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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 ANNUITY

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 you did not meet the Program's requirements related to annuities. 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.

Since you did not meet the following requirements related to annuities, Medical Assistance will not pay for your nursing facility services:

____1. You did not name the State of Maryland as the remainder beneficiary for an annuity owned by yourself (or your spouse), behind only any spouse or minor or disabled sons or daughters that you have. Because of this, you will not be covered by Medical Assistance for nursing facility services until the State of Maryland is named as a remainder beneficiary in the correct position for the total amount of Medical Assistance expenditures on your behalf.

____2. You are considered to have transferred assets for less than fair market value because on _______________:

 You (or your spouse) purchased an annuity and did not name the State of Maryland as the remainder beneficiary, behind only any spouse or minor or disabled sons or daughters that you have.

 You (or your spouse) purchased an annuity, added money to an annuity, withdrew money from an annuity, or changed payments from an annuity that made your money unavailable or for which you did not receive fair market value.

 You purchased an annuity, added money to an annuity, withdrew money from an annuity, changed payments from an annuity, or made another change to an annuity's payments or principal and the annuity either does not meet certain requirements of the Internal Revenue Code to be excluded from consideration or does not meet all of the following Medical Assistance requirements: is irrevocable, non-assignable, and actuarially sound and provides for payments, with no deferral and no balloon payments, in approximately equal amounts through the annuity's term to you or any spouse or minor or disabled child that you have.

Because of the action specified in #2 above, you are considered to have transferred assets for less than fair market value in the amount of $________________. 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."

DHMH 4235C (LTC) Revised 12/08 (1 of 3) White–Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy Pink-Case Record Copy