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COMAR 10.09.24.03
396 State of Maryland Medical Assistance Manual Revised July 2012
MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF RETROACTIVE ELIGIBILITY UNDER THE PICKLE AMENDMENT
Date:
Case Number:
Dear:
: This is to notify you that based on your application for retroactive Medical Assistance filed on
you have been determined eligible effective
through
. Within a short time, you will receive a red and white plastic card. You must show your Medical Assistance card and any other health insurance membership cards for all unpaid health care services you received during this period. If you have already paid for medical care received during this period. If you have already paid for medical care received during this period please see the enclosed notice for instructions on how to receive reimbursement for their expenses. 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 current card unless you are notified otherwise. You are still responsible for reporting changes in your situation which may affect your current eligibility. You have the right to request a hearing if you disagree with any decisions relating to your period of eligibility or the services provided. The procedures for requesting a hearing are on the back of this letter.
Sincerely.
Case Manager
Department of Social Services
Telephone Number