The Alabama 211 form serves as an application for Medicare Savings Programs through the Alabama Medicaid Agency, aimed at assisting individuals with the costs of Medicare premiums and deductibles, without providing full Medicaid benefits. It is imperative for applicants to provide complete and accurate information, including verification of income, Medicare, and Social Security details, to avoid penalties for false statements or omissions. To facilitate access to these benefits, interested individuals are encouraged to carefully review and follow the instructions outlined in the form.
Click the button below to start filling out your Alabama 211 form.
Individuals seeking assistance with their Medicare premiums and deductibles in Alabama can find crucial support through the Alabama Medicaid Agency's Application for Medicare Savings Programs, commonly referred to as the Form 211. This specialized application is designed not to extend full Medicaid benefits but to provide a financial safety net for those facing the high costs associated with Medicare, specifically aiding with premiums and the often burdensome deductibles. It's important to note that while this program can relieve some financial pressures, its reach for drug coverage is limited explicitly to those medications covered under Medicare Part D, explicitly excluding any drugs not covered by Part D. Applicants are guided through a series of steps beginning with the submission of documents for verification purposes, such as Medicare, Social Security cards, and proof of monthly income, to the signing and mailing of the application to the district office pertinent to their county of residence. The form underscores the legal implications of misrepresentation or falsification of information, citing both criminal and civil penalties for false statements, which could lead to denial of the application or even prosecution under Alabama law. Additionally, the form emphasizes compliance with several key statutes for the protection of applicants, underscoring a commitment to fair treatment under the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Federal Age Discrimination Act of 1975, and the Americans with Disabilities Act of 1990, thereby ensuring a process that seeks to be both inclusive and accessible to all applicants.
Alabama Medicaid Agency
Application for Medicare Savings Programs
This is NOT an application for full Medicaid.
These programs cover Medicare premiums and deductibles. Medicaid’s drug coverage is limited to the drugs covered under Medicare Part D only. Medicaid will not pay for any excluded drugs under Medicare Part D.
Instructions: Read this application carefully and follow all instructions given throughout the form. Answer each question completely and accurately.
1.Send a copy of your Medicare card to verify your Part A coverage.
2.Send a copy of your Social Security card.
3.Send verifi cation of the gross (before taxes) amount of your monthly income.
4.Sign the application.
5.Mail the application to the District Offi ce serving your county.
(See attachment for the address of the District Offices.)
Form 211 (Revised 5/2014)
www.medicaid.alabama.gov
Notice to Applicants and Sponsors
Federal and state laws provide both criminal and civil penalties for false statements or material omissions in an application for Medicaid benefi ts or payments. Also, any application found to contain material misstatements or omissions will be denied.
The following statutes are excerpts from the Code of Alabama pertaining to the Medicaid program:
S22-1-11. Making false statement or representation of material fact in claim or application for payments on medical benefi ts from Medicaid agency generally; kickbacks, bribes, etc.; exceptions; multiple offenses.
(a)Any person who, with intent to defraud or deceive, makes, or causes to be made or assists in the preparation of any false statement representation or omission of a material fact in any claim or application for any payment, regardless of amount, from the Medicaid agency, knowing the same to be false; or with intent to defraud or deceive, makes, or causes to be made, or assists in the preparation of any false statement, representation or omission of a material fact in any claim or application for medical benefits from the Medicaid agency, knowing the same to be false; shall be guilty of a felony and upon conviction there of shall be fi ned not more than $10,000.00 or imprisoned for not less than one nor more than five years, or both.
* * *
(e)Any two or more offenses in violation of this section may be charged in the same indictment in separate counts for each offense and such offense shall be tried together, with separate sentences being imposed for each offense of which defendant is found guilty. (Acts 1980, No. 80-539, p. 837, Sections 1-5.)
S22-6-8, Revocation of eligibility of recipient upon determination of abuse, fraud, or misuse of benefits; when eligibility may be restored.
(a)Upon determination by a utilization review committee of the designated state Medicaid agency that a Medicaid recipient has abused, defrauded, or misused the benefi ts of the program said recipient shall immediately become ineligible for Medicaid benefits.
(b)Medicaid recipients whose eligibility has been revoked due to abuse, fraud or other deliberate misuse of the program shall not be deemed eligible for future Medicaid services for a period of not less than one year and until full restitution has been made to the designated state Medicaid agency.
