PFZDKTYBT J GJPDJKZOB{ CRJYJVBNM GHB JGKFNT ECKEU GHJUHFVVS MEDICARE

							          PFZDKTYBT J< EXFCNBB D GHJUHFVVF{> GJPDJKZ?OB{ C"RJYJVBNM
        GHB JGKFNT ECKEU GHJUHFVVS MEDICARE !MEDICARE SAVINGS PROGRAMS@

Ltgfhnfvtyn cjwbfkmyjuj j,tcgtxtybz b plhfdjj[hfytybz infnf Dfibyunjy !Department of Social
and Health Services> DSHS@ ghtlkfuftn ghjuhfvvs> gjvjuf/obt dfv jgkfxbdfnm xfcnm dfib[
hfc[jljd gj ghjuhfvvt Medicare. "nb ghjuhfvvs ghtlyfpyfxtys lkz kbw> bvt/ob[ ghfdj yf
exfcnbt bkb pfgbcfyys[ d Xfcnm F ghjuhfvvs Medicare !Medicare Part A@.


                    QMB                                                  SLMB
  Ghjuhfvvf Qualified Medicare Beneficiary            Ghjuhfvvf Specified Low-Income Medicare
   !ghjuhfvvf lkz gjkexfntktq kmujn gj                 Beneficiary !ghjuhfvvf lkz gjkexfntktq
      ghjuhfvvt Medicare> jndtxf/ob[                      kmujn gj ghjuhfvvt Medicare c
          nht,jdfybzv ghjuhfvvs@                       jghtltktyysv ybprbv ehjdytv lj[jljd@
   Lfyyfz ghjuhfvvf ghtlyfpyfxtyf lkz
   kbw> bvt/ob[ ghfdj yf exfcnbt d                      Lfyyfz ghjuhfvvf ghtlyfpyfxtyf lkz
   Xfcnb F ghjuhfvvs Medicare b bvt/-                   kbw> bvt/ob[ ghfdj yf exfcnbt d
   ob[ juhfybxtyyst frnbds b lj[jl yf                   Xfcnb F ghjuhfvvs Medicare b bvt/-
   ehjdyt bkb yb;t 100% atlthfkmyjuj                    ob[ juhfybxtyyst frnbds b lj[jl>
   ghj;bnjxyjuj vbybvevf !Federal                       rjnjhsq ghtdsiftn 100%
   Poverty Level> FPL@. Ghjuhfvvf QMB                   atlthfkmyjuj ghj;bnjxyjuj
   jgkfxbdftn> d ckexft ytj,[jlbvjcnb>                  vbybvevf !FPL@> yj cjcnfdkztn vtytt
   cnjbvjcnm exfcnbz d Xfcnb F                          120% FPL. Ghjuhfvvf SLMB
   ghjuhfvvs Medicare> cnhf[jdst                        jgkfxbdftn njkmrj cnhf[jdst dpyjcs
   dpyjcs Xfcnb B ghjuhfvvs Medicare>                   Xfcnb D ghjuhfvvs Medicare.
   f nfr;t gjrhsdftn ahfyibps
   ghjuhfvvs Medicare> c,jhs d cdzpb
   c cjdvtcnysv cnhf[jdfybtv b
   ljgkfns.

                                    Qualified Individual (Q-1) - ESLMB
                                  Ghjuhfvvf Expanded Specified Low-
                                Income Medicare Beneficiary !ghjuhfvvf
                                 lkz gjkexfntktq kmujn gj ghjuhfvvt
                                 Medicare c jghtltktyysv edtkbxtyysv
                                        ybprbv ehjdytv lj[jljd@
                                Lfyyfz ghjuhfvvf ghtlyfpyfxtyf lkz
                                kbw> bvt/ob[ ghfdj yf exfcnbt d
                                Xfcnb F ghjuhfvvs Medicare b bvt/-
                                ob[ juhfybxtyyst frnbds b lj[jl>
                                rjnjhsq ghtdsiftn 120%
                                atlthfkmyjuj ghj;bnjxyjuj
                                vbybvevf !FPL@> yj cjcnfdkztn vtytt
                                135% FPL. Jlyj b nj ;t kbwj yt
                                vj;tn jlyjdhtvtyyj bvtnm ghfdj yf
                                exfcnbt d ghjuhfvvt Medicaid b
                                gjkexfnm kmujns gj ghjuhfvvt QI-1.
                                Ghjuhfvvf QI-1 jgkfxbdftn njkmrj
                                cnhf[jdst dpyjcs Xfcnb D ghjuhfvvs
                                Medicare. Abyfycbhjdfybt 'njq
                                ghjuhfvvs juhfybxtyj.

