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COMAR 10.09.24.05

532

State of Maryland Medical Assistance Manual Revised July 2012

Attachment C- Notice of Ineligibility

Notice Ineligibility (Non-Financial Reasons) Maryland Medical Assistance Program Maryland Children’s Health Program NOTICE OF INELIGIBILITY

SERVICES FOR INELIGIBLE OR ILLEGAL ALIENS Applicant’s Name:

Date of Notice:

Applicant’s Address:

Local Department:

Client ID:

Dear

:

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

, you have determined ineligible for full Medical Assistance or Maryland Children’s Health Program benefits or for coverage or emergency medical services for the reason (s) checked below:

� You are not a resident of the State of Maryland � The Medicaid Utilization Control Agent determined that you are not disabled. � The Department of Human Resources State Review Team determined that you are not disabled. � You failed to appear at the local department for the required interview. � You did not provide the following required information or verifications: Specify:

� Other

This decision is based on COMAR 10.09. . You may reapply at any time. If you do not agree with the 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