U S Department of Health and Human Services www.hhs.gov
  CMS Home > Medicaid > Dual Eligibility > Model Application for Medicare Savings Programs

Model Application for Medicare Savings Programs

The Medicare, Medicaid, and State Child Health Insurance Program (SCHIP) Benefits Improvement and Protection Act (BIPA) of 2000 enacted a provision that required the Secretary of Health and Human Services to develop a simplified national application form for states, at their option, to use for individuals who apply for medical assistance for Medicare cost-sharing under the Medicaid program. To fulfill this mandate, the Centers for Medicare & Medicaid Services (CMS), worked with states and beneficiary groups to create a model application.

Application Instructions

The two-page (front and back) application was developed by a state workgroup convened by the American Public Human Services Association (APHSA) under a contract with CMS. This simplified application is intended to help minimize the deterrent effect that a complex application process may have on participation in the Medicare Savings Programs. Working together with states and beneficiary groups, CMS has further revised the model application for the Medicare Savings Programs.

This application contains the elements that the work group, states, and beneficiary groups believed to be common requirements across all states. However, because states vary in their eligibility requirements for these benefits, the form may be modified to reflect each state's unique needs.

Fourteen point font or higher is used throughout most of the form, as a significant percent of dual eligible beneficiaries have visual impairments. In addition, the maximum amount of space feasible was left for completing answers. We suggest that the form be printed with black ink to further increase readability.

To further reduce the impediments to enrollment for people with Medicare, CMS suggests that, in addition to a simplified application, states allow mail-in applications without a requirement for an in-person interview or unnecessary verification requirements. We also encourage states to work with community and local groups to distribute the application and to assist people with Medicare with completing the application. Properly trained, community and local groups can play a paramount role in getting potential beneficiaries enrolled.

CMS encourages states to simplify their application, enrollment, and redetermination process in partnership with community and local groups as a first step in reducing barriers to enrollment for dual eligible beneficiaries.

See the model application in the Downloads section below.


Model Application for Medicare Savings Programs [PDF, 141 KB]
Related Links Inside CMS

There are no Related Links Inside CMS
Related Links Outside CMSExternal Linking Policy

There are no Related Links Outside CMS


Page Last Modified: 01/02/2009 1:46:09 PM
Help with File Formats and Plug-Ins

Submit Feedback