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COMAR 10.09.24.03
388 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 4214
MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY FOR MEDICAL ASSISTANCE (Pickle Amendment- Applicant)
Date of Notice: ________________ Case Number: _________________
Dear _____________________:
On __________________ you applied for Medical Assistance under the Pickle Amendment. This requires that you meet certain criteria and that your income and resources be compared to SSI standards. This is to notify you that you have been determined ineligible for the reason(s) checked below:
You are not currently receiving Social Security benefits due to age, blindness or disability.
You were not terminated from SSI since April 1977.
You did not receive both Social Security and SSI at the time of SSI termination.
You do not meet the non-financial requirements for SSI. (Specify) __________________________________________________________.
You failed to appear at the Local Department for the required interview.
You did not provide the information/verifications required to determine your eligibility.
Your total countable resources of $_____________ exceed the applicable SSI resource standard by $ __________________.
Your income exceeds the applicable SSI payment standard by $ ________ monthly. Your Social Security cost-of-living increases have been deducted in arriving at this amount.
Other (Specify) _______________________________________________
This decision is based on COMAR 10.09.24.03B (3). If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You also have the right to reapply and request that your eligibility be tested under the medically needy provisions.
Sincerely,
______________________________
Case Manager
______________________________
Department of Social Services
______________________________
Telephone Number