Form De-103 - Application For Ahcccs Health Insurance And Medicare Savings Programs printable pdf download

APPLICATION FOR AHCCCS HEALTH

INSURANCE AND MEDICARE SAVINGS

PROGRAMS

You can apply online by using Health-e-Arizona Plus at

Keep Pages A, B, C, and D for your records

If you are over age 65, blind or disabled, or if you are eligible for Medicare, use this application to apply for AHCCCS Health Insurance and/or Medicare

Savings Programs. Or, you can apply online at .gov.

How can I qualify for AHCCCS Health Insurance?

•

Your gross monthly income can be no more than $1,005 for an individual or $1,354 for a couple (after a $20 standard deduction and other allowed

deductions if you have earned income and/or dependent children).

•

You must be a resident of the state of Arizona and a United States citizen or a non-citizen who meets Medicaid requirements.

•

You must apply for pension, disability or retirement benefits if potentially available to you.

•

If you are under age 65 and not receiving Social Security Disability income, a disability determination will be part of your application process.

What medical services are covered by AHCCCS Health Insurance?

Prescription Medication *

Medical Supplies

Immunizations (shots)

Doctor's Office Visits**

Medically Necessary Transportation

Chemotherapy

Laboratory and X-ray Services

Medically Necessary Specialist Care

Emergency Medical Care

Hospital Services

Behavioral Health Care

Rehabilitation Services

Dialysis

90 days of nursing care services

AHCCCS prescription coverage is limited for people who have Medicare.

Wellness visits for people age 21 and over are not covered.

How Can I Qualify for a Medicare Savings Program?

If you are receiving or eligible for Medicare Part A, use this application to apply for help with your Medicare premium(s), copayments and

deductibles.

There are three Medicare Savings Programs. Each one has a different income limit and different benefits.

Medicare Savings Program

Specified Low-Income

Qualified Medicare

Qualified

Beneficiary (SLMB)



Beneficiary (QMB)

Individual – 1 (QI-1)

General Eligibility

• You must be a resident of the state of Arizona.

Requirements:

• You must be a United States citizen or a non-citizen who meets Medicaid requirements.

• You must apply for pension, disability or retirement benefits if potentially available to you.

Monthly Income Limits

$0 - $1,005 (Individual)

$1,005.01 - $1,206 (Individual)

$1,206.01-$1,357 (Individual)

(after allowed deductions):

$0 - $1,354 (Couple)

$1,354.01 - $1,624 (Couple)

$1,624.01-$1,827 (Couple)

Specific Requirements:

Receiving or eligible for

Receiving

Medicare Part A

• Pays your Medicare Part B

What is the Benefit?

Premium

• Pays your Medicare

Part A Premium (if not free)

• Pays your Medicare coinsurance

• Pays your Medicare Deductibles*

* If you are enrolled with a

Medicare HMO, your co-pays will also

be paid. If you elect additional

coverage from a Medicare HMO, you

will be responsible for any additional

premiums and costs.

If you are a Qualified Disabled Working Individual (QDWI) who is under age 65 and who lost Title II Social Security Disability benefits because of earnings,

use this application to apply for payment of your Medicare Part A premium.

DE-103 (Rev. 6/2017)

Page A