⇨

Blank Alabama 211 PDF Form

The Alabama 211 form is an application used to enroll in Medicare Savings Programs, which help cover Medicare premiums and deductibles. It is important to note that this form is not for full Medicaid benefits and has specific requirements, including the submission of verification documents. To ensure you receive the benefits you may qualify for, consider filling out the form by clicking the button below.

Article Guide

The Alabama 211 form is a crucial document for individuals seeking assistance through Medicare Savings Programs, specifically designed to help cover Medicare premiums and deductibles. It is important to note that this form does not serve as an application for full Medicaid benefits. Instead, it focuses on providing financial relief for those who qualify under specific criteria. To successfully complete the application, applicants must carefully follow the provided instructions, ensuring that all questions are answered accurately and completely. Key requirements include submitting a copy of the Medicare card to verify Part A coverage, a copy of the Social Security card, and documentation of monthly income before taxes. Once the application is filled out, it should be mailed to the appropriate District Office based on the applicant's county of residence. The form also emphasizes the importance