DSHS 13-691 RU (REV. 10/2005)
RFRBV NHT<JDFYBZV Z LJK:TY JNDTXFNM*
1. Ds ljk;ys bvtnm djpvj;yjcnm exfcndjdfnm d Xfcnb F b Xfcnb D ghjuhfvvs Medicare.
2. Cnjbvjcnm dfib[ frnbdjd> nfrb[ rfr ,fyrjdcrbq cxtn> frwbb b j,kbufwbb> yt
    vj;tn ghtdsifnm 4 000 ljkkfhjd yf jlyjuj xtkjdtrf b 6 000 ljkkfhjd yf
    ceghe;tcre/ gfhe. Frnbds b lj[jl dfituj cegheuf exbnsdftncz lf;t d njv
    ckexft> tckb dfi cegheu yt exfcndetn d ghjuhfvvt Medicare bkb yt gjlftn
    pfzdktybz j gjkextybb kmujn.

3. Dfi lj[jl yt ljk;ty ghtdsifnm jghtltktyys[ ehjdytq> ecnfyjdktyys[ lkz rf;ljq
    ghjuhfvvs. "nb ecnfyjdktyyst ehjdyb lj[jljd gthtcvfnhbdf/ncz t;tujlyj.
4. Xnj,s gjlfnm pfzdktybt bkb pflfnm ljgjkybntkmyst djghjcs> dfv cktletn
    cdzpfnmcz c Jnltkjv cjwbfkmyjuj j,tcgtxtybz !Community Services Office> CSO@
    ltgfhnfvtynf DSHS> j,cke;bdf/obv njn hfqjy> ult ds ghj;bdftnt. Yfqlbnt
    yjvth ntktajyf ,kb;fqituj r dfv jnltkf CSO yf cnhfybwf[ ntktajyyjuj
    cghfdjxybrf> jndtltyys[ lkz ujcelfhcndtyys[ jhufyjd infnf> d hfpltkt
    «Cjwbfkmyst eckeub b Eckeub plhfdjj[hfytybz» !Social and Health Services@ bkb
    d hfpltkt «Jnltk cjwbfkmyjuj j,tcgtxtybz» !Community Services Office@.
RFR GJLFNM PFZDKTYBT*
1. Pfgjkybnt ghbkfuftvjt pfzdktybt yf exfcnbt d ghjuhfvvf[ QMB> SLMB b
    QI-1 !bkb ESLMB@.
2. Ghbkj;bnt rjgbb dfitq rhfcyjq> ,tkjq b cbytq rfhnjxrb ghjuhfvvs Medicare
    !kbwtdjq b j,hfnyjq cnjhjys@ b dfituj eljcnjdthtybz kbxyjcnb. Nfr;t ghbkj;bnt
    rjgb/ dfitq cnhf[jdjq rfhnjxrb !kbwtdjq b j,hfnyjq cnjhjys@> tckb e dfc tcnm
    lheufz vtlbwbycrfz cnhf[jdrf. Gj;fkeqcnf> jnghfdkzqnt rjgbb> f yt jhbubyfks.
3. Jnghfdmnt gj gjxnt pfzdktybt b rjgbb gthtxbcktyys[ dsit ljrevtynjd d dfi
    vtcnysq Jnltk cjwbfkmyjuj j,tcgtxtybz !CSO@.
4. Ghjwtcc hfccvjnhtybz dfituj pfzdktybz vj;tn pfyznm lj 45 lytq c vjvtynf
    gjkextybz dfituj pfzdktybz Ltgfhnfvtynjv cjwbfkmyjuj j,tcgtxtybz b
    plhfdjj[hfytybz. Tckb ds yt gjkexbnt ybrfrjq byajhvfwbb bp Ltgfhnfvtynf
    cjwbfkmyjuj j,tcgtxtybz b plhfdjj[hfytybz d ntxtybt 20 lytq> gjpdjybnt d Jnltk
    cjwbfkmyjuj j,tcgtxtybz !CSO@ dfituj hfqjyf> xnj,s epyfnm j njv> rfr
    ghjldbuftncz hfccvjnhtybt dfituj pfzdktybz.




