Page 91

COMAR 10.09.24.03

390 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 4215

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY UNDER THE PICKLE AMENDMENT (Current Recipients)

Date of Notice: ___________ Case Number: ____________

Dear ______________________:

This is to advise you that your Medical Assistance case has been reviewed to determine if you are eligible under the Pickle Amendment. That amendment requires that you meet certain criteria and that your income and resources be compared to the appropriate SSI standards. This is to notify you that you have been determined ineligible under that amendment 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 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). Since you are a current recipient of Medical Assistance as a result of an earlier application, your eligibility will continue for the dates shown on your card unless you are notified otherwise.

You are still responsible for reporting changes in your situation which may affect your current eligibility.

If you believe this decision is incorrect, you have the right to request a hearing. The procedures for requesting a hearing are on the back of this letter. You continue to have the right to reapply when your current eligibility expires.

Sincerely,

____________________________

Case Manager

____________________________

Department of Social Services

____________________________

Telephone Number

Page 91

Official source

COMAR 10.09.24.03

390 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 4215

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY UNDER THE PICKLE AMENDMENT (Current Recipients)

Date of Notice: ___________ Case Number: ____________

Dear ______________________:

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 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) _______________________________________________

You are still responsible for reporting changes in your situation which may affect your current eligibility.

Sincerely,

____________________________

Case Manager

____________________________

Department of Social Services

____________________________

Telephone Number