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State of Maryland Medical Assistance Manual Revised April 2014

Maryland Medical Assistance Program Notice of Eligibility for the Post-Eligibility Medical Expense Deduction Re: ______________________________ Date:_______________________ (Name)

___________________________________ (Client ID #) Dear__________________________________:

This is to notify you that based on the medical bills, totaling $________________________, that you submitted on _________________________, you are determined eligible for the Post-Eligibility Medical Expense Deduction in the amount of $________________________. You are determined ineligible in the amount of $_________________. The attached report shows every expense item, if you are eligible for the deduction, and the amount of the deduction that you are eligible to receive. If you were not eligible for the service, it will indicate the reason for your ineligibility. □ The amount of $_______________ will be deducted from the amount you are responsible to pay the nursing home for the month of ___________________. The amount of the deduction is less than your monthly contribution to the nursing home cost of care. This is a onetime only deduction. □ The amount of $ ______________will be deducted from your nursing home cost of care contribution beginning the month of ______________________ and will continue until the month of __________________. If there are no changes to your countable monthly income, we anticipate $ __________________of the allowable deduction will remain at the end of your current consideration period. The remaining amount will be applied to the consideration period that immediately follows.

The decision is based on the requirements found in COMAR 10.09.24.10. 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 OES 011 (LTC) White-Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy Pink-Case Record Copy