TCKB DFV YTJ<{JLBVF LTYT:YFZ> VTLBWBYCRFZ BKB GHJLJDJKMCNDTYYFZ GJVJOM>
NJ DS LJK:YS PFGJKYBNM LHEUJT PFZDKTYBT. GJ:FKEQCNF> GJPDJYBNT D CDJQ
JNLTK CJWBFKMYJUJ J<TCGTXTYBZ !COMMUNITY SERVICES OFFICE> CSO@> B DFV
GHBIK?N CJJNDTNCNDE?OE? AJHVE.




 DSHS 13-691 RU (REV. 10/2005)
                                 PFZDKTYBT J< EXFCNBB D GHJUHFVVF{> GJPDJKZ?OB{ C"RJYJVBNM GHB
                                                  JGKFNT ECKEU GHJUHFVVS MEDICARE
                                               APPLICATION FOR MEDICARE SAVINGS PROGRAMS
                                Gj;fkeqcnf> ghjxnbnt yb;tcktle/ott> ght;lt xtv pfgjkyznm pfzdktybt.
Dfv ytj,[jlbvj ,eltn jndtnbnm yf dct djghjcs> ght;lt xtv vs jghtltkbv> cvj;tv kb vs
dfv gjvjxm. Tckb dfv gjnht,etncz gjvjom ghb pfgjkytybb rfrjq-kb,j xfcnb lfyyjq ajhvs>
gjpdjybnt d cdjq vtcnysq Jnltk cjwbfkmyjuj j,tcgtxtybz !Community Services Office@.

IFU 1                                                           Gj;fkeqcnf> pfgjkybnt gtxfnysvb ,erdfvb.
1. BVZ                                         JNXTCNDJ                                       AFVBKBZ



2. FLHTC GHJ:BDFYBZ                                  UJHJL                        INFN            BYLTRC



3. GJXNJDSQ FLHTC !TCKB JNKBXFTNCZ@                  UJHJL                        INFN            BYLTRC




4. YJVTHF NTKTAJYJD                                5. TCNM KB E DFC CKJ:YJCNB C HFPUJDJHJV> XNTYBTV BKB
LJVFIYBQ                                           GBCMVJV YF FYUKBQCRJV ZPSRT*
                                                                LF               YTN

LKZ CJJ<OTYBQ                                     DFV YE:TY GTHTDJLXBR*

                                                                LF               YTN

                                                  TCKB DFV YE:TY GTHTDJLXBR> VS DFV TUJ GHTLJCNFDBV.
                                                  YF RFRJV ZPSRT DS UJDJHBNT*




                                                 J<OFZ BYAJHVFWBZ
TCKB DS CJCNJBNT D <HFRT> ERF:BNT NFR:T BVZ DFITUJ CEGHEUF. BCGJKMPEQNT JABWBFKMYST BVTYF.
                                                                                   GJLFTN         YJVTH
                         BVZ                         CNTGTYM                    PFZDKTYBT J    CJWBFKMYJUJ      GJK
              !BVZ> JNXTCNDJ> AFVBKBZ@              HJLCNDF C          LFNF      GJKEXTYBB      J<TCGTXTYBZ   V BKB :
                                                      DFVB           HJ:LTYBZ       KMUJN*          !SSN@
                                                                                  LF YTN

                                                    Z CFV!F@

                                                     CEGHEU
                                        BYAJHVFWBZ J VTLBWBYCRJV CNHF{JDFYBB
                     GJCNFDMNT JNVTNRB D CJJNDTNCNDE?OB{ RDFLHFNF{                               YJVTH MEDICARE

Bvt/ ghfdj bkb gjkexf/% Xfcnm F Medicare Z cfv!f@                      Lf        Ytn

