Paad Form – Fill Out and Use This PDF

New Jersey Department of Human Services

Pharmaceutical Assistance to the Aged and Disabled (PAAD),

Lifeline and Special Benefit Programs

Senior Gold Prescription Discount Program (Senior Gold)

P.O. Box 715

Trenton, NJ 08625-0715

www.nj.gov/humanservices

UNIVERSAL APPLICATION FOR

PAAD, SENIOR GOLD AND OTHER SPECIAL BENEFIT PROGRAMS

By filling out the attached application, you may be eligible for benefits provided by the Pharmaceutical Assistance to the Aged and Disabled (PAAD) or the Senior Gold Prescription Discount programs. This application is ONLY for people who are applying for PAAD or Senior Gold benefits for the first time. If you are married, and you and your spouse wish to apply for benefits, each of you must complete a separate application.

PAAD and Senior Gold are state-funded prescription programs that help eligible New Jersey residents with the cost of prescribed medication (including insulin, insulin needles, and needles for injectable medicines used for the treatment of multiple sclerosis).

While you are applying for assistance with your prescription costs by filling out this application, you may be eligible for several other valuable benefits if you are eligible for PAAD. For example, if eligible for PAAD, you may be eligible for benefits through the Lifeline utility assistance and Hearing Aid Assistance to the Aged and Disabled programs.

Once you are on the PAAD program, you may qualify for a property tax freeze, reduced motor vehicle fees, and Communications Lifeline.

Further, by filling out this application, you will be screened for benefits provided by the Universal Service

Fund (USF) and the Low-Income Home Energy Assistance Program (LIHEAP) – two more programs that help pay for utility costs. In addition, you will be screened for “Extra Help with Medicare Prescription Drug Plan Costs” – a program that helps pay Medicare Part D costs; the Specified Low-Income Medicare

Beneficiary (SLMB) or SLMB Qualified Individual programs – two programs that pay Medicare Part B premiums; and the New Jersey Supplemental Nutrition Assistance Program (NJ SNAP) – also known as Food Stamps, this program provides supplemental nutrition assistance to help people who meet certain income criteria buy groceries.

If it appears that you may be eligible for USF, LIHEAP, the “Extra Help,” SLMB/SLMB QI-1, and/or NJ SNAP, PAAD will forward your information to these programs for eligibility consideration.

Turn this page over for a comparison of PAAD and Senior Gold.

For More Information,

Visit www.njpaad.gov or www.njsrgold.gov

Or, Call 1-800-792-9745

AP-2 (Instructions)

JAN 16

2016 COMPARISON OF PAAD AND SENIOR GOLD

1-800-792-9745

	Pharmaceutical Assistance to the Aged and
				Senior Gold Prescription Discount Program
	Disabled Program
					www.njsrgold.gov
	www.njpaad.gov
	PAAD beneficiaries must fill out all pages of this application.		Senior Gold beneficiaries do not qualify for the Lifeline
			Credit/Tenants Lifeline Assistance Program or the Hearing
			Aid Assistance to the Aged and Disabled Program and,
			therefore, do not need to answer questions 24, 25, 26 and
			27 of this application.
	Income limit: less than $26,575 (single)		Income limit: between $26,575 and $36,575 (single)
	less than $32,582 (married)			between $32,582 and $42,582 (married)
	ID Number starts with 6.		ID Number starts with 7.
	PAAD co-pay is:		Senior Gold co-pay for Senior Gold covered drugs is $15 +
	∙ $5 per PAAD covered generic drug		50% of the remaining cost of the prescription or actual drug
	∙ $7 per PAAD covered brand name drug.		cost, whichever is less. (Co-pay will change with change in
			drug price.)
	Catastrophic cap does not apply.		Catastrophic cap:		$2,000 (single)
					$3,000 (married)
			Once the beneficiary‟s annual out of pocket expenses reach
			the catastrophic cap, co-pay is $15 (or the reasonable cost
			of the drug, whichever is less) for the balance of that
			eligibility period.
	If Medicare-eligible, must enroll in a Medicare Part D		If Medicare-eligible, must enroll in a Medicare Part D
	Prescription Drug Plan unless prohibited from doing so.		Prescription Drug Plan unless prohibited from doing so.
	If a Part D plan is the primary payer for a drug covered on its		If a Part D plan is the primary payer for a drug covered on its
	formulary, PAAD will provide coverage as secondary payer if		formulary, Senior Gold will provide coverage as secondary
	needed for that drug, and the PAAD beneficiary will pay the		payer if needed for that drug, and the Senior Gold
	regular PAAD copayment for PAAD covered drugs.		beneficiary will pay the regular Senior Gold copayment for
			Senior Gold covered drugs.
	However, if a Part D plan does not pay for a medication
	because the drug is not on its formulary, PAAD beneficiaries		However, if a Part D plan does not pay for a medication
	will have to switch to a drug on their Part D plan‟s formulary,		because the drug is not on its formulary, Senior Gold
	or their doctor will have to request an exception due to		beneficiaries will have to switch to a drug on their Part D
	medical necessity directly to the Part D plan.		plan‟s formulary, or their doctor will have to request an
			exception due to medical necessity directly to the Part D
			plan.
	Third-party insurance must be billed BEFORE PAAD.		Third-party insurance must be billed BEFORE Senior Gold.
	PAAD DOES NOT pay for diabetic testing supplies (for		Senior Gold DOES NOT pay for diabetic testing supplies (for
	example, test strips and lancets).		example, test strips and lancets).

