016.20.00 Ark. Code R. 021

Current through Register Vol. 49, No. 9, September, 2024

Rule 016.20.00-021 - Medicare Beneficiaries Application (DCO-808)

Medicare Savings Benefits for Qualified Beneficiaries

Arkansas Medicaid offers Medicare beneficiaries four categories of supplemental benefits: QMB, SMB, QM, and QI-2. The-chart below describes benefits and eligibility requirements. These categories do not provide fiiQ Medicaid-coverage. If you are already receiving regular Medicaid, you already receive these benefits,______________

QMB	SMB	QI-1	'"ia-2
Benefits	* Pays monthly	* Pays monthly	* Pays monthly	« Pays a portion of the
Medicare premium(s)	Medicare part B	Medicare part B	monthly Medicare
Pays Medicare	premium only	premium only	part B premium only
deductibles	* Recipient does not	* Recipient cannot be	($2.87 per month for
* Pays Medicare co-	receive a Medicaid	certified in another	2000)
insurance payments	card	Medicaid category at	* Payments will be
* Pays co-payments for	* Recipient CAN be	the same time	issued once a year to
Medicare managed	certified in another	* Recipient does not	the recipient
care (HMO's)	Medicaid category at	receive a Medicaid	* Recipient cannot be
* Recipient receives QMB card	the same time.	card	certified in another Medicaid category at the same time * Recipient does not receive a Medicaid card
Monthly Gross	Individual $715.83	Greater than $715.83,	At least S855.00,	At least $959.37,
Income	but less than $855.00	but less than $959.37	but less than $1227.70
Eligibility	Couple $957.50	Greater than $957.50,	At least $1145.00,	At least 1285.63,
Requirement*	but less than $1145.00	but less than $1285.63	but less than $1660,63
Asset Eligibility	Individual $4,000 Your home and one (1) vehicle		are disregarded as an asset
Requirement	Couple $6,000 We also exclude some burial funds as an asset

Current Income Limits for 4/1/2000-3/31/2001

How do I apply?

1) Fill out the attached form.

2) Sign and date the last page of the application. If you and your spouse are applying, you both must sign.

3) Mail or take the form and copies of your Medicare card and any other insurance cards to your local Department of Human Services (DHS) office.

You will not be required to visit the county office. If there are any questions about your application, a caseworker may contact you. You will be placed in the Medicare savings benefit package with the most coverage based on your eligibility. You will receive a notice in the mail within 45 days telling you if you qualify for Medicare savings benefits and when your eligibility will begin.

If you are approved for QMB, SMB, or QI-1, Medicaid will pay your monthly Medicare premium. This is called the Buy-In. The Buy-In should occur within 90 to 120 days from the time you receive your approval notice. You will receive a reimbursement check for the premiums you paid from your first month of eligibility to the time Buy-In begins. If you do not see an increase in your Social Security or Railroad Retirement benefits within 120 days after your application has been approved, contact your local DHS office.

NOTE: This is not an application for full Medicaid coverage, cash assistance, or food stamps. If you want to apply for these programs, contact your county Department of Human Services.

Click here to view image

Please detach the application and mail or return it to the DHS County Office where you reside.

