Medicaid QMB Application - Help with Medicare Copays/Deductibles 

Goto the following link to view financial eligibility requirements.
http://jfs.ohio.gov/ohp/consumers/MPAPIncomeGuidelines.pdf

Click on the link below to start to complete an online application:

http://www.odjfs.state.oh.us/forms/file.asp?id=43097

This is an “Application for Help with Medicare Expenses”. When you complete this application and return it to your county department of job and family services (CDJFS), your eligibility for several kinds of Medicaid will be explored. Your situation will be reviewed to see if you qualify for one of the following:

Qualified Medicare Beneficiary (QMB)

The QMB program acts like a free Medicare supplement policy. QMB pays:
     • All deductibles and coinsurance that Medicare does not pay
     • Medicare Part B premium ($109.40/month in calendar year 2008)

Specified Low Income Medicare Beneficiary (SLMB)

The SLMB program has higher limits than QMB. Once you qualify, SLMB pays:
    • Medicare Part B premium ($109.40/month in calendar year 2008)
    • Retroactive Part B premium amounts for each of the past three months

Qualified Individuals-1 Medicaid (called QI-1) 

This program provides the same benefits as SLMB;however, the income standards are higher than those allowed for SLMB.

Qualified Individuals-2 Medicaid (called QI-2) 

This program reimburses you for the part of the Part B premium that you have already paid which went toward home health care. You will receive areimbursement check once a year. The income limits are higher than in QI-1 Medicaid.

Qualified Working Disabled Individual (called QWDI)

This program pays for your Medicare Part A premium only. QWDI can help you if you have lost eligibility for Title II disability benefits due to earnings.

The date of application is the date when the original signed and dated application is received by the CDHS. You may mail or fax your application to the CDJFS,  but if you fax it, you must still mail in the original application with your signature on it. The CDJFS must have the original application before approving benefits. You are NOT required to have an in-person interview when you apply for any of the above kinds of help. You will be contacted about what verification(s) you must supply when this application is received and reviewed by a caseworker.

Do not send original documents in the mail. The CDJFS can assist you if you are having problems getting the needed information.