AP-2 (Instructions)

JAN 16

New Jersey Department of Human Services

Pharmaceutical Assistance to the Aged and Disabled (PAAD),

Lifeline and Special Benefit Programs

Senior Gold Prescription Discount Program (Senior Gold)

This form will be scanned for computerized data capture. Please follow these instructions to ensure that your application is processed quickly and accurately.

∙Use blue or black ink. Do not use red ink or pencil.

∙Print clearly in uppercase block letters (see examples below).

∙Print only one number or letter in each box.

∙Stay inside boxes.

∙Correct errors with white correction fluid.

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

1

2

3

4

5

6

7

8

9

0

If you have questions or need help filling out this form, call toll free 1-800-792-9745.

DO NOT SEND ORIGINAL SUPPORTING DOCUMENTS. SEND COPIES.

ORIGINALS WILL NOT BE RETURNED.

Please see reverse for list of necessary documents.

AP-2 (Instructions)

JAN 16

You must submit proof with this form.

Processing will be delayed if all necessary documents are not sent with this form.

If you are applying for PAAD or Senior Gold supply the following documents:

∙Proof of age (must show date of birth)

∙Proof of current Social Security disability benefits if over age 18 and under age 65

∙Proof of principal place of residence, dated within the last 6 months

∙Copy of your Medicare Card

∙Copy of the front and back of each health and prescription insurance card(s).

PAAD, Lifeline, HAAAD and Senior Gold programs require individuals be aged 65 or older OR over age 18 and under age 65 and receiving Social Security Disability benefits.

	If you are 65 years of age or older…			Send proof of date of birth.
If you are over age 18 and under age 65 AND				Send proof of date of birth AND proof of current disability status.
	you receive Social Security Disability…
Submit a COPY of one of the following to document DATE OF BIRTH:
∙	Birth Certificate	∙	Social Security record that indicates your date of birth
∙	Baptismal Certificate	∙	Railroad Retirement record that indicates your date of birth

If you cannot supply the above document(s), copies of any TWO of the following that indicate DATE OF BIRTH will be acceptable.

∙	Driver’s License	∙	Delayed Birth Certificate	∙	State or Federal Census record	∙	School Record
∙	Foreign Passport	∙	Voting record	∙	Marriage Record	∙	Insurance Policy

If you receive Social Security Disability, ALSO submit a COPY of one of the following to document disability status:

∙Social Security Award Certification (SSA-L30) issued by the Social Security Administration within the last six months

∙Verification through a benefit verification letter which indicates your current Social Security Disability status. You may obtain this letter by calling the Social Security Administration toll-free at 1-800-772-1213 (TTY 1-800-325-0778)

If you are applying for Lifeline Utility Credit/Tenants Lifeline Assistance Program, supply the following documents:

∙Copy of your current gas and electric bill(s) if you are a utility customer, or

∙Copy of your current lease agreement, if your rent includes the cost of electric/gas, and

∙List the monthly amount of rent that you pay on Page 9 of the application.

If you are also applying for assistance from the Universal Service Fund (USF)/Low-Income Home Energy Assistance Program (LIHEAP), supply the above documents plus the following:

∙If your home‟s primary source of heat is not gas/electric, submit a copy of your last bill from your heating supplier (e.g. oil, propane or wood supplier).

Please Note: In certain cases, additional documentation may be required.

AP-2 (Instructions)

JAN 16

New Jersey Department of Human Services

Pharmaceutical Assistance to the Aged and Disabled (PAAD), Lifeline and

Special Benefit Programs/Senior Gold Prescription Discount Program (Senior Gold)

PO Box 637, Trenton, NJ 08646-0637

Toll Free Hotline 1-800-792-9745

PLEASE PRINT YOUR NAME ON THE TOP OF EACH PAGE.

