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COMAR 10.09.24.03

370 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__________________________: It has been determined that you are no longer eligible as of _________________________________________ for the State‟s payment of your Medicare Part A Hospital Insurance premium. This determination is based on the following reasons:  1. You no longer meet the following eligibility requirements: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________  2. You failed to complete the redetermination process. Your eligibility will be considered and may be re-established without a gap in coverage if you file the redetermination package or a new application with your Case Manager by ______________________.  3. You failed to provide the requested information needed to determine your continued eligibility. The information required is: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

If you send this information to your Case Manager before ________________________, you will not have to file another redetermination application. This agency will re-activate your original redetermination application and determine your continued eligibility for State payment of the Medicare Part A premium.

 4. You or your authorized representative declined to continue to participate in the Medicare Part A Hospital Insurance Buy-In Program as a Qualified Disabled Working Individual.  5. Other reason(s) ______________________________________________________________________________________ This decision is based on COMAR10.09.24 and/or the Social Security Act [1902(a)(10)(E)(ii), 1905(p)(3)(A)(I)]. If you do not agree with this decision, you have the right to request a Fair Hearing within ninety (90) days of the date of this notice. If you have any questions about this notice, you may contact your Case Manager at the telephone number below.

Sincerely,

________________________ Case Manager

________________________ Telephone