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COMAR 10.09.24.03
399 State of Maryland Medical Assistance Manual Revised July 2012
MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY FOR RETROACTIVE COVERAGE UNDER THE PICKLE AMENDMENT
Date:
Case Number:
Dear
:
This is to notify you that based on your application for retroactive Medical Assistance filed on
You have been determined ineligible for the retroactive period
through
.
You have been determined ineligible for that period for the reason(s) checked below:
You were not receiving Social Security benefits due to age, blindness or disability during that period
You did not meet the non-financial requirements for SSI during that period.
(Specify)
.
You did not provide the information/verifications required to determine your eligibility for that period.
Your total countable resources of $
exceeded the applicable SSI resources
standard by $
.
Your income exceeded the applicable standard by $
monthly.
Other (Specify)
.
This decision is based on COMAR 10.09.24.03B (3). Since you are a current recipient of Medical Assistance as a result of an earlier application, your eligibility will continue for the dates shown on you current card unless you are notified otherwise.
You are still responsible for reporting changes in your situation which may affect your current eligibility.
If you believe this decision is incorrect, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You continue to have the right to reapply when your current eligibility expires. Sincerely,
Case Manager
Department of Social Services
Telephone Number