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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM DISCHARGE FROM LONG TERM CARE Date: _________________________________ Re: _______________________________

_________________________________ Name

Client ID Dear _______________________________,

The Department of Social Services has been notified that the above named person has been discharged from the Long Term Care Facility. The portion of available income to be paid to the facility for the month of discharge has been recalculated as follows:

Effective _____________________

Social Security

$__________________ Veterans Benefits

__________________ Pension _______________________ __________________ Other __________________________ __________________ Total Income

$__________________ Medical Assistance Standard

__________________ Income Disregard

__________________ Other ___________________

__________________ Total Deductions

─__________________ Available Income to be Paid to Cost of Care

$__________________

Eligibility has been reviewed because of this change in living arrangement and the following decision has been made:

 Medical Assistance will continue and you will be notified when another redetermination of eligibility will be required.

 Medical Assistance will be cancelled effective ________________________ because income exceeds the Medical Assistance standards.

 Medical Assistance will be cancelled effective _____________________________________________ because____________________________________________________________________________ __________________________________________________________________________________.

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,

___________________________________

Case Worker

___________________________________ Department of Social Services

___________________________________ Telephone cc: Recipient/Representative Long Term Care Facility

DHMH 4239 (LTC) 7/13

Page 79

Official source

State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM DISCHARGE FROM LONG TERM CARE Date: _________________________________ Re: _______________________________

_________________________________ Name

Client ID Dear _______________________________,

Effective _____________________

Social Security

$__________________ Veterans Benefits

__________________ Pension _______________________ __________________ Other __________________________ __________________ Total Income

$__________________ Medical Assistance Standard

__________________ Income Disregard

__________________ Other ___________________

__________________ Total Deductions

─__________________ Available Income to be Paid to Cost of Care

$__________________

Eligibility has been reviewed because of this change in living arrangement and the following decision has been made:

 Medical Assistance will continue and you will be notified when another redetermination of eligibility will be required.

 Medical Assistance will be cancelled effective ________________________ because income exceeds the Medical Assistance standards.

___________________________________

Case Worker

___________________________________ Department of Social Services

___________________________________ Telephone cc: Recipient/Representative Long Term Care Facility

DHMH 4239 (LTC) 7/13