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COMAR 10.09.24.03

367 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 ___________________:

Based on the application you filed on __________________, you are not eligible for Medical Assistance coverage of health care services or for State payment of your Medicare Part A Hospital Insurance premium. You are not eligible for the following reason(s):  1.You did not provide the information necessary to complete your eligibility determination. The information required is: ____________________________________________________________________________________ ______________________________________________________________________________________________ If you send in this information before __________________________, you will not have to file another application form. This agency will re-activate your original application and determine your eligibility.  2. Your income exceeds the maximum allowable amount of:

Income Standards

Medical Assistance Qualified Disabled Working Individual $__________________ $____________________ The type and amount of income counted is listed below: ______________________________ $____________________ ______________________________ $____________________ ______________________________ $____________________ The amount of income deducted is: ______________________________ $ ____________________ ______________________________ $ ____________________ ______________________________

$_____________________

The total amount of your countable income is: $_____________________  3. Your assets exceed the maximum allowable amount of:

Asset Standards

Medical Assistance Qualified Disabled Working Individual

$________________ $____________________ The assets counted are listed below: _______________________________________

$_______________________ _______________________________________

$_______________________ _______________________________________

$_______________________ _______________________________________

$_______________________

The total amount of your countable assets is: $_____________________