Form Dhmh-4233 - Maryland Medical Assistance Program - Notice Of Eligibility

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MARYLAND MEDICAL ASSISTANCE PROGRAM
NOTICE OF ELIGIBILITY
Re:
_________________________________
Date: _____________
Name
Client Identification Number: ______________
LTC Facility: __________________________
Dear _______________________________:
This is to notify you that the individual identified above has been determined eligible for
Medical Assistance (MA) for the period __________________through__________________. The
MA card will be sent to the Long Term Care Facility. A portion of the patient’s income
must be paid directly to the Facility, and you must contact the Facility to establish the
time and manner
of pay ment.
(
NOTE: The Department of Social Services and the LTC facility must be notified of any increase in the
patient’s current income benefits and/or any new benefits received. The increased amount must be paid
to the facility when received, whether or not a notice of increased payment requirement is received from
the Department of Social Services or the facility has billed for it.)
T he portion of income to be paid to the Long Term Care Facility has been calculated as follows:
Effective _____
Effective _____
Effective _____
Social Security
$_________
$_________
$_________
Veterans Benefits
_________
_________
_________
Pension ________
_________
_________
_________
Other ___________
_________
_________
_________
Total Income
$_________
$_________
$_________
Personal Needs
_________
_________
_________
Health Insurance
_________
_________
_________
Medicare
_________
_________
_________
Other __________
_________
_________
_________
_______________
_________
_________
_________
T otal Deductions
-_________
-_________
-_________
Cost of Care
$_________
$_________
$_________
If these amounts are not correct, you must contact the Department of Social Services immediately and,
if necessary, the Department will adjust these amounts.
Any change in income, resources, health insurance premiums, medical expenses, living arrangements,
persons living in the home, etc., must be reported within 10 working days to the Department of Social
Services. The recipient, representative, and Long Term Care Facility are responsible for reporting such
changes. Any of these changes could affect eligibility and income paid for the cost of care. 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.
The procedures for requesting a hearing are attached.
Sincerely,
___________________________________
Case Manager
___________________________________
Department of Social Services
__________________________
_
Telephone
DHMH 4233 (LTC) - Revised 3/08
White–Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy
Pink-Case Record Copy

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