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COMAR 10.09.24.03

386 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 3802

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF MEDICAL ASSISTANCE ELIGIBILITY FOR FORMER SUPPLEMENTAL SECURITY INCOME RECIPIENTS

(Pickle Amendment)

Application

Redetermination

Date of Notice:_____________

Case Numbers: _____________

Dear __________________:

This is to notify you that:

Based on your application for Medical Assistance filed on _____________ you have been determined eligible effective _________________. Within a short time, you will receive a red and white plastic card. You must show your Medical Assistance card and any other health insurance membership cards for all health care services you have received or will receive.

Based on a review of your Medical Assistance eligibility you have been determined eligible effective _________________.

You will continue to receive your Medical Assistance cards until you are notified that you are no longer eligible. You will be required to reestablish your eligibility at least once every 12 months. You will be notified of this requirement at least 45 days before the expiration of your current eligibility period. The necessary instructions and forms will be made available to you at that time.

Except for Social Security benefit cost-of-living increases you receive, you must notify this agency of any changes in your circumstances or your family‟s circumstances such as employment, income, savings, property, stocks, bonds, marital status, living arrangement, address and telephone number. Any of these changes could affect your eligibility. You must report any changes in your situation within 10 working days of this change.

You have the right to request a hearing if you disagree with any decisions relating to your period of eligibility or the services provided. The procedures for requesting a hearing are in the back of this letter.

Sincerely,

_________________________________

Case Manager

__________________________________

DEPARTMENT OF SOCIAL SERVICES

__________________________________

TELEPHONE NUMBER