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COMAR 10.09.24.04
335 State of Maryland Medical Assistance Manual Revised July 2012
400.17 Steps Taken to Complete Form
The LTCF or client representative completes Part A of the DHMH 3871B for the Client and it is submitted to the attending physician. The attending physician completes Part B-E of the DHMH 3871 B-E of the DHMH 3871B and it is returned to the facility. The LTCF completes the top portion of the 257 and sends the 257 and 3871B to the UCA The UCA completes the bottom portion of the 257 and Part F of the DHMH 3871B The UCA sends a copy of the 257 and the DHMH 3871B to the LTCF, and the completed original 257 to the LDSS DHMH 257-Long Term Care Patient Activity Report DHMH 3871B-Medical Eligibility Review Form
(a) Demographic Information
The LDSS/LHD verifies an applicant’s Social Security Number and benefits and any Medicare number and enrollment by checking SDZX/SVES/SOLQ. It is only necessary to request verifications from the A/R (e.g. copy of social security card or Medicare card) if there is a discrepancy or the LDSS cannot otherwise obtain the required information. The A/R’s declaration on the application that the applicant is a US citizen is accepted without verification, and only needs to be verified by the A/R if there is a discrepancy. If the A/R reports that the applicant is a legal alien, the LDSS verifies the applicant’s alien status through Systematize Alien Verification Systems (SAVE), and only requests verification if there is a discrepancy or need for additional information. It is necessary for the A/R to provide verification of the applicant’s marital status such as a copy of the marriage certificate or divorce decree. Maryland does not recognize common law marriage. A couple which is considered married under state law has a spouse to spouse financial responsibility until they have received a divorce decree or until one spouse dies.
(b) Income
SSI, Social Security, and Railroad retirement benefits are verified by the LDSS through SDX/SVES/SOLQ. MABS is available as an additional verification of the amount of each type of countable income received by the applicant. Earnings must be verified for the past month or 4 weeks. The CM may request additional verifications if necessary to determine the A/R’s gross countable income. See the section “Verification/Documentation” in the Appendix of this Manual for examples of acceptable income verifications.
(c) Resources
If the spousal share has not already been calculated, resources of both the applicant and spouse must be verified for computation of the spousal share as of the beginning of the applicant’s first continuous period of institutionalization. For determination of current LTC eligibility, the A/R is required to provide verification for the value of each type of countable resource owned by the applicant and /or spouse as of the 1st day of the month of application. Typically, the value of liquid assets (e.g. bank