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COMAR 10.09.24.03
395 State of Maryland Medical Assistance Manual Revised July 2012 MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF POTENTIAL RETROACTIVE ELIGIBILITY UNDER THE PICKLE AMENDMENT
Date: _______________________
Case Number: ________________
Dear ___________________________:
A review of your Medical Assistance case indicates that you may be eligible for retroactive coverage beginning November 1, 1984. This means that you may be eligible for payment or reimbursement for medical expenses incurred before you applied under the Pickle Amendment. In order to be eligible for this retroactive coverage you must:
- Have incurred medical expenses coverable under the Program during the period November 1, 1984 through _____________________;
- Complete the enclosed application and return it to the local Department of Social Services;
- Appear for a face-to-face interview; and
- Meet all eligibility requirements during the retroactive period.
If you did incur medical expenses during the period specified above, and you wish to apply for coverage or reimbursement of these expenses, complete the enclosed application and return it within 30 days of the date of this notice. A decision not to apply for retroactive coverage will not affect your current eligibility. You will remain eligible for Medical Assistance until you are notified otherwise.
Sincerely,
___________________________
Case Manager
___________________________
Department of Social Services
___________________________
Telephone Number