Application for FREE

Supplemental Healthcare Coverage (prescription drug coverage and more)

or Payment of Medicare Premiums ($58.70/mo or more)

for Persons on Medicare.

 

TAG LINES GO HERE. 

 

EACH ALTERNATIVE LANGUAGE TAG LINE SHOULD SAY:

 

This is an application for supplemental healthcare coverage or payment of premiums

for persons with Medicare.  If you need this application in a different language or someone to interpret it, contact your local County Assistance Office (which is listed in your phone book)

or call us at 1-800-842-2020 or TDD 1-800-451-5886.

 

THE ALTERNATIVE FORMAT TAG LINE SHOULD SAY:

 

This application is available in alternative formats.  If you would like this application in a different format, contact your local County Assistance Office (which is listed in your phone book) or call us at 1-800-842-2020 or TDD 1-800-451-5886.

 

Persons with Medicare are often able to get help from other programs.  Some programs pay for additional health care coverage, including prescription drugs, and some save you money.  This application is for healthcare and cost savings programs that are available to persons with limited resources.  However, it may also get you in to other state programs that may help you. 

 

Should I apply?  Please do.  Even if you are not sure you are eligible, it cannot hurt to apply and it could REALLY help.  Everyone has the right to and is encouraged to apply. 

 

How do I apply?  Use the attached application and mail it to the address below.  If you need additional space to complete any answer, please just use and attach a separate piece of paper.  Applications may also be made online at www.compass.state.pa.us.  We have provided instructions on the next page which we hope will help you understand how to complete the application.

 

What do I need to send?  Simply send the attached application.  If you wish to send proof of your date of birth, address, social security number, income and assets, you may.  But, no additional documents are necessary.  We will check the information that you provide with other state and federal agencies.

 

Where do I send the application?  When you have completed the attached form, please send it to:

Department of Public Welfare – OIM

Applications for Health Care (fictional address at this time)

PO Box 2675

Harrisburg, PA 17101

 

Who is eligible?    There are several different programs.  You may be eligible for one of these.  You will also be considered for other healthcare programs available in Pennsylvania.

 

QMB +            Pays all Medicare Part A and Part B Premiums, Deductibles, and Co-Payments, plus provides Full Medical Assistance.  Full Medical Assistance includes prescription drug coverage, transportation to medical appointments, and more.  Available in 2003 to persons with countable* monthly income less than $749 for one person and $1010 if married. 

 

QMB               Pays all Medicare Part A and Part B Premiums, Deductibles, and Co-Payments.  Available in 2003 to persons with countable* monthly income less than $749 for one person and $1010 if married.

 

SLMB             Pays Part B Premiums.  Available in 2003 to persons with countable* monthly income less than $898 for one person and $1,212 if married.

 

QI-1                 Having their Part B Premiums paid for them.  Available in 2003 to persons with countable* monthly income less than $1011 individual/$1,384 married.

 

* Not all income counts.

 

How long will it take to learn whether I have been found eligible?  By law, in Pennsylvania, it should take 30 days, but may take up to 45 days if we are having trouble checking the information you provided.  We will contact you if we have questions.

 

What if I am denied?  If you are denied, you have a right to receive a written notice of that decision. You may appeal our decision.  Your local legal services agency provides FREE assistance in filing such appeals.  Please contact them if you have any questions as to whether we made the right decision.    Your notice will contain contact information for your local legal services office. If this contact information is not included in your notice, you can find your local legal services office listed in your phone book.

 

If I need help, who can I call?  Please call us at 1-800-842-2020 or TDD 1-800-451-5886 with any questions.

 

Instructions for Completing the Application:

 

Question #1:  In this question, we want to know who you are, how to contact you, your date of birth, Social Security number, and immigration status.   

 

Question #2:  In this question, we want to know about your spouse, if you live together.  You may also use this space to enter the information about anyone else in your household that also wants to apply for healthcare or cost savings programs.

 

Question #3:  In this question, we want to know about your income and the income of your spouse or any other person you listed in Question 2.  Please know that not all income is counted.  For example, we do not count at least $20 of income and have numerous other deductions that may be made.  List the amount of income before deductions (such as taxes or insurance or Medicare premiums) are taken out.  (Attach additional paper if necessary). 

 

Question #4:  Some people must pay to receive their income.  This question is asking whether any applicant had to pay for such things as Impairment Related Work Expenses, Attorneys Fees, Court Costs, or Transportation to receive the income that was listed in Question #3. 

 

Question #5:  In this question, we want to know each applicant’s resources.  Resources are assets or savings that you may have.  Please know that not all resources are counted.  For example, we do not count the home that you live in.  Check yes or no for each resource listed.  For each yes, use the space in the chart to tell us more about that resource. 

 

Question #6:  In this question, we want to know about any cars or vehicles and their value.  Please know that not all vehicles are counted in determining eligibility.  For example, we do not count the first car or $4,500 of the value of a second car.

 

Question #7:  In this question, we want to know about any life insurance policies and their face and cash value, to the extent that this information is known by you.  It is okay if you do not have this information.  We will verify it with the company using the account number you provide.  