County	Address	P.O. Box	Citv, State, ZiD Code	Phone Number
Arkansas	100 Court Square	Dewitt,AR 72042	870-946-4519
Arkansas	203 S. Leslie	P.O. Box 270	Stuttgart, AR 72160	870-673-3597
Ashley	201 W.Lincoin	P.O. Box 190	Hamburg, AR 71646 ..	870-853-9816
Barter	204 Bucher Drive	P.O. Box 408	Mountain Home, AR 72654	870-425-6011
Benton	900 SE 13* Court	Bentonville, AR 72712	501-273-9011
Boone	2126 Capps Road.	P.O. Box 1096	Harrison, AR 72602-9970	870-741-6107
Bradley	902 Halligan Street	P.O. Box 509	Warren, AR 71671	870-226-5878
Calhoun	136 Archer	P.O.Box 1068	Hampton, AR 71744-1068	870-798-4201
Carroll	304 Hailey Road	P.O. Box 425	Berryville, AR 72616	870-423-3351
Chicot	1736 Hwy. 65 South & 82 West	P.O. Box 71	Lake Village, AR 71653	870-265-3821
Clark	602 S. 10* Street.	P.O. Box 968	Arkadelphia, AR 71923	870-246-9886
Clay	187 N. 2^nd Street	P.O. Box 366	Piggott,AR 72454	870-598-2282
Clay	1007 Ada Street	Corning, AR 72422	870-857-6544
Cleburne	1521 W. Main Street	P.O. Box 1140	Heber Springs, AR 72543.	501-362-3298
Cleveland	5^th and Main Street	P.O. Box 465	Rison,AR 71665	870-325-6218
Columbia	601 E. University	P.O. Box 1109	Magnolia, AR 71754	870-234-4190
Conway	#2 Bruce Street	P.O. Box 228	MorriIton,AR72U0	501-354=2418
Craighead	2920 McCIellan Drive	Jbnesboro, AR 72401	870-972-1732
Crawford	704 Cloverleaf Circle	Van Buren, AR 72956	501-474-7595
Crittenden	250 Shoppingway	West Memphis, AR 72301	870-732-5170
Cross	803 E. Hwy. 64	P.O. Box 572	Wynne, AR 723 96	870-238-8553
Dallas	1202 W. 3^rf Street	Fordyce, AR 71742	870-352-5115
Desha	200 N. First Street	P.O. Box 1009	McGehee, AR 71654	870-222-4144
Drew	444 Hwy. 425 N.	P.O. Box 1350	Monticello, AR 71657	870-367-6835
Faulkner	1000 E. Siebenmorgan Road	P.O. Box 310	Conway, AR 72033-0310	501-730-9900
Franklin	800 W. Commercial	Ozark, AR 72949	501-667-2379
Fulton	201 Byron Road	P.O. Box 650	Salem, AR 72576	870-895-3309
Garland	115 Market Street	Hot Springs, AR 71901	501-321-2583
Grant	#16 Opportunity Drive	P.O. Box 158	Sheridan, AR 72150	870-942-5151 .,
Greene	809 Goldsmith Road.	P.O. Box 839	Paragould,AR 72451	870-236-8723
Hempstead	116 N.Laurel	Hope, AR 71802-0723	870-777-8656
Hot Spring	2505 Pine Bluff Street	P.O. Box 813	Malvern, AR 72104	501-332-2718
Howard	534 N. Main	P.O. Box 1740	Nashville, AR 71852	870-845-4334
Independence	1750 Myers Street.	Batesville, AR 72501	870-698-1876
Independence	Hwy. 25 North	P.O.Box 2517	Batesvilie, AR 72501	870-793-6876
Izard	620 E. Main Street	P.O. Box 65	Melbourne, AR 72556	870-368-4318
Jackson	3^rd & Hazel Street	P.O. Box 658	Newport, AR72U2	870-523-9828
Jefferson	1222 W. 6^th & Mulberry	P.O. Box 5670	Pine Bluff; AR 71611	870-534-4200
Johnson	900 S. Rogers Street	P.O. Box 1636	Ciarksville, AR 72830	501-754-2355
Lafayette	Hwy 29 North	P.O. Box 970	Lewisville, AR 71845	870-921-4283
Lawrence	400 N.W. 4^th Street	P.O. Box 69	Walnut Ridge, AR 72476	870-886-2408
Lee	772 W. Chestnut Street	P.O. Box 248	Marianna, AR 72360	870-295-2597
Lincoln	101 W.Wiley Street	Star City, AR 71667	870-628-4105-
Little River	90 Waddell Street	Ashdown,AR7l822	870-898-5155 '
Logan	#17 W. McKeen	Paris, AR 72855	501-963-2783
Logan	398 East 2^nd Street	Booneville, AR 72927	501-675-3091
Lonoke	100 Park Street	P.O. Box 260	Lonoke, AR 72086	501-676-3113

