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.
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.
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.
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.
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.
| Question | Answer |
|---|---|
| Form Name | Alabama Form 211 |
| Form Length | 8 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min |
| Other names | form 211 medicare, form 211 for medicare savings program, medicaid form 211, al medicaid form 211 |