                                                          Cegheu       Lf        Ytn

Bvt/ ghfdj bkb gjkexf/% Xfcnm D Medicare                  Z cfv!f@     Lf        Ytn

                                                          Cegheu       Lf        Ytn

DSHS 13-691 RU (REV. 10/2005)                                                                                  PAGE 1
Z#vs bvttv lheue/ vtlbwbycre/ cnhf[jdre. Lf         Ytn
Tckb «lf»> nj rfre/ cnhf[jdre> b rnj gj ytq pfcnhf[jdfy*


Gkfnbkb kb ds cnhf[jdst dpyjcs gj ghjuhfvvt Medicare pf xfcnm F bkb xfcnm D
ghjuhfvvs Medicare d ntxtybt gjcktlyb[ 3 vtczwtd* Lf       Ytn
Tckb lf> gj;fkeqcnf> cjj,obnt yfv> pf rfrbt vtczws
                                                LJ{JL
Yb;t erf;bnt lj[jl rf;ljuj xtkjdtrf> bvt/otuj lj[jls b drk/xtyyjuj d lfyyjt
pfzdktybt. Erf;bnt cevve lj[jlf lj dsxtnjd !nfrb[ rfr yfkjub bkb cnhf[jdst dpyjcs@.
Lj[jl drk/xftn d ct,z> yj yt juhfybxty cktle/obv%
• Pfhgkfnf            • Gjcj,bz             • Fkbvtynyst gkfnt;b           • Ljgjkybntkmyfz
• Lj[jls jn             ;tktpyjljhj;ybrfv
                                            • Gjcj,bz gj                     cjwbfkmyfz gjvjom !SSI@#
  bylbdblefkmyjq        !Railroad Benefits@   ,tphf,jnbwt bkb                Dsgkfns j,otcndtyyjq
  ghtlghbybvfntkmcrjq • Gjcj,bz gj            dsgkfns> cdzpfyyst             gjvjob !Public
  ltzntkmyjcnb          cjwbfkmyjve           c ytcxfcnysv                   Assistance@
• Rjvbccbjyyst          j,tcgtxtyb/           ckexftv yf                   • Gtycbb
                                              hf,jxtv
• Gkfnf pf gbnfybt b • Gjcj,bz dtnthfyfv      vtcnt !Workers               • Lbdbltyls bkb ghjwtyns
  ghj;bdfybt#fhtylyfz   djqys !Veterans       Compensation@                • Lheujt
  gkfnf                 Benefits@

                         BVZ        HF<JNJLFNTKM BKB BCNJXYBR LJ{JLF   CEVVF LJ DSXTNJD    RFR XFCNJ
                                                                                           GJKEXFTNT*




                                                FRNBDS
Cevvf vjb[ frnbdjd cjcnfdkztn vtytt 4 000 ljkkfhjd yf jlyjuj xtkjdtrf bkb                   Lf     Ytn
vtytt 6 000 ljkkfhjd yf ceghe;tcre/ gfhe. R frnbdfv jnyjczncz nfrbt chtlcndf>
rfr ,fyrjdcrbt cxtnf> ltgjpbnyst cthnbabrfns> c,thtufntkmyst j,kbufwbb>
bylbdblefkmyst gtycbjyyst cxtnf !IRA@> frwbb b j,kbufwbb> ljkb dj dpfbvys[
ajylf[> yfkbxyst chtlcndf> bveotcndj !rhjvt ljvf bkb fdnjvj,bkz@.

                                Tckb «lf»> nj> gj;fkeqcnf> erf;bnt yb;t%

                BVZ DKFLTKMWF                   NBG FRNBDJD#YJVTH CXTNF                    NTREOFZ
                                                                                          CNJBVJCNM




DSHS 13-691 RU (REV. 10/2005)
                                                                                                 PAGE 2
 B. Ds bkb dfi cegheu dkflttnt fdnjvj,bktv bkb lheubv nhfycgjhnysv                                  Lf        Ytn
 chtlcndjv !uhepjdbr> kjlrf> ljv yf rjktcf[> vjnjwbrk> ljv-fdnjghbwtg b#bkb
 nhtqkthjv@ bkb cj,bhftntcm ghbj,htcnb tuj*
                                      Tckb «lf»> nj> gj;fkeqcnf> erf;bnt yb;t%

