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State of Maryland Medical Assistance Manual Revised July 2012 Attachment F- Lien Worksheet

MARYLAND MEDICAL ASSISTANCE PROGRAM LIEN WORKSHEET NOTE: COMPLETE THIS FORM ONLY IF THE PERSON OWNS HOME PROPERTY.

PART I. INSTITUTIONALIZED PERSON’S IDENTIFICATION

Name

Case Number

Date

Representative Name

Representative Telephone Number

Representative Address

PART II. INSTITUTIONALIZED PERSON’S REAL PROPERTY

HOME PROPERTY Address or Description

Owner(s)

OTHER REAL PROPERTY (Within Eligibility Limits) Address or Description

Owner(s) Is the home property, listed above, occupied by the institutionalized person‟s: a. Spouse? Yes No b. Child under 21? Yes No c. Blind or Disabled son or daughter? Yes No d. Brother or sister who has an equity interest in the home property and who has lived in the property at least one year? Yes No

- If any response is YES, the lien provision is not applicable to the institutionalized person‟s real property. File form in case record. - If all responses are NO, the medical review process is applicable to the institutionalized person. Go to Part III and Follow the instructions.

PART III. MEDICAL REVIEW PROCESS The following actions are taken when the medical review process is applicable to the institutionalized person.

1. Complete Part I of form DHMH 4245 (LTC), Physician Report. 2. Give the Report to the person or his/her representative to have the person‟s attending physician complete Part II. 3. The attending physician completes Part II and returns the Report to the person or representative. 4. The person or representative returns the Report to the Local Department of Social Services (LDSS). 5. The LDSS submits the Report to the Utilization Control Agent for a Medical Review. 6. The Utilization Control Agent will notify the LDSS of the Medical Review decision by form DHMH 4246 (LTC), Notice of Medical Review Decision. 7. When the Notice of Medical Review Decision is received by the LDSS, proceed to Part IV.

PART IV. LIEN APPLICABLITY Complete the following when the Notice of Medical Review Decision is received by the LDSS. Based on the form DHMH 4246 (LTC), is the person expected to be able to resume living in his home property?

Yes. The lien provision is not applicable to the person‟s real property. File this worksheet and Medical Review Decision in the case record. Instruct the representative to report any changes in home occupancy. No. The lien provision is applicable to the person‟s real property. Submit the original of this form, the Deed(s). and tax assessment(s) for the property(ies) to: Medical Care Compliance Administration, Division of Recoveries, P.O. Box 13045, Baltimore, Maryland 21203.