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COMAR 10.09.24.04

340 State of Maryland Medical Assistance Manual Revised July 2012

Attachment A-Notice of Ineligibility

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE OF INELIGIBILITY DUE TO EXCESS INCOME Date:____________________

Re: _______________________________ CID# ____________________

Name

Dear _______________________________, This is to notify you that based on the application filed on , the above named person has been determined ineligible for Medical Assistance due to excess income. The income for the period to has been calculated as follows:

Source of Income Monthly Amount for Period Social Security _____________ $_____________ Veterans Benefits _____________ _______________ Pension _____________ _______________ Other _____________ _______________ Total Income $____________ Deductions Personal Needs Allowance _____________ $____________ Spousal/Dependent Allowance _____________ _____________ Residential Allowance _____________ _____________ Cost of Long Term Care _____________ _____________ Other Medical Expenses _____________ _____________ Total Deductions -$____________ Total Available Income $____________ Cost of Care -$____________ Excess Income For Period _____________

If medical expenses are incurred that will not be covered by health insurance or other sources and these expenses equal or exceed the amount of excess income, eligibility for Medical Assistance may be established under the spend-down provision. Enclosed is a sheet that tells you how to keep records of medical expenses. If incurred medical expenses equal the amount of excess income within the time period specified above, you should immediately report this to the Department of Social Services. This decision is based on COMAR 10.09.___.________. 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 have the right to reapply. Sincerely, ________________________ _______________________ Case Manager Telephone Number ___________________________________ Department of Social Service