Page 77
State of Maryland Medical Assistance Manual Revised April 2014
MARYLAND MEDICAL ASSISTANCE PROGRAM
NOTICE OF INELIGIBILITY DUE TO EXCESS INCOME
Date:__________________ Re: _______________________________
CID# ___________________
Name Dear _______________________________,
This is to notify you that based on the application filed on___________________, the above named person has been determined ineligible for Medical Assistance due to excess income. The income for the period _____________ to _____________ has been calculated as follows:
Source of Income
Monthly Amount
Amount for Period Social Security
_____________
$_____________ Veterans Benefits
_____________
_____________ Pension
_____________
_____________ Other _____________
_____________
_____________
Total Income $_____________ Deductions Personal Needs Allowance
_____________
$_____________ Spousal/Dependent Allowance _____________
______________ Residential Allowance
_____________
______________ Cost of Long Term Care _____________
______________ Other Medical Expenses
_____________ ______________
Total Deductions -$
Total Available Income -$
Cost Of Care -$
Excess Income for Period -$
If medical expenses are incurred that will not be covered by health insurance or other sources and these expenses equal or exceed the amount of excess income, eligibility for Medical Assistance may be established under the spend-down provision. Enclosed is a sheet that tells you how to keep records of medical expenses. If incurred medical expenses equal the amount of excess income within the time period specified above, you should immediately report this to the Department of Social Services.
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.
Sincerely,
____________________________________________
Caseworker
Telephone Number
__________________________________
Department of Social Services cc: Representative ___________________________ Long Term Care Facility ______________________
DHMH 4236-LTC (Revised 12/08)