1.Enter your name, date of birth and sex. List your Social Security number. Use CAPITAL LETTERS. Print only one letter or number in each box. List date of birth verified by Social Security.

2.If your spouse is also applying, both of you must complete separate applications. Even if your spouse is not applying, we need all of the questions answered and signatures for both of you, if

married and living together.

Spouse’s

Suffix

Last

(Jr., Sr.,

Name

etc.)

First

Middle

Sex

Name

Initial

Male/Female

Spouse’s

Month

/

Day /

Year

Social

-

-

Date of

Security

Birth

/

/

Number

3. Please identify your current marital status. Please

only one box.

X

*If you are separated from your spouse, call the toll-free number above to request form „Affidavit of Separation‟ which MUST accompany this application.

AP-2
JAN 16	- 1 -	WEB

Name: ___________________________________

SEASONAL OR TEMPORARY RESIDENCE IN NJ OF WHATEVER DURATION, DOES NOT QUALIFY AS YOUR PRINCIPAL PLACE OF RESIDENCE FOR PAAD, LIFELINE, HAAAD AND SENIOR GOLD.

Submit two (2) proofs of residence with this application. Proofs must be current and dated. The date must be clearly visible and within the last 6 months.

If you use a post office box or if you have a mailing address also complete the address below and submit proof

of your actual street address with this application. If using a Power of Attorney or a care of (c/o) address, complete mailing address below and submit proof of applicant‟s actual street address and Power of Attorney or

Guardianship Papers.

Examples of acceptable proofs of residence are:

∙Public utility records and receipts (e.g. bill for heating source, electric bill, telephone bill, etc.)

∙Social Security records (e.g. Third Party Query, Form SSA-2458, etc.)

∙Bills of business or professional people (e.g. doctors, pharmacies, etc.)

∙Post Office Records

5.Enter your Mailing Address (if different from home address).

Street

Address

If YES, you must submit signed copies of each return, including all schedules, with this application.

AP-2
JAN 16	- 2 -	WEB

Name: ___________________________________

Income

7.If you (or your spouse, if married and living together) receive income from any of the sources listed below, please enter the total current YEARLY income in the appropriate boxes. DO NOT LIST CENTS. Do not list Social Security, wages and self-employment, public assistance, medical reimbursements or foster care payments here. If you (or your spouse) do not receive income from any of the sources listed below, place an X in the NONE box.

∙

Railroad Retirement

YOU:

NONE

$

,

SPOUSE

NONE

$

,

(if living together):

∙

Veterans

YOU:

NONE

$

,

SPOUSE

NONE

$

,

(if living together):

∙

Other Pensions

YOU:

NONE

$

,

SPOUSE

NONE

$

,

(if living together):

∙

YOU:

NONE

$

,

Annuities

SPOUSE

NONE

$

,

(if living together):

∙Other income not listed above, including

net rental income, workers compensation,

YOU:

NONE

$

,

alimony (Specify)

Net Rental

Alimony

SPOUSE

NONE

$

,

Worker‟s Comp

(if living together):

Other

8.

Have any amounts included above decreased in the last two years?

YES

NO

9.

Have you (or your spouse) worked in the last 2 years?

YOU:

YES

NO

(if living together):SPOUSE

YES

NO

10.If you or your spouse answered YES, list current YEARLY amounts below:

∙ What do you expect to earn in wages

YOU:

NONE

$

,

before taxes THIS YEAR?

SPOUSE

NONE

$

,

(if living together):

∙ If self-employed, what do you expect your

YOU:

NONE

$

,

net earnings or loss to be THIS YEAR?

SPOUSE

NONE

$

,

(if living together):

∙ If you (or your spouse) expect a net loss, put an X here:

YOU:

SPOUSE:

AP-2
JAN 16	- 3 -	WEB

Name: ___________________________________

12.If you (or your spouse) recently stopped working or plan to stop working, enter the month and year.

∙If you are 65 or older, skip question 13.

∙If you are married and living with your spouse and both you and your spouse are 65 or older, skip question 13.

13.Do you (or your spouse, if married and living together) have to pay for things that enable you to work? We will count only a part of your earnings toward the Medicare Part D income limit if you work and receive Social Security benefits based on a disability or blindness and you have work-related expenses for which you are not reimbursed. Examples of such expenses are: the cost of medical treatment and drugs for AIDS, cancer, depression, or epilepsy; a wheelchair; personal attendant services; vehicle modifications, driver assistance or other special work-related transportation needs; work-related assistive technology; guide dog expenses; sensory and visual aids; and Braille translations.

