Page 95

COMAR 10.09.24.03

394 State of Maryland Medical Assistance Manual Revised July 2012 MARYLAND MEDICAL ASSISTANCE PROGRAM

IMPORTANT NOTICE ABOUT YOUR MEDICAID ELIGIBILITY

IF YOU ONCE RECEIVED SSI BENEFITS YOU SHOULD READ THIS IMPORTANT NOTICE ABOUT YOUR ELIGIBILITY FOR MEDICAID BENEFITS. (If you never received SSI or if you now receive SSI or TCA or if you live in a Long-Term-Care facility, this notice will not apply to you.)

A federal law called the Pickle Amendment applies to people who meet three tests:

1. They now receive Social Security benefits (a green check); and

2. They used to receive SSI benefits (a gold check) but don‟t receive them now; and

3. They received both a Social Security and an SSI check in the same month, in at least one month since April, 1977.

IF YOU MEET ALL THREE OF THESE TESTS, YOU MAY BE ELIGIBLE TO RECEIVE THE SAME MEDICAID BENEFITS YOU RECEIVED WHEN YOU WERE GETTING SSI. To find out if you are eligible, you (or someone on your behalf) should contact your local Department of Social Services. For more information, call the Department of Social Services in your area. Phone numbers and addresses are listed on the back of this notice.

PLEASE NOTE THAT TO APPLY FOR MEDICAID UNDER THE PICKLE AMENDMENT, YOU OR YOUR REPRESENTATIVE MUST GO TO YOUR LOCAL DEPARTMENT OF SOCIAL SERVICES. TAKE THIS NOTICE WITH YOU WHEN YOU GO.

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Page 95

Official source

COMAR 10.09.24.03

394 State of Maryland Medical Assistance Manual Revised July 2012 MARYLAND MEDICAL ASSISTANCE PROGRAM

IMPORTANT NOTICE ABOUT YOUR MEDICAID ELIGIBILITY

IF YOU ONCE RECEIVED SSI BENEFITS YOU SHOULD READ THIS IMPORTANT NOTICE ABOUT YOUR ELIGIBILITY FOR MEDICAID BENEFITS. (If you never received SSI or if you now receive SSI or TCA or if you live in a Long-Term-Care facility, this notice will not apply to you.)

A federal law called the Pickle Amendment applies to people who meet three tests:

1. They now receive Social Security benefits (a green check); and

2. They used to receive SSI benefits (a gold check) but don‟t receive them now; and

3. They received both a Social Security and an SSI check in the same month, in at least one month since April, 1977.

IF YOU MEET ALL THREE OF THESE TESTS, YOU MAY BE ELIGIBLE TO RECEIVE THE SAME MEDICAID BENEFITS YOU RECEIVED WHEN YOU WERE GETTING SSI. To find out if you are eligible, you (or someone on your behalf) should contact your local Department of Social Services. For more information, call the Department of Social Services in your area. Phone numbers and addresses are listed on the back of this notice.

PLEASE NOTE THAT TO APPLY FOR MEDICAID UNDER THE PICKLE AMENDMENT, YOU OR YOUR REPRESENTATIVE MUST GO TO YOUR LOCAL DEPARTMENT OF SOCIAL SERVICES. TAKE THIS NOTICE WITH YOU WHEN YOU GO.