Since not everyone will be able to use the online Application for Extra Help with Medicare Prescription Drug Plan Costs, we need you to answer a few questions to help us figure out if you should use this application form. Any time there is a link at the end of a question that says "HELP," you can follow that link to get help with that question.
| |
|
1.
|
|
Are you assisting someone (other than your spouse who lives with you) with this application?
Note: If you are completing this form for someone else other than your spouse, it is important that you answer Yes here. By answering Yes, we will be able to collect contact information from you later so someone can contact you if there are problems with this application. If you are helping another person fill out this application, answer the following questions as if you were the person. HELP
|
|
In order to collect the appropriate contact information, we need to know if this form is being filled out by someone other than an applicant or their spouse. If you are assisting someone other than your spouse who lives with you, answer Yes. |
|
question: 445: ct_thrd_pty_xnd
answerfields: 5415.0 |
|
|
Yes
No
|
| |
| |
|
2.
|
|
Did you (or your spouse, if married and living together) get an application in the mail from the Social Security Administration? HELP
|
|
Social Security mailed paper applications for Help With Medicare Prescription Drug Plan Costs to people who appeared to be below the income limits based on the information already in their records. However, if you received an application, it does not mean that you automatically qualify for assistance. |
|
question: 446: ct_mail_xnd
answerfields: 5410.0 |
|
|
Yes
No
|
| |
| |
|
3.
|
|
Do you (or your spouse, if married and living together) have Medicare? HELP
|
|
Only people who are eligible for Medicare, or have Medicare, may use this application. If you (or your spouse, if married and living together) are eligible, you may be able to receive Extra Help to pay for your monthly premiums, annual deductible, and co-payments under the Medicare Prescription Drug Coverage. |
|
question: 447: ct_receive_medicare_xnd
answerfields: 5413.0 |
|
|
Yes
No
|
| |
| |
|
4.
|
|
Are you (or your spouse, if married and living together) currently receiving benefits from or participating in any of the following public programs? HELP
|
|
Please check all the programs in which you (and or your spouse, if married and living together) currently receive assistance. It is important that you answer this question because this information will help determine if you should apply for the Low Income Subsidy. (If you are enrolled in a Medicaid Spend-down program and you have already met your spend-down amount, you should select that you are receiving Medicaid. If you are enrolled in a Medicaid Spend-down program and you have not met your spend-down amount, leave the Medicaid box blank.) |
|
question: 448: ct_receive_medicaid_xnd
answerfields: 92.0; 4267.0; 129.0 |
|
|
Medicaid
Medicare Savings Programs (QMB, SLMB, or QI)
Supplemental Security Income (SSI)
|
| |
| |
|
5.
|
|
Are you (or your spouse, if married and living together) 64 years and 9 months old or older? HELP
|
|
The purpose of this question is to help us determine if you may be eligible for Medicare. If you are eligible for Medicare and have not yet applied, call Social Security toll-free at 1-800-772-1213. If you are deaf or hard of hearing, call their toll-free TTY number at 1-800-325-0778. |
|
question: 449: ct_older_xnd
answerfields: 5412.0 |
|
|
Yes
No
|
| |
| |
|
6.
|
|
Have you (or your spouse, if married and living together) received: Social Security disability benefits for 24 months; Disability benefits based on Lou Gehrig's disease (ALS); or Renal dialysis treatments or a kidney transplant HELP
|
|
The purpose of this question is to help Social Security determine if you may be eligible for Medicare. To apply for Medicare a person must:
be at least 64 years and 9 months old;
have received Social Security disability benefits for 24 months;
receive Social Security disability benefits based on Lou Gehrig's disease (ALS);
or
have received renal dialysis treatments or a kidney transplant.
If you are eligible for Medicare and have not yet applied, call Social Security toll-free at 1-800-772-1213. If you are deaf or hard of hearing, call their toll-free TTY number at 1-800-325-0778. |
|
question: 450: ct_ss_disblty_xnd
answerfields: 5414.0 |
|
|
Yes
No
|
| |
| |
|
7.
|
|
In which state do you (and your spouse, if married and living together) live? HELP
|
|
To be eligible for the extra help with Medicare prescription drug plan costs, you must live in one of the 50 states or the District of Columbia. Select the state where your permanent residence is located. |
|
question: 451: ct_live
answerfields: 7090.0 |
|
|
|
| |
| |
|
8.
|
|
What is your marital status? HELP
|
|
If you are married and living with your spouse, Social Security counts the income and resources of both you and your spouse when they determine whether you are eligible to receive help with prescription drug plan costs. Social Security considers that you are living together if you and your spouse live in the same household. They count the income and resources of you and your spouse regardless of whether one or both of you are filing for this help. They consider that you are still living together if you or your spouse are temporarily absent from the household and are temporarily residing in a hospital or nursing home. |
|
question: 452: ct_mrtl_stus
answerfields: 5411.0 |
|
|
|
| |
| |
|
9.
|
|
Do you have combined savings, investments, and real estate (other than the home you live in) worth more than:
$17,220 if you are not married or not living with your spouse; or
$34,360 if you are married and living with your spouse?
Include the things you own by yourself, with your spouse, or with someone else.
DO NOT include the home you live in, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
Note: Social Security excludes many different types of resources when figuring out a person's eligibility for the Extra Help. For a list of these exclusions, click on the HELP link. HELP
|
|
To be eligible for help with Medicare prescription drug plan costs, your resources must be within certain limits. Your resources may include bank accounts (checking, savings, and certificates of deposit), stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts (IRAs), and any other cash at home or anywhere else. Your resources also include real estate you own except for the home that you live in. Examples of other real estate are summer homes, rental properties, or undeveloped land you own. Include the things you own by yourself, with your spouse, or with someone else. DO NOT include vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
If you are sure that your combined savings, investments, and real estate (other than the home you live in) are worth more than $14,390 if you are not currently married or not living with your spouse, or more than $28,720 if you are married and living with your spouse, select Yes. The actual limit for eligibility is $12,890 if you are not currently married or not living with your spouse, or $25,720 if you are married and living with your spouse. However, since Social Security may not count some of the resources you expect to use for funeral or burial expenses, you may be able to have up to $14,390 if you are not currently married or not living with your spouse, or up to $28,720 if you are married and living with your spouse.
Other examples of resources that should NOT be counted are:
Resources you could not easily convert to cash, such as jewelry or home furnishings;
Property you need for self support that is used in a trade or business;
Life insurance policies;
Irrevocable burial trusts;
Disaster assistance;
Certain distributions received by an Alaska Native from an Alaska Native Regional and Village Corporation;
Land held in trust by the United States for an individual Indian or tribe;
Funds held in trust by the Secretary of the Interior for an Indian tribe and distributed per capita to members of the tribe;
Payments to members of specific Indian tribes as provided by Federal legislation; and
Up to $2,000 per year received by an Indian that is derived from individual interests in trust or restricted lands.
NOTE: Certain other money you may be holding is not counted for nine months, such as:
Retroactive Social Security or Supplemental Security Income benefits;
Tax advances and refunds related to earned income tax credits and child tax credits;
Compensation you receive as a crime victim;
Relocation assistance from a state or local government; and
Scholarships and education grants. |
|
question: 453: be_sav_lmt_xnd
answerfields: 5391.0 |
|
|
Yes
No or Not Sure
|
| |