14.If you (or your spouse, if married and living together) receive income from any of the sources listed below, please enter the total current YEARLY income in the appropriate boxes. DO NOT LIST CENTS. If you or

∙ Social Security Benefits (Net)

YOU:

NONE

$

,

SPOUSE

NONE

$

,

(if living together):

∙ Medicare Part B Premium

YOU:

NONE

$

,

(if deducted from Social Security check)

SPOUSE

NONE

$

,

(if living together):

∙ Medicare Part D Premium

YOU:

NONE

$

,

(if deducted from Social Security check)

SPOUSE

NONE

$

,

(if living together):

∙ Interest (Including tax-exempt)

YOU:

NONE

$

,

SPOUSE

NONE

$

,

(if living together):

∙

Dividends

YOU:

NONE

$

,

SPOUSE

NONE

$

,

(if living together):

∙

IRA Distributions

YOU:

NONE

$

,

SPOUSE

NONE

$

,

(if living together):

AP-2

JAN 16

- 4 -

WEB

Name: ___________________________________

Low Income Subsidy and SLMB ASSET

IMPORTANT NOTICE:

The asset information WILL NOT be used as a requirement by the State of New Jersey for the PAAD, Lifeline, HAAAD or Senior Gold Programs. The asset information is required to determine eligibility for extra Medicare benefits and will only be used for that purpose.

15.If you are single, a widow(er) or your spouse does not live with you, are your savings, investments and real estate (other than your home) worth more than $13,440? If you are married and living together, are they worth more than $26,860? Include the things you own by yourself, with your spouse or with someone else. DO NOT include the value of your home, vehicles, burial plots or personal possessions in this amount.

If you put an X in the YES box, you are not eligible for the extra help,

skip questions 16 through 21 and continue at question 22.

16.Enter the money amounts of bank accounts, investments or cash that either you, your spouse (if married and living together) or both of you own in the boxes below. Include items that either of you own with another person. If you or your spouse (if married and living together) do not own an item listed, either separately, jointly or with another person, place an X in the NONE box.

∙ Bank accounts (checking, savings, and certificates of	NONE		$						,
deposit)
∙ Stocks, bonds, savings bonds, mutual funds, Individual	NONE		$						,
Retirement Accounts or other similar investments
∙ Any other cash at home or anywhere else	NONE
			$						,
17.

Owner’s Name

Year/Make

Amount Owed

Current Value

$ ,

AP-2
JAN 16	- 5 -	WEB

Name: ___________________________________

18.Do you expect to use money from any sources listed in question 16 to pay for funeral or burial expenses for yourself (or your spouse, if married and living together)?

19.Other than your home and the property on which it is located, do you (or your spouse, if married and living together) own any real estate?

20.Your living situation may affect the amount of help you can get for Medicare Part D. Therefore, we need to know how many relatives who live with you (and your spouse, if married and living together) depend on you or your spouse to provide at least one-half of their financial support. Relatives may include anyone related to you by blood, marriage or adoption.

How many relatives who live with you and your spouse depend on you or your spouse to provide at least one-half of their financial support? Do not include yourself or your spouse in this number.

NONE			1	2		3		4		5		6			7	8		9 or more

21.

Do you (or your spouse, if living together) own any valuable personal property such as jewelry, coin/stamp collections, furs, etc? (Do NOT include wedding or engagement rings.)

Social Security’s Privacy Act

Section 1860 D-14 of the Social Security Act authorized the collection of information requested on this form. The information you provide will be used to enable the Social Security Administration to determine if you are eligible for help paying your share of the cost of a Medicare Prescription Drug Plan. You do not have to give us the information requested. However, if you do not provide the information, we will be unable to make an accurate and timely decision on your application. We may provide information collected on this form to another Federal, State, or local government agency to assist us in determining your eligibility for the extra help or if a Federal law requires the release of information.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

AP-2
JAN 16	- 6 -	WEB

Name: ___________________________________

22.Medicare Information

List your (and your spouse‟s, if married) Medicare Claim Number(s) and suffix or Railroad Retirement

Number(s) and prefix exactly as it is shown on your Medicare card(s), if applicable. Indicate your (and your spouse‟s, if married) Medicare coverage and effective date(s). You must submit a copy of your (and your spouse‟s, if married) Medicare card(s).

YOU:
If NO Medicare coverage put an X here ►
Medicare Claim Number		SUFFIX	PREFIX	Railroad Retirement Medicare Claim Number
-	-	-	OR
Medicare Coverage:			Month	Day	Year
Part A (Hospital):	YES	NO	effective date	/	/
Part B (Medical):	YES	NO	effective date	/	/
Part D (Prescription):	YES	NO	effective date	/	/

If you are enrolled in a Medicare Prescription Drug Plan, identify your Prescription Drug Plan (PDP).

PDP Name:

SPOUSE (if married):