If you have limited income you may be able to get help to pay your Medicare costs

Medicare Savings Program Application – DOH–4328 (PDF) 
How to complete the MEDICARE SAVINGS PROGRAM APPLICATION

Qualified Individual (QI):

Gross Monthly Income Limits: 186% FPL + 20%

$2,280 - single person

$3,077 - married & living together

• Pay Medicare Part B premium
• Must have Medicare part A in order to be eligible for QI
• QI's - 3 month retroactive not in to previous calendar year

Qualified Medicare Beneficiary (QMB):

Gross Monthly Income Limits: 138% FPL +$20

$1,697 - single person 

$2,288 - married & living together 
 

• Pays the Medicare Part A and Part B premiums
• Pays the Medicare Part A and Part B Deductibles, Co insurances & Co-payments
  • Providers cannot charge copays for Medicare-covered services
• QMB’s - has no retroactivity - effective 1st of following month

Medicaid

Dual Eligible (Medicare & Medicaid)
Gross Monthly Income 138% FPL & Asset Limits:

$1,697 & $30,182 asset - single person
 
$2,288 & $40,821 asset—married & living together

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• Covers Medicare cost-sharing and other services and supplies not covered by Medicare
• You may be eligible to pay a Medicaid Spend-down to access Medicaid benefits
• You may be eligible for a Medicaid Spend Down if you are above income guidelines 

• Are you still working?  
  you might still qualify for MSP benefits - Work Income is counted at less than half. 
   
• Are you paying a health insurance premium?  
  Subtract premiums to help qualify—Medigap, Medicare Advantage, Dental, Vision and more. 
   
• Do you need help paying prescription drug (Part D) costs?  
  You automatically qualify for the Extra Help program if you have Medicaid or MSP. 
   

This snap shot provides general information only 
These amounts may increase each year. If your income is slightly higher, you should still apply. 
The standard $20 Monthly income disregard has been included in the MSP guidelines. Effective 4/17/2021 

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For questions and application assistance -

Call Clinton County HIICAP 
Health Insurance  Information Counseling & Assistance Program 
OFA: (518)565-4620 & JCEO: (518)561-6310

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This product was funded in part by The Administration for Community Living