Madison	1.013 N. College Avenue	P.O. Box 128	Huntsville,AR 72740	501-738-2161
Marioa	36 Main Street	P.O. Box 447	Yellville,AR 72687	870-449-4058
Miller	3809 Airport Plaza	Texarfcana,AR 71854	* * 870-773-0563
Mississippi	1104 Byrum Road	Blytheville,AR72315	870-763-7093
Mississippi	437 S. Country Club Road	-	Osceola, AR 72370	870-563-5234
Monroe	Hwy. 302 North	P.O. Box 354	Clrendon, AR 72029	870747-3329
Monroe	301/2 N. New Orleans	Brinkley, AR 72021	870-747-3329
Montgomery	205 Hwy. 27 South	P.O. Box 445	Mount Ida, AR 71957	870-867-3184
Nevada	355 W. 1* Street	P.O. Box 292	Prescott,AR 71857	870-887-6626
Newton	Co-op Building	P.O. Box 452	Jasper, AR 72641	870-446-2237
Ouachita	222 Van Buren Street	P.O. Box 718	Camden, AR 71711	870-836-8166
Perry	403 Houston Avenue	Perryville,AR 72126	501-889-5105
Phillips	104 D'Auna Place	P.O. Box 277	Helena, AR 72342	870-338-8391
Pike	' 331 £.13* Street	P.O. Box 200	Murfreesboro, AR 71958	870-285-3111
Poinsett	406 South Illinois	P.O. Box 526	Harrisburg, AR 72432	870-578-5491
Polk	606 Pine Street	Mena,AR 71953	501-394-3100
Pope	701 N. Denver	RussellvilIe,AR 72801	501-968-5596
Prairie	#4 Market Street	P.O. Box 356.	DeVallsBhuXAR 72041 ,	870-998-2581
*Pulaski East	1424 E. 2^nd Street	P.O. Box 8083	Little Rock, AR 72203-9512	501-371-1300
*PuIaski	2636 W. Main	P.O. Box 626	Jacksonville, AR 72078	501-371-1200
Jacksonville
*Pulaski North	1900 E. Washington Avenue	P.O. Box 5791	NLR, AR 72119-9985	501-682-0100
*Pulaski South	1105 Martin Luther King Drive	P.O. Box 2620	Little Rock, AR 72202	501-682-9200
*Pulaski	6801 Baseline Road	P.O. Box 8916	Little Rock, AR	501-371-1100
Southwest	72219-8916
Randolph	1408 Pace Road	Pocahontas, AR 72455	870-892-4475
Saline	1603 Edison	Benton, AR 72015	501-315-1600
Scott	S. Hwy., 71B	P.O. Box 840	Waldron,AR 72958	501-637-4141
Searcy	"350 School	Marshall, AR 72650	870-448-3153
Sebastian	616 Garrison Avenue, Roo	m231	Fort Smith, AR 72901	501-782-4555
Sevier	W. Collin/Raye Drive TNI	»B	DeQueen,AR 71832	870-642-2623
Sharp	Hwy. 167 N.	P.O. Box 159	Ash Flat, AR 72513	870-994-7358
St Francis	1200 E. Broadway	P.O. Box 899	Forrest City, AR 72335	870-633-1242
Stone	RC. 71, Box 180	Mountain View, AR 72560	870-269-4321
Union	123 W. 18* Street	El Dorado, AR 71730	870-862-6631
Van Bar en	Rt.6, Box 260-1	Clinton, AR 72031	501-745-4192
Washington	4044 Frontage Road	Fayetteville, AR 72703	501-521-1270
White	608 Rodgers Drive	Searcy, AR 72143	501-268-8696
Woodruff	1200 Hwy. 33 North	P.O. Box 493	Augusta, AR 72006	870-347-2537
Yell	818MStreet/Hwy. 10 E.	P.O. Box 277	Danville, AR 72833	501-495-2723

*If you live in Pulaski County please check the zip code listing below to ensure mat you mail or return vour application to the appropriate Pulaski County DHS Office.

Pulaski East: Parts of 72016, 72053, Parts of 72126, 72135, 72201,72202,72203,72205,72207,72212 72223 72227

Pulaski North: 72046- England-Pulaski County, 72113, 72114, 72115,72117, 72118,72119,72142-Scott-PuIaski Countv

72190, 7223L... '*

Pulaski Jacksonville: 72023-Cabot-PuIaski County; 72076,72078,72099, 72116,72120,72124

Pulaski South: 72204, Parts of 72206

Pulaski Southwest: Parts of 72002,72065, Parts of 72103, Parts of 72206,72208,72209,72210,72211,72164,72180,72183

If you are not sure if a particular Pulaski County Office services your zip code please call one of the Pulaski County Offices.*

016.20.00 Ark. Code R. 021

8/31/2000