Dhmh-4236 Notice Of Ineligibility Due To Excess Income Form
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1
2MARYLAND 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
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 Services
DHMH 4236 (LTC) Revised 12/08
White–Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy
Pink-Case Record Copy
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