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COMAR 10.09.24.03
365 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. The federal government has determined that the effective date for the State to start making your premium payments is ______________________.
If you have paid for any months of Medicare Part A premiums that the State will now pay, the U.S. Social Security Administration will pay you back for those months. If the federal government determines that you must pay a surcharge, besides the regular premium, you are responsible for payment of any surcharge. The State does not pay any surcharges. If you elect to participate in Medicare Part B, you are responsible for paying the premium to the Social Security Administration. Contact the Department of Health and Mental Hygiene‟s Buy-In Unit at 1-800-638-3403 if you have any questions about your Medicare Buy-In.
Contact your Case Manager at the telephone number below, if you have any questions about this notice or your eligibility.
Sincerely,
_______________________________
Case Manager
_______________________________
Telephone