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COMAR 10.09.24.03
392 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 4226
MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF TERMINATION OF MEDICAL ASSISTANCE (Former Pickle Amendment Recipient)
Date of Notice: __________________
Case Number: _____________________
Dear ______________________:
This is to notify you that based on a recent review of your eligibility for Medical Assistance; we have determined that you are no longer eligible effective _______________ for the reason(s) checked below: A. Financial:
Your countable income has increased from $ _____________ to ____________. This results in excess income of $ ____________ monthly or $ _____________ for a (circle one) 3 month 6 month period based on the applicable medically needy income level. This decision is based on COMAR 10.09.24.09C. You may become eligible again in the future if you receive medical expenses which equal or exceed the excess amount; however, you must reapply so that an accurate determination can be made.
Your resources exceed the applicable medically needy resource level by $ _______________. This decision is based on COMAR 10.09.24.09C(3). The excess amount must be used to pay for medical or necessary living expenses.
B. Non-Financial: You did not submit a completed and signed application for a redetermination of your eligibility. You failed to appear at the Local Department for the required interview. You did not provide the information/verifications required to determine continued eligibility. Other- Specify: ______________________________________________________. This decision is based on COMAR 10.09.24. ______________________________. 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 at any time.
Sincerely,
________________________
Case Manager
________________________
Department of Social Services
________________________
Telephone Number