Instructions:

Step 1: Print the MEDICARE SAVINGS PROGRAM APPLICATION 

Step 2: Complete the Application

Be sure to answer all the questions. If you are married and living with your spouse, you must complete both the "Self" & "Spouse" questions on the application (even if the spouse is not applying for the MSP). 

Step 3: Read all the information on page #2 

Step 4: Sign and Date the Application 

If both spouses are applying, both must sign the MSP application.

Step 5: Gather and include the following verification documents (or equivalents) with your application:

• A photocopy of the front and back of your Medicare card (red, white and blue card). 
• Proof of Date of Birth, such as State Driver’s license, U.S. Birth Certificate, U.S. passport, Permanent Resident Card (“Green Card”), or NYS Benefit Identification Card.
• Proof of Residence, such as lease/ letter/ rent receipt with your home address from landlord, utility bill (gas, electric, phone, cable, fuel or water), property tax records or mortgage statement, or a postmarked envelope (cannot use if sent to a P.O. Box). These documents must be dated within 6 months of when you signed the application.
• Proof of income, such as paycheck stubs (4 weeks), a letter from employer, pension information indicating amount and frequency of payment, income tax return, award letter for any unearned income benefit such as Social Security, unemployment, or veteran’s benefit, or letter from renter, boarder or tenant.
• Proof of any other health insurance premium that you pay other than Medicare, such as a letter from employer, premium statement or pay stub.
• If you are not a U. S. citizen, you must provide documents indicating your current immigration status such as I-551 Permanent Resident Card (“Green Card”), I-766 Employment Authorization Card.

If there is an applying spouse, the spouse must also provide the documentation mentioned above.

Step 6: Before mailing your application, be sure you answer all the questions, sign and date it, and include your documentation. Make a copy of your completed application for your records.

Step 7: Mail the application and required documentation to your Local Department of Social Services (LDSS) 

Clinton County DSS, 13 Durkee Street, Plattsburgh, New York 12901, (518) 565-3300

Step 8: The LDSS will send you a Notice of Action within 45 days of filing an application. This notice will tell you if you will get the MSP benefit.

You will need to renew (recertify) your MSP every year.

If you need further help contact Clinton County HIICAP (Health Insurance Information Counseling & Assistance Program)

Office for the Aging: (518)565-4620 & JCEO: (518)561-6310