Form Dhmh-4235a - Notice Of Non-Coverage Of Nursing Facility Services - 2008
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1
2MARYLAND MEDICAL ASSISTANCE PROGRAM
NOTICE OF NON-COVERAGE OF NURSING FACILITY SERVICES
DUE TO DISPOSAL OF ASSETS FOR LESS THAN FAIR MARKET VALUE
Date
______________________
e
R
: ________________________________
Name
________________________________
CID #
Dear_______________________________,
This is to notify you that based on the application/redetermination filed on ________________,
you are determined ineligible for Medical Assistance coverage of nursing facility services. This is
because income and/or assets have been transferred or otherwise disposed for less than fair market value.
However, you are eligible for medical services covered under the red and white Medical
Care Program Identification Card. Your eligibility for Medical Assistance:
began effective ____________.
.
will continue unless you receive a cancellation notice
The transfers considered are listed below:
Asset
Date Transferred
Value
Amount Transferred
_________________ _______________ $ _______________
$______________
_________________ _______________ $ _______________
$______________
_________________ _______________ $ _______________
$______________
_________________ _______________ $ _______________
$______________
The total amount transferred for less than fair market value was $________________.
This results in a penalty period of _____ months and _____ days, which begins on _______________
and expires on _______________.
You are not covered by Medical Assistance for nursing facility services until the penalty period expires,
at which time you may have to complete a new application. If you cannot access these funds and the
penalty would cause you to be deprived of medical care, food, clothing, shelter, or other necessities so
that your health or life would be endangered, contact the case worker below to find out about requesting
an "undue hardship waiver."
This decision is based on COMAR 10.09.24.___.
If you do not agree with this decision, you have the right to request a hearing within 90 days of
the date on this notice. The procedures for requesting a hearing are attached. If you have any questions
about this letter, please call your Case Manager at the number below.
_________________________________
Case Manager
_________________________________
Department of Social Services
_________________________________
Telephone Number
DHMH 4235A (LTC) Revised 12/08
White–Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy
Pink-Case Record Copy
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