Page 81
State of Maryland Medical Assistance Manual Revised April 2014
MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF CHANGE IN AVAILABLE INCOME
Date: __________________ Re: ________________________ Name
___________________________ _______________________ Client ID Number
LTC Facility
Dear_______________________:
Based on a review of Medical Assistance eligibility for the person named above, the portion of income to paid to the Long Term Care Facility has been recalculated as follows:
Effective ______ Effective______ Effective______
Social Security $_________ $___________ $____________ V.A. __________ ____________ _____________ Pension __________ ____________ _____________ Other __________ ____________ _____________
Total Income $__________ $___________ $____________
Personal Needs $_________ $__________ $____________ Health Insurance __________ ___________ ____________ Medicare __________ ___________ ____________ Other________ __________ ___________ ____________ ____________ __________ ___________ ____________
Total Deductions -_________ -__________ -___________
Cost of Care: $__________ $__________ $__________
If these amounts are not correct, you must contact the Department of Social Services immediately and, if necessary, the Department will adjust these amounts.
Any change in income, resources, health insurance premiums, medical expenses, living arrangements, persons living in the phone, etc., must be reported within 10 working days to the Department of Social Services. The recipient, representative, and Long Term Care Facility are responsible for reporting such changes. Any of these could affect eligibility and income paid for the cost of care.
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. The procedures for requesting a hearing are attached.
Sincerely,
__________________________
Case Manager
_________________________
Department of Social Services
_________________________
Telephone Number