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COMAR 10.09.24.05

530

State of Maryland Medical Assistance Manual Revised July 2012

Attachment B- Notice of Eligibility

Maryland Medical Assistance Program

Maryland Children’s Health Program

NOTICE OF ELIGIBILITY

State Funded or Emergency Medical Services for Ineligble or Illegal Aliens

Applicant’s Name:

Date of Notice:

Applicant Address:

Local Department:

Client ID:

Dear

:

This is to notify you that based on the application you filed on

, Eligibility is approved for: � Coverage of full Medical Assistance benefits � Coverage of full Maryland Children’s Health Program benefits The following person or persons are covered:

You will receive a Medical Care Program card for each approved person. When it is time for eligibility to be redetermined, the Program will send you a packet to complete and return by a specified due date.

� Eligibility is approved for coverage of emergency medical services only for the following person:

. Eligibility is limited to services received Between

and

.

When this period ends, you must file a new application in order to be considered for further assistance. Full benefits under Medical Assistance (COMAR 10.09.24) or Maryland Children’s Health Program (COMAR 10.09.11) are not approved because the Program’s citizenship or qualified alien requirements are not met at this time. You will not receive a Medical Care Program card. You must show this notice and any other health insurance membership card to the providers(s) of all emergency medical services received, so they may bill Medical Assistance.

If you have any questions about this notice, call your Case Manager at the number below. 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 notice.

Sincerely,

Case Manager

Telephone Number