(c)The provisions of this section shall not be effective if they are found by a court of competent jurisdiction to contravene federal laws or federal regulations applicable to the Medicaid program.
(Acts 1980, No. 80-127, p.190.)
Medicaid Eligibility Policies and Procedures are in compliance with Civil Rights Act of 1964,
Section 504 of the Rehabilitation Act of 1973, Federal Age Discrimination Act of 1975
and the Americans with Disabilities Act of 1990.
Form 211
5-2014
Please print clearly using dark ink.
1
APPLICANT
Name___________________________________________________________________________________
First
Middle/Maiden
Last
Suffix
Mailing Address __________________________________________________________________________
Street or 911 Address
________________________________________________________________________________________
City
State
Zip Code
Phone # (_______)_________________
Other Phone (_______)_________________ Whose? _________________________
email ___________________________________________
Fax ________________________________
Current Resident Address __________________________________________________________________
(If different from Mailing Address)
County of Residence ______________________________ Date of Birth ____________________________
Social Security # _______________________________
Medicaid # ______________________________
2
MARITAL STATUS
Marriage Information
I am Married _________________ (Date Married)
If married, does your spouse have Medicare? Yes
No
I am Single (Never Married)
I am Divorced ________________ (Date Divorced)
I am Widowed _______ (Date Widowed)
I am Separated _______________ (Date Separated)
3
MEDICARE
Do you have Medicare Part A (Hospital) Coverage?
Yes No
Name on Medicare card _______________________________________________________________
Medicare # ________________________________________________________
4
RACE
White
Black
American Indian
Hispanic Asian
Other_________
5
SEX
Female
Male
District Offi ce Use Only
Date Received ____________
Date Accepted ____________
Medicare Card Received Yes No
Income Verification Received
Yes
No
Applicant’s Name __________________________________________ SS # ________________________________
6
FAMILY SIZE
List names of anyone living in your home
Name
Age
Relationship
_______________________________________________
_______
________________________________________________
7
SPONSOR (If the applicant is unable to complete the application or provide additional information, the Medicaid sponsor should be the person most familiar with the fi nancial situation of the applicant.) Please complete the Appointment of Representative form on Page 6 of this application.
Relationship to Applicant ______________________________
Name ______________________________________________
Home Phone ________________________
Address ____________________________________________
Work Phone ________________________
___________________________________________________
Cell Phone _________________________
Zip
email ______________________________________________
FAX ____________________________
8
SPOUSE INFORMATION
(Complete even if divorced, separated or widowed.)
Phone # (_______)___________________
(First, Middle, Last)
Date of Birth _______________________
(Street or Box Number)
__________________________________________________
SS # ______________________________
County
email _________________________________________ Spouse’s Medicaid # _______________________
9
FORMER SPOUSE INFORMATION
(Must be completed if you are widowed or divorced.)
(For all previous marriages, list most recent first.)
1. Former Spouse’s Name ________________________________________
SS # _____________________
Marriage Began _________________ Ended ______________
Reason Death Divorce Other
Date
2. Former Spouse’s Name _______________________________________
SS # ______________________
Page 2
Applicant’s Name ___________________________________________ SS # ________________________________
10
VETERAN’S STATUS
Are you a Veteran? Yes No
Are you a dependent of a Veteran? Yes
If yes to either of the questions above, complete the following:
Veteran Name ____________________________________________________________________________
Middle
Veteran Claim Number __________________________ Relationship to Veteran _______________________
Have you applied for Veteran’s benefi ts under the new Veterans & Survivor’s Improvement Act? Yes No
If no, you must apply and send verification.
11
RESIDENCY INFORMATION
Are you a United States Citizen? Yes No
Are you a lawfully admitted alien? Yes No
Where were you born?______________________________________________________________________
Country
Do you live in Alabama and plan to stay?
What language do you usually speak?
English Spanish Other___________________
Do you or a family member speak English?
Have you ever applied for or received SSI?
No
If yes, were you terminated from SSI?
When? _____________________________
Month/Year
12
OTHER INSURANCE
No
Do you have medical insurance other than Medicare?
Yes
If yes, provide information below:
1. Name/Address of Health Insurance Company
2. Name/Address of Health Insurance Company
____________________________________________
_________________________________________
Policy # ________________________________
Group # ________________________________
3. Name/Address of Health Insurance Company
4. Name/Address of Health Insurance Company
(You may list other policies on a separate sheet(s) and attach to this application, if needed.)
