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COMAR 10.09.24.05

534

State of Maryland Medical Assistance Manual Revised July 2012

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

SERVICES FOR INELIGIBLE OR ILLEGAL ALIENS

Financial Reasons

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

� Your income is more than the amount allowed. The income considered for the period is:

SOURCE

AMOUNT

DEDUCTIONS Your total income is $

. The amount of deduction is $

. Your net amount of income is $

. The most net income allowed for person(s) is $

. Therefore, you have $

more than is allowed.

This decision is based on Medical Assistance policy at COMAR 10.09. 24.08 and 10.09. 24.09. You may reapply at any time. If you do not agree with this decision, you have the right to request a hearing. The procedures for requesting are on the back of this notice.

Sincerely,

Case Manager

Telephone Number