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COMAR 10.09.24.03

404 State of Maryland Medical Assistance Manual Revised July 2012

Pickle Amendment Instructions for Use of Notices

1. DHMH 3802 Notice of Medical Assistance Eligibility for Former Supplemental Security Income Recipients

This letter is used to notify all persons who found eligible under the Pickle Amendment. Check the appropriate space in the heading of the letter, “Application” or “Redetermination”, and the corresponding space in the body of the letter, “Application” or Redetermination”, and the corresponding space in the body of the letter. Complete the body with appropriate dates.

For new applicants (non-recipients) check the first black in the heading and the body of the letter. For recipients found eligible as a result of the one-time review, annual review, scheduled or unscheduled redetermination, check the second black in the heading and the body of the letter.

2. DHMH 4214 Notice of Ineligibility for Medical Assistance (Pickle Amendment Applicant)

This letter is used to notify those persons who apply for medical assistance under the Pickle Amendment only and are found ineligible. These are persons who are not current Medical Assistance recipients and who file an application in response to the individual or public notice of potential eligibility.

3. DHMH 4215 Notice of Ineligibility Under the Pickle Amendment (Current Recipients)

This letter is used to notify current Medical Assistance recipients that they have been considered for Pickle eligibility but have been found ineligible under this provision. These are current recipients who have had a Pickle determination made as a result of the one-time review or annual review. This letter does not affect the person‟s current eligibility as medically needy.

4. DHMH Notice of Termination of Medical Assistance (Pickle Amendment)

This letter is used to notify persons who were previously eligible under the Pickle Amendment that their eligibility has been redetermined and they are no longer eligible. Excess income and/or resource amount are based on the medically needy standards that have been applied after the person was determined no longer eligible under the Pickle Amendment. If Pickle eligibility was lost due to a cessation of disability or blindness the person would be considered under MASO regulations and income is to be considered for a 3 month period. Persons who lose Pickle eligibility for other reasons will have income considered for 6 months under the ABD regulations. Circle the appropriate period.