Page 3
Applicant’s Name _______________________________________
SS # ________________________________
13
GROSS INCOME:
(This means “money coming in” before anything is taken out). Answer the following.
Do you or your spouse have “money coming in” from any of the sources listed below?
If yes, fi ll in the claim number and gross amount. (A copy of most recent check stub or other verifi cation must be
provided.)
NOTE: If you are applying on behalf of a married individual, the spouse must also answer these questions.
How Often
Applicant
Spouse
Minor Child
Received?
Type of Income
Gross
(Quarterly,
Claim Number
Amount
Annually, etc.)
1.
Social Security
(include Medicare Premiums)
2.
SSI (Gold Check)
3.
Public Assistance (Welfare)
4.
Railroad Retirement
5.
Veterans Benefits, Pensions,
Compensation or Insurance
6.
Federal Civil Service Annuity
7.
State Retirement/Pension
8.
Private Pension
9.
Miner’s Benefits
10.
Black Lung Benefits
11.
Cash Contributions (from
relatives, friends, others)
12.
Rental (land, buildings, or
from roomer)
13.
Personal loans (relatives,
friends, others)
14. Unemployment Compensation
15.
Insurance Annuity or Proceeds
16.
Government Payments on land
17.
Coal, Oil, Gravel Rights and
Timber Leases
18.
Royalties
19.
Court Ordered Support
20.
N/A
21.
Other: Specify ____________
22.
23.
Legal Settlements
24.
Sheltered Workshop Earnings
25. Wages/Salary
26.
Self Employment
Page 4
Applicant’s Name ___________________________________________ SS #________________________________
RELEASE OF INFORMATION
*I hereby authorize and give my consent for the Alabama Medicaid Agency to obtain information from any source for the purpose of determining my eligibility for Medicaid benefi ts. I authorize this release form to be in effect for as long as I am on Medicaid regardless of the date that it is signed. I further authorize copies of this document to be used in place of the original. I give my consent for the release of information for those purposes directly related to the administration of the Medicaid program. These purposes include, but are not limited to, establishing eligibility for benefi ts, determination of the amount of medical assistance received, the provision of services, and investigation of program violations.
AFFIRMATION AND AGREEMENT
*I give permission to the Alabama Medicaid Agency to use my Social Security number to get information about my resources and income from banks, fi nancial institutions, employers, and other county, state and federal agencies, and/or to see if I qualify for assistance or to see if I have insurance.
*If I am approved for Medicaid, I assign all insurance and medical support benefi ts to Medicaid. If Medicaid pays my bills, then my insurance or other benefi ts (such as lawsuit settlements) must be used to pay Medicaid back. I agree to help and cooperate with Medicaid in identifying and collecting this money, or I may lose my Medicaid benefi ts. I give permission for my insurance company, employer, and others to give needed information to Medicaid in order to administer the Medicaid program.
*I understand that if this application or other information shows that I may be eligible for payments or benefits from other sources, I am required to apply for them.
*I understand that my case is subject to review by State and Federal Quality Control and that I must cooperate in completing the application process or in any subsequent reviews of my eligibility, including reviews resulting from reported changes, recertifi cation, or as a part of a State or Federal Quality Control Review.
*I understand that resources that have been sold, transferred, disposed of, or given away within the past 60 months will not affect my application for Medicaid for the Medicare Savings Programs, but may affect eligibility for Medicaid in a medical institution.
RESPONSIBILITIES
*I agree to notify the Medicaid District Offi ce within ten (10) days, if there is a change in my address, living arrangements, family size, income or resources.
FALSE STATEMENTS
I know that anyone who makes or causes to be made a false statement, representation or omission of a material fact in an application or for use in determining eligibility for Medicaid commits a crime punishable under Federal or State law or both. I affi rm under penalty of perjury that all information I give in this document or in support of it is true.
Date _________________________
Signature of Applicant or Representative
Signature of Applicant’s Spouse or Representative
Witness’ Signature (If applicable)
Medicaid Eligibility Policies and Procedures are in compliance with the Civil Rights Act of 1964,Section 504 of the Rehabilitation Act of 1973, the Federal Age Discrimination Act of 1975 andthe Americans with Disabilities Act of 1990.
