Page 75

State of Maryland Medical Assistance Manual Revised April 2014

Note: You are required to inform the case manager named below of any change in your income or resources within 10 days of the change. This includes notifying your case worker when you (or your spouse) purchase, sell, or make any change to an annuity, such as changing the ownership or the amount of payments.

This decision is based on the requirements set forth in the Deficit Reduction Act of 2005 (Public Law 109-171) Section 6012, as codified in 42 U.S.C. 1396p, and/or 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

cc: Representative

Long Term Care Facility

DHMH 4235C (LTC) Revised 12/08 (2 of 3) White–Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy Pink-Case Record Copy