 

Signature:  By signing the application you are stating that all the information provided is true and correct.  You are also giving us permission to check that it is.  Lastly, you are giving us permission to share this information with other Pennsylvania agencies to help learn if you might be eligible for additional helpful programs. 

 

Tear off this page and keep it for your records. 

Complete the next page (back and front) and send it in to apply.
Application for FREE

Supplemental Healthcare Coverage (prescription drug coverage and more)

or Payment of Medicare Premiums ($58.70/mo or more)

for Persons on Medicare.

1.         Tell us about YOU, Applicant #1:

Last Name:

Jr, Sr, etc:

 

First Name:

 

Middle Initial:

Social Security Number:

 

Date of Birth:

Race:

                             Sex:   M  or   F

Address (include apartment number if applicable):

 

City:

 

State:

 

Zip Code:

 

Telephone Number:

 

               School District:                      Township:

Medicare ID Number:

Citizenship Code:

Alien Registration Number (if applicable):

 

Race:

What language do you speak best?

 

What language do you read best?

 

Do you want an Interpreter?  If so, in what language?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.         Tell us about your spouse if he or she lives with you.  Leave this section blank if you live by yourself:

 

Last Name:

Jr, Sr, etc:

 

First Name:

 

Middle Initial:

Social Security Number:

 

Date of Birth:

Race:

Sex:

 

M     or      F

Relation to Applicant?

Medicare ID Number:

Citizenship Code:

Alien Registration Number (if applicable):

 

Race:

Wants to apply?   Y    or    N

 

 

 

 

 

 

 

 

 

 

 

 

 

3.         INCOME:  Do you (or anyone else you live with who wants to apply) have any of the following sources of income?   

Wages            [] Yes  []No                                                                 Sick benefits             []Yes  []No

Pensions        [] Yes  []No                                                    Support or Alimony   []Yes  []No

Unemployment/workers compensation      []Yes []No                   Commissions            []Yes  []No

Money for college or training                       []Yes [] No                  Veterans Benefits     []Yes  []No

Room and board or rent paid to you   []Yes []No                   Dividends or interest  []Yes  []No

Social security                                       []Yes []No                   SSI/SSDI                    []Yes  []No

 

For each source of income to which you checked YES in #3, please tell us:

Whose Income (write your own name or another applicant’s):

Type of Income (write a category listed above) or Name of Employer:

Amount before deductions:

How often income is received (monthly, yearly, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.         Some people pay expenses such as attorneys’ fees, court costs, transportation costs and impairment related work expenses in order to receive their income.  If you pay any such expenses, list them here: 

 

Whose expense?

Type of Expense

Amount

How Often Paid

 

 

 

 

 

 

 

 

 

 

 

5.         RESOURCES:  Do you (or anyone else you live with who wants to apply) have any of the following resources?     

 

Cash-on-hand            --              [] Yes  []  No                      U.S. Savings Bonds --                      [] Yes  []  No 

Savings Account -          [] Yes  []  No                      Christmas or Vacation Club            [] Yes  []  No 

Checking Account -      [] Yes  []  No                      Stocks or Bonds --                            [] Yes  []  No 

Certificate of Deposit                [] Yes  []  No                      Trust Fund --                                      [] Yes  []  No 

Non-Resident Property              [] Yes  []  No                      Other: _______________   [] Yes  []  No 

IRA, KEOGH, other retirement plan            [] Yes  []  No 

Burial Spaces, Reserves, or Trusts  [] Yes  []  No 

 

For EACH resource to which you answered YES in #5, please tell us:

Whose Resource:

Type and Location/ Financial Institution:

Account Number:

Current Value:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Do any applicants own or are they buying a car, truck, or motorcycle? 

[] Yes  []  No    If yes, tell us:

 

Whose vehicle:

Year, Make and Model

Licensed?

Amount Owed?

 

 

 

[] Yes  []  No

 

 

 

 

[] Yes  []  No

 

 

7.         If you (or another applicant) have a life insurance policy, please fill out this section to the best of your knowledge.  It is okay if you do not have all the information.    

Whose policy:

Insurance Company

Policy Number

Face Value

Cash Value

Who is Covered?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please have all applicants sign their names.  By signing below and submitting this application, you are declaring that the information provided is true, to the best of your knowledge, you are authorizing us to independently verify the information that you have provided, and you are authorizing us to share this information with other Commonwealth agencies to determine you eligibility for helpful programs that they offer. 

 

Applicant #1’s Signature:

 

Date:

Applicant #2’s Signature:

 

Date:

Address of Representative (Street, City, State, Zip):

 

 

Signature of Witness if Applicant

signed an X above:

 

 

Address of Witness:

Witness Phone:

 

Date:

 

Please send completed application to:

Department of Public Welfare – OIM

Applications for Health Care (fictional address at this time)

PO Box 2675

Harrisburg, PA 17101

 

Please call us at 1-800-842-2020 or TDD 1-800-451-5886 with any questions.