to complete a new application. If you cannot access these funds and the penalty would cause you to be deprived of medical care, food, clothing, shelter, or other necessities so that your health or life would be endangered, contact the case worker below to find out about requesting an "undue hardship waiver."

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 within 90 days of the date on this notice. The procedures for requesting a hearing are attached. If you have any questions about this letter, please call your Case Manager at the number below.

Case Manager

Department of Social Services

Telephone Number

DHMH 4235A (LTC) Revised 12/08

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