                                                                     BCGJKMPETNCZ LKZ                  CEVVF LJKUF PF
                                  YFBVT-      UJL       VFHRF#                               WTYF       NHFYCGJHNYJT
       BVZ DKFLTKMWF                                                NHFYCGJHNBHJDRB YF
                                 YJDFYBT                VJLTKM      VTLBWBYCRBT GHBTVS*                    CHTLCNDJ



                                                                       Lf      Ytn

                                                                       Lf      Ytn

                                                                       Lf      Ytn
 C. Tcnm kb e dfc bkb dfituj cegheuf gjkbc cnhf[jdfybz ;bpyb ltyt;yjq cnjbvjcnm/
 ,jktt 1 500 ljkkfhjd* Nfr;t> gj;fkeqcnf> erf;bnt dct gj[jhjyyst cnhf[jdrb bkb
 erf;bnt> d rfrb[ cnhf[jds[ gkfyf[ yf ckexfq gj[jhjy ds exfcndetnt. Lf       Ytn

                                      Tckb «lf»> nj> gj;fkeqcnf> erf;bnt yb;t%

    DKFLTKTW GJKBCF             YFPDFYBT CNHF{JDJQ RJVGFYBB#     YJVBYFKMYFZ     LTYT:YFZ           RNJ PFCNHF{JDFY*
                                        YJVTH GJKBCF              CNJBVJCNM      CNJBVJCNM




                                  DYBVFNTKMYJ GHJXNBNT> GHT:LT XTV GJLGBCSDFNM
                                       Z GJYBVF? XNJ%
  • Z ljk;ty ytvtlktyyj cjj,ofnm d Ltgfhnfvtyn cjwbfkmyjuj j,tcgtxtybz b plhfdjj[hfytybz
    !DSHS@> gbcmvtyyj bkb gj ntktajye> j k/,s[ bpvtytybz[ vjtuj gjkj;tybz. Ytcdjtdhtvtyyjt
    cjj,otybt vj;tn ghbdtcnb r ytghfdbkmyjve yfxbcktyb/ gjcj,bq.
 • Vjt gjkj;tybt gjlkt;bn ghjdthrt ltgfhnfvtynjv DSHS bkb lheubvb ujcelfhcndtyysvb jhu
    infnf bkb atlthfkmysvb jhufyfvb.
  • Z ljk;ty ghtljcnfdbnm gj nht,jdfyb/ gjlndth;lf/obt ljrevtyns> xnj,s gjkexbnm ghfdj yf
    gjvjom. Ltgfhnfvtyn DSHS vj;tn gjvjxm vyt gjkexbnm gjlndth;lf/obt ljrevtyns bkb
    cdzpfnmcz lkz 'njuj c lheubvb kbwfvb bkb jhufyfvb.
  • J,hfofzcm pf kmujnfvb gj vtlbwbycrjve j,cke;bdfyb/ b gjkexfz b[> z gthtlf/ infne
     Dfibyunjy dct ghfdf yf k/,e/ vfnthbfkmye/ gjvjom> cdzpfyye/ c vtlbwbycrbv
     j,cke;bdfybtv> b yf k/,st gkfnt;b nhtnmb[ cnjhjy yf vtlbwbycrjt j,cke;bdfybt.
                                           PFZDKTYBT B GJLGBCM!GJLGBCB@
 Z ghjxbnfk b gjyzk byajhvfwb/> bpkj;tyye/ d yfcnjzotv pfzdktybb. Z pfzdkz/ gjl cnhf[jv
 yfrfpfybz pf k;tcdbltntkmcndj> xnj byajhvfwbz> ghtljcnfdktyyfz vyj/ d lfyyjv pfzdktybb> gj
 vjtve e,t;ltyb/> zdkztncz bcnbyyjq> njxyjq b gjkyjq.

