Form Adad-16 - Application For Illinois Cares Rx - Illinois Department On Aging Page 2
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1
2
3Step 2: Spouse’s Information.
8
Spouse’s Social Security number
9
Spouse’s name ____________________________________________________________
First
M I
Last
10
Spouse’s birth date
Month
Day
Year
11 a
Yes,
If no, go to Step 3.
I want help paying for drugs or a monthly rebate for my spouse.
b
See instructions.
Is your spouse a
U.S. citizen or
qualified noncitizen?
Note:
Your spouse may still qualify for Illinois Cares Rx Basic if no box is checked in Line 11b.
12
yes
no
If no, go to Line 13.
Is your spouse eligible for Medicare for hospital or doctor expenses?
a
“yes,”
yes
no
If
is your spouse enrolled in a Medicare Part D prescription drug plan?
b
If your spouse is enrolled in a Medicare Part D prescription drug plan, what is the name of your spouse’s plan?
United AARP MedicareRx
Health Alliance
WellCare HMO
1
5
9
UnitedHealth Rx Basic
HealthSpring
Other: ________________________
2
6
10
WellCare Signature
OSF Health Plans
3
7
Group Health Plan (GHP)
SecureHorizons by United Healthcare
4
8
c
yes
no
Has your spouse applied with Social Security for “extra help” under Medicare Part D?
d
yes
no
See instructions for new “wrap around” benefits.
Does your spouse have HIV/AIDS?
e
Print the name and claim number as it appears on your spouse’s Medicare card or Railroad Retirement card.
___________________________________________
First
Last name
Claim number
13
instead of
Your spouse can choose to receive a $25 monthly rebate
help paying
See instructions.
for prescriptions.
a
Does your spouse have private, creditable health insurance, Veterans Administration benefits, or a non-
yes
no
coordinating Medicare Part D plan that pays for prescription drugs?
If no, go to Step 3.
b
If your spouse has private, creditable health insurance that pays for prescription drugs, can he or she enroll
yes
no
in Medicare Part D without a loss of coverage or benefits?
c
yes
no
Does your spouse want a $25 monthly rebate instead of help paying for prescriptions?
Do not mark "yes" if your spouse is receiving prescriptions through a coordinating Medicare Part D
plan and needs “wrap around” benefits under Illinois Cares Rx.
Step 3: Schedule C Filing.
only
Complete this step
if you or your spouse are eligible for Medicare for hospital or doctor expenses.
14
Do you, your spouse (if married and living together), or both of you own any of the following items:
–
Bank accounts (checking, savings and certificates of deposit);
or
–
Stocks, bonds, savings bonds, mutual funds, individual retirement accounts and similar investments;
yes
no
–
Any other cash at home or elsewhere?
a
If yes,
yes
no
Single: Is the total value of the items listed $11,710 or less?
b
yes
no
Married and living together: Is the total value of the items listed $23,410 or less?
“yes”
must
If you answered
on Line 14a or 14b, you
complete Schedule C.
(R-3/07) ADAD-16,
Page 2
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