Page 5
Applicant’s Name _________________________________________ SS# ________________________________
APPOINTMENT OF REPRESENTATIVE
I hereby appoint ________________________________________________________________________ (Sponsor’s Name)
as my legal representative to act in my stead and on my behalf to apply, reapply and make claim for Medicaid benefits under Title XIX of the Social Security Act from the Alabama Medicaid Agency, hereby ratifying and confi rming the acts of my said representative on my behalf. This appointment authorizes my said representative to fully act in my stead in connection with all Medicaid matters involving me, including, but not limited to, making applications, reapplications and claims of all kinds, accepting and giving notice in connection with eligibility determinations and Fair Hearings, requesting information, and presenting and eliciting evidence. This appointment shall remain in full force and effect until I have notifi ed the Alabama Medicaid Agency in writing that this authority has been withdrawn.
Done this the ______________________ day of ________________________________________, 20 __________.
WITNESSES
__________________________________________________ _____________________________________________
(Signature of Medicaid Claimant)
(Social Security Number)
If claimant cannot sign his/her name but can make a mark; this is acceptable if witnessed by two adults.
The mark may be labeled. Example:
X (Her mark)
Jane Doe
.
If claimant cannot sign his/her name or make a mark and there is no one legally designated as guardian, conservator, etc., representative must answer the questions below.
What is your relationship to claimant? ________________________________________________________________
Why can’t claimant sign? __________________________________________________________________________
To what extent are you responsible for claimant? ________________________________________________________
If claimant has a legally appointed guardian, conservator or someone with durable power of attorney who will represent him/her for Medicaid purposes, claimant’s signature on this form is not required. Representative should sign the Representative portion of the form only and attach to this form a copy of evidence of legal authority to act on claimant’s behalf (Letter of Conservatorship/Guardianship or Durable Power of Attorney).
ACCEPTANCE OF APPOINTMENT
I hereby accept the foregoing appointment. I certify that I have not been suspended or prohibited from practice before the Alabama Medicaid Agency and am not otherwise disqualifi ed from acting as an appointed representative. I acknowledge that representations and applications made by me on behalf of the claimant are made under an affi rmation which subjects me to penalties for perjury and that false statements may subject me to penalties or fraud.
My relationship to the above is __________________________________________________ (Attorney, relative, etc.)
(Signature of Sponsor/Representative)
(Address)
(City, State, Zip)
(Telephone Number)
Page 6
The process of filling out the Alabama 211 form is a critical step towards applying for Medicare Savings Programs. This form helps to cover Medicare premiums and deductibles but is not an application for full Medicaid. Attention to detail is crucial when completing this form to ensure accurate and complete information is provided. This helps in avoiding any delays or potential issues with the application process. Below are the steps needed to fill out the form correctly and efficiently.
It's important to complete every section of the form to the best of your ability. Accurate and complete answers contribute to a smoother application process for Medicare Savings Programs through the Alabama Medicaid Agency.
What is the Alabama 211 form used for?
The Alabama 211 form is designed for individuals applying for the Medicare Savings Programs administered by the Alabama Medicaid Agency. These programs help cover Medicare premiums and deductibles but do not provide full Medicaid coverage. The coverage for medications is limited to those included under Medicare Part D, excluding any drugs not covered by Medicare Part D.
Who should complete the Alabama 211 form?
Any resident of Alabama who is seeking assistance with their Medicare premiums and deductibles through the Medicare Savings Programs should complete this form. It's essential for applicants to already have Medicare Part A (Hospital Insurance) coverage.
What documentation is required to apply?
Applicants must provide (1) a copy of their Medicare card to verify Part A coverage, (2) a copy of their Social Security card, (3) verification of their monthly income before taxes, and (4) their signature on the application. These documents must accompany the completed form when it's mailed to the District Office serving their county.
How do I know which District Office to send my application to?
The application includes an attachment with addresses for the District Offices. Applicants should find the office serving their county and send their completed form and required documents there.
What happens if I provide false information on my application?
Providing false information or omitting material facts in the application can lead to criminal or civil penalties. The application highlights that false statements or significant omissions will result in the denial of the application for benefits. It is crucial to answer all questions truthfully and accurately.
Can I apply if I'm not a United States citizen?
Yes, you can apply if you are a lawfully admitted alien. The form asks for your citizenship status and, if applicable, information about your lawful admission into the country.
What if I am unable to complete the application on my own?
If an applicant cannot complete the form or provide additional information themselves, they should designate a sponsor. This person, most familiar with the applicant's financial situation, can help complete the application. There is a specific section on the form for appointing a representative.