GJLGBCM PFZDBNTKZ                                                                             LFNF



GJLGBCM CEGHEUF                                                                               LFNF



GJLGBCM KBWF> GJVJUFDITUJ PFZDBNTK?                      JHUFYBPFWBZ                          LFNF



DSHS 13-691 RU (REV. 10/2005)
                                                                                                               PAGE 3
                                                    HFCRHSNBT BYAJHVFWBB
 Z hfphtif/ ltgfhnfvtyne DSHS hfcrhsnm byajhvfwb/> bvt/oe/ jnyjitybt r vjtve pfzdktyb/
 j, exfcnbb d ghjuhfvvf[ Medicare Savings Programs> kbwe> jrfpsdf/otve gjvjom d pfgjkytybb
 yfcnjzotuj pfzdktybz> bkb ghtlcnfdbntk/ jhufybpfwbb 'njuj kbwf.
GJLGBCM PFZDBNTKZ                                                                            LFNF




                                                    LJ<HJDJKMYFZ BYAJHVFWBZ
 Vs ghjcbv dfc lj,hjdjkmyj cjj,obnm yfv cdj/ hfce bkb 'nybxtcrjt ghjbc[j;ltybt. Lfyyfz
 byajhvfwbz yt ,eltn bcgjkmpjdfyf ghb ghbyznbb htitybz j dfitv ghfdt yf gjkextybt kmujn.

         <tksq                  Kfnbyjfvthbrfytw         Xthysq    Fvthbrfycrbq bylttw#rjhtyyjq ;bntkm Fkzcrb
         Dmtnyfvtw#kfjctw#rfv,jl;btw                               Gktvz%
         Lheufz fpbfncrfz yfwbjyfkmyjcnm bkb                       Lheujt%
         yfwbjyfkmyjcnm nb[jjrtfycrb[ jcnhjdjd

IFU 2                                   GHBKJ:BNT GJLNDTH:LF?OBT LJREVTYNS

Lkz njuj> xnj,s hfccvjnhtnm dfit pfzdktybt> yfv gjnht,etncz ytrjnjhfz byajhvfwbz. Jnghfdkzqnt yf
rjgbb ljrevtynjd> yt jnghfdkzqnt jhbubyfks.


• Eljcnjdthtybt kbxyjcnb                           Djlbntkmcrbt ghfdf> gfcgjhn bkb eljcnjdthtybt c ajnjuhfabtq
• Ghjuhfvvf Medicare                               Rfhnjxrf-eljcnjdthtybt exfcnybrf ghjuhfvvs Medicare !kbwtdf
                                                   j,hfnyfz cnjhjyf@
• Lheufz vtlbwbycrfz cnhf[jdrf                     Cnhf[jdfz rfhnjxrf !kbwtdfz b j,hfnyfz cnjhjyf@

Tckb ds yt vj;tnt gjkexbnm gjlndth;lf/obt ljrevtyns> nj ltgfhnfvtyn DSHS vj;tn dfv gjvjxm.
Gj;fkeqcnf> ghbkj;bnt pfgbcre c erfpfybtv ghbxbys> gj rjnjhjq ds yt vj;tnt ghtljcnfdbnm
gjlndth;lf/obt ljrevtyns.


IFU 3
Gjlgbibnt b gjcnfdmnt lfne yf dfitv pfzdktybb b jnghfdmnt tuj dvtcnt c rjgbzvb dfib[
ljrevtynjd d cdjq vtcnysq Jnltk cjwbfkmyjuj j,tcgtxtybz !CSO@. Gjpdjybnt d cdjq vtcnysq
jnltk CSO> tckb dfv ytj,[jlbv rjydthn c jgkfxtyysvb gjxnjdsvb hfc[jlfvb.




    Dj dct[ ghjuhfvvf[ b vthjghbznbz[> ghjdjlbvs[ Ltgfhnfvtynjv cjwbfkmyjuj j,tcgtxtybz b
    plhfdjj[hfytybz !DSHS@> pfghtotyf lbcrhbvbyfwbz. Ybrnj yt vj;tn ,snm bcrk/xty bp lfyys[ ghjuhfvv
    b vthjghbznbq yf jcyjdfybb hfcjdjq ghbyflkt;yjcnb> wdtnf rj;b> e,t;ltybq> gjkbnbxtcrb[ dpukzljd>
    yfwbjyfkmyjuj ghjbc[j;ltybz> htkbubb> gjkf bkb bydfkblyjcnb.



DSHS 13-691 RU (REV. 10/2005)

                                                                                                         PAGE 4