Alabama Form 211 PDF Details

Form 211, the Application for Medicare Savings Programs (MSP), is issued by the Alabama Medicaid Agency to help residents who have Medicare Part A cover costs they cannot afford on their own. The form is 8 pages and covers personal information, Medicare enrollment details, income, family size, and current insurance coverage.

Medicare Savings Programs Covered by Form 211

Form 211 lets you apply for four MSP categories at the same time. The Qualified Medicare Beneficiary (QMB) program covers Part A and B premiums, deductibles, and co-payments. The Specified Low-Income Medicare Beneficiary (SLMB) program covers Part B premiums only. The Qualifying Individual (QI-1) program also covers Part B premiums for applicants with slightly higher income. The Qualified Disabled and Working Individuals (QDWI) program covers Part A premiums for disabled workers who lost Medicare benefits after returning to work.

Who Qualifies for the Medicare Savings Program

To qualify, you must be an Alabama resident enrolled in Medicare Part A. Income limits vary by program category and are updated each year based on the federal poverty level. For QMB, monthly income must generally be at or below 100 percent of the federal poverty level. For SLMB, income may be up to 120 percent. For QI-1, income may be up to 135 percent. You must also disclose your marital status, all household income sources, and any current insurance policies.

Documents Required to Complete Form 211

Before filling out Form 211, gather these items. You will need your Medicare card, your Social Security card, and proof of monthly income such as a recent pay stub or Social Security award letter. You should also have your most recent bank statements and any health insurance policy information available. Submit copies of all documents, not the originals.

Related Alabama Health Benefit Forms

If you are applying for other Alabama health benefits at the same time, the Alabama Medicaid Referral form may be required by your doctor or caseworker. For Medicare supplement coverage, the AARP Medicare Supplement application is also available on FormsPal. Those who need a Medicare authorization document can use the Medicare consent form to grant access to their records.

QuestionAnswer
Form NameAlabama Form 211
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesform 211 medicare, form 211 for medicare savings program, medicaid form 211, al medicaid form 211

Form Preview Example

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)

Alabama Medicaid Agency

 

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

 

Application for Medicare Savings Programs

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)

 

 

 

 

 

________________________________________________________________________________________

 

 

 

 

 

 

 

City

 

State

 

 

Zip Code

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 211 (Revised 5/2014)

Alabama Medicaid Agency

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 _________________________

 

 

 

City

State

 

Zip

 

 

 

 

 

email ______________________________________________

FAX ____________________________

 

 

 

 

 

 

8

 

SPOUSE INFORMATION

(Complete even if divorced, separated or widowed.)

 

 

 

Name ______________________________________________

Phone # (_______)___________________

 

 

 

(First, Middle, Last)

 

 

 

 

 

 

 

Address ____________________________________________

Date of Birth _______________________

 

 

 

(Street or Box Number)

 

 

 

 

 

 

__________________________________________________

SS # ______________________________

 

 

 

City

State

Zip

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

 

Date

 

 

 

 

2. Former Spouse’s Name _______________________________________

SS # ______________________

 

 

 

Marriage Began _________________ Ended ______________

Reason Death Divorce Other

 

 

 

 

Date

 

Date

 

 

Page 2

Applicant’s Name ___________________________________________ SS # ________________________________

 

10

VETERAN’S STATUS

 

 

 

 

 

 

 

 

 

 

 

Are you a Veteran? Yes No

 

 

 

 

 

 

 

 

 

 

 

Are you a dependent of a Veteran? Yes

No

 

 

 

 

 

 

 

If yes to either of the questions above, complete the following:

 

 

 

 

Veteran Name ____________________________________________________________________________

 

 

First

 

 

Middle

 

 

 

Last

 

 

 

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?______________________________________________________________________

 

 

City

 

County

 

 

 

State

Country

 

 

Do you live in Alabama and plan to stay?

 

Yes

 

 

No

 

 

 

 

What language do you usually speak?

 

English Spanish Other___________________

 

 

Do you or a family member speak English?

Yes

 

 

No

 

 

 

 

Have you ever applied for or received SSI?

 

Yes

 

 

 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 # ________________________________

 

 

 

 

Policy # ________________________________

 

 

Group # ________________________________

 

 

 

 

Group # ________________________________

 

 

3. Name/Address of Health Insurance Company

 

 

 

4. Name/Address of Health Insurance Company

 

 

____________________________________________

 

_________________________________________

 

 

____________________________________________

 

_________________________________________

 

 

____________________________________________

 

_________________________________________

 

 

Policy # ________________________________

 

 

 

 

Policy # ________________________________

 

 

Group # ________________________________

 

 

 

 

Group # ________________________________

(You may list other policies on a separate sheet(s) and attach to this application, if needed.)

Page 3

How to Edit Alabama Form 211 Online for Free

FormsPal's PDF editor lets you complete the Application for Medicare Savings Programs online without downloading any software. Follow the steps below to fill out and save your document on any device.

Step 1: Click the orange "Get form now" button at the top of this page to open the form in the editor.

Step 2: The form opens on a page-by-page editing canvas. Click any field to type into it or update existing entries.

Enter your full name, date of birth, address, and Social Security number in the personal information section shown below.

form 211 alabama medicaid fields to fill in

On pages 2 and 3, complete the Medicare and marital status sections. Enter your Medicare Part A enrollment date, your Medicare card number, and your race and sex information. If you are divorced or separated, fill in the relevant date fields.

Entering details in form 211 alabama medicaid step 2

In the household section, list the names, ages, and relationships of everyone living with you. Enter your total family size. If a sponsor or authorized representative is helping you apply, add their name, phone number, and address in the sponsor fields.

form 211 alabama medicaid Applicants Name SS FAMILY SIZE, List names of anyone living in, Name, Age, Relationship, SPONSOR, If the applicant is unable to, Relationship to Applicant, Name Home Phone, and Address Work Phone blanks to fill out

Complete the spouse information section even if you are currently divorced. Enter your spouse's full name, date of birth, mailing address, and Medicaid number if applicable. Fill in the former spouse section if it applies to your situation, including the dates your marriage began and ended.

Completing form 211 alabama medicaid step 4

The final pages ask about your income, assets, and verification information. Enter your monthly income amounts from all sources, your bank account information, and the dates of any prior marriages. Read each question carefully before submitting the page.

stage 5 to completing form 211 alabama medicaid

Step 3: When all pages are complete, click the "Done" button. Save the finished document to your device or send it to your email address.

Step 4: Print two copies of your completed application before mailing or hand-delivering it to your local Alabama Medicaid district office.

Frequently Asked Questions

Who qualifies for the Medicare Savings Program in Alabama?

Alabama residents enrolled in Medicare Part A with income at or below 135 percent of the federal poverty level may qualify for one or more MSP categories. Exact thresholds depend on family size and the specific program you are applying for.

What happens after I submit Form 211?

The Alabama Medicaid Agency reviews your application and sends a decision by mail. Processing generally takes 30 to 45 days. If approved, benefits are typically applied back to the month you submitted the form.

Are there other Alabama health forms I may need?

Many applicants also file the Alabama Medicaid Referral form at the same time. If your caseworker requests documentation related to the Form 211P program variant, you can also access the Form 211P on FormsPal.

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