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COMAR 10.09.24.03

363 State of Maryland Medical Assistance Manual Revised July 2012 Maryland Medical Assistance Program Notice of Eligibility for Medicare Hospital Insurance (Part A) Buy-In Only As a Qualified Disabled Working Individual

Date: ____________________________________________ Customer ID: _____________________________________ District: __________________________________________

Dear ___________________: This is to notify you that based on the application you filed on _____________________, we have determined that you are eligible for State payment of your Medicare Part A Hospital Insurance premiums. After the federal government determines the effective date, you will be informed when the State will begin paying your Medicare Part A premiums. The State will issue payment directly to the U.S. Social Security Administration. The State‟s payments will continue until you are notified that you are no longer eligible. You will not receive a Maryland Medical Care Program card because you are just eligible for coverage of Medicare Part A premiums. You are not eligible for Medical Assistance (Medicaid) to cover medical services. You should continue to pay the monthly premium for Medicare Part A until you are notified of when the State will begin paying the Medicare Part A premiums for you. If you pay for the same month that the State pays, the Social Security Administration will pay you back. If the federal government determines that you must pay a surcharge, besides your regular premium, you are responsible for payment of the surcharge. The State does not pay any surcharges. If you elect to participate in Medicare Part B, you are responsible for paying the Part B premium to the U.S. Social Security Administration. You will be required to re-establish your eligibility for this coverage at least once every 12 months. You will be notified of that requirement in advance of the due date. The necessary instructions and forms will be mailed to you at that time. You must notify this agency of any changes in your situation such as employment, income, savings, property, stocks, bonds, insurance, address, and telephone number. Any of these changes could affect your eligibility. You must report changes within 10 working days of the change to your Case Manager at the telephone number below. If you have any questions about this notice, you should contact your Case Manager.

Sincerely, ________________________ Case Manager

_________________________ Telephone