Is this application only for individuals, or can couples apply together?
Couples can apply together if both are seeking assistance under the Medicare Savings Programs. The form requests information about marital status and, if applicable, details about the applicant's spouse, including their Medicare status. This helps the Alabama Medicaid Agency determine eligibility and the correct level of assistance.
Filling out the Alabama 211 form, an application for the Medicare Savings Programs offered by the Alabama Medicaid Agency, is a critical step towards receiving assistance with Medicare premiums, deductibles, and limited drug coverage under Medicare Part D. However, applicants often encounter pitfalls during this process that may hinder their ability to gain the benefits they need. Here are eight common mistakes to avoid:
Attentiveness to these details can greatly enhance your application's chances of timely and successful processing. Applicants who take the time to carefully review and accurately complete their applications will find that they are better positioned to receive the assistance they need. As always, for further clarification on filling out the Alabama 211 form or understanding the broader aspects of the Alabama Medicaid Agency’s Medicare Savings Programs, seeking advice from legal or professional services can be hugely beneficial.
When applying for Medicare Savings Programs in Alabama using the Form 211, applicants may need to gather and submit additional documents and forms to support their application. These documents are essential for verifying the information provided in the application and ensuring eligibility for benefits. Below is a list of other forms and documents often used along with the Alabama 211 form, each described briefly to help applicants understand their purpose and importance.
Understanding which documents to gather can streamline the application process for the Medicare Savings Programs through Alabama's Medicaid Agency. It's essential for applicants to read the Form 211 application instructions carefully and ensure all supporting documentation is complete and accurate. Submitting the necessary forms and documents helps the agency efficiently evaluate eligibility and provide benefits to which applicants may be entitled.
The Alabama 211 form, titled "Alabama Medicaid Agency Application for Medicare Savings Programs," serves a distinct purpose but parallels several other documents in the domain of health benefits and public assistance, each with unique attributes but sharing a common goal of providing aid to eligible individuals.
Firstly, the form closely resembles the Application for Health Coverage & Help Paying Costs (commonly encountered in state-based health insurance marketplaces). Like the Alabama 211 form, this application assesses eligibility for health coverage assistance, focusing on premiums and cost-sharing reductions. Both require detailed personal, financial, and residency information to determine eligibility, yet the marketplace application extends its scope to include a broader range of health coverage options beyond Medicare Savings Programs.
Another document that shares similarities with the Alabama 211 form is the Supplemental Security Income (SSI) Application. The SSI application process assesses eligibility for monthly financial aid to aged, blind, or disabled people who have limited income and resources, similar to how the Alabama 211 form determines eligibility for Medicare cost assistance based on financial criteria. While both demand comprehensive income and resource information, the Alabama 211 form specifically targets assistance with Medicare expenses, distinguishing it from the broader financial aid provided by SSI.
Additionally, the Medicaid application form used for gaining full Medicaid coverage parallels the Alabama 211 form in several respects. Both are administered by state Medicaid agencies and require applicants to furnish detailed personal information, financial status, and residency details. However, the Medicaid application seeks to enroll individuals in full Medicaid coverage, which encompasses a wider array of healthcare services, as opposed to the Alabama 211 form’s limited aim of assisting with Medicare premiums and deductibles alone.
When completing the Alabama 211 form, which is an application for Medicare Savings Programs through the Alabama Medicaid Agency, careful attention to detail is essential. Below are recommended dos and don'ts to guide applicants through the process.
Dos:
Don'ts:
Misunderstandings about the Alabama 211 form, the application for Medicare Savings Programs provided by the Alabama Medicaid Agency, can create confusion among applicants. Here is a clarification of some common misconceptions:
Understanding these aspects of the Alabama 211 form can help applicants correctly complete their application and set realistic expectations about the benefits for which they might qualify.
When it comes to seeking assistance with Medicare premiums and deductibles through Alabama's Medicaid, the Alabama 211 form plays a crucial role. Understanding how to properly fill out and use this form can significantly streamline the application process. Here are five key takeaways that applicants should remember:
Understanding these key aspects can help applicants navigate the complexities of applying for Medicare Savings Programs in Alabama with more confidence and clarity. Each step, from filling out the form to submitting it with the required documentation, is designed to ensure that eligible individuals receive the financial support they need for their Medicare expenses.
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