Application For Medicare Savings Program (Qmb, Slmb, Qi) (Page 2 of 4) in pdf

4. The Division of Family Resources County Office will send you a notice that tells you whether

your application was approved or denied. You may request a fair hearing if you disagree

with any decision about your eligibility, or if your application is not processed within forty five

(45) days.

5. We ask about your racial-ethnic heritage to show compliance with the Federal Civil Rights

Law. However, you are not required to tell us this information.

6. You must give accurate and complete information on your application. A person who

receives assistance by giving false information or by misrepresenting the truth is committing

a crime and can be prosecuted under the law and required to repay benefits received in

error.

7. The immigration status of lawful immigrants may be verified by the Citizen and Immigration

Service.

8. You must tell us your Social Security Number. We will use it to check information of other

state and federal agencies, such as the Social Security Administration.

9. You must file for any benefits you may be entitled to such as Social Security or disability

benefits.

10. If any of the information you give on your application changes, you must tell the Division of

Family Resources County Office within ten (10) days.

11. Your rights to medical support and payment for medical care are assigned to the State if you

are found eligible for the Medicare Savings Program. This assignment does not apply to

Medicare payments. You will be required to cooperate in obtaining medical support or third

party payments. This means that you must tell us about medical insurance coverage that

you have now or that you obtain in the future, any court orders which provide for the payment

of any or all of your medical bills, and any legal action you take or intend to take against a

third party for any injuries you sustain in an accident.

You may be excused from the above requirements if you can show that cooperating would

cause you physical or emotion harm. If you claim good cause, you will receive a notice

explaining the good cause circumstances and the type of information you must submit to

support your claim. You may ask for the good cause notice to help you decide if you want to

claim good cause.

12. Federal law does not permit the State to file a claim against your estate after your death to

recover the amount of benefits that the Medicare Savings Program (MSP) pays for you.

Estate recovery is a provision of the full coverage Medicaid program; however, it does not

include benefits paid the MSP for services incurred on and after January 1, 2010.

13. If you believe you have been discriminated against in the determination of eligibility for

benefits, you have the right to file a civil rights complaint by contacting the Department of

Health and Human Services, Director of the Office of Civil Rights, Room 506F, 200

Independence Avenue, S.W., Washington, D.C., 20201. The telephone number is (202)619-

0403, or TDD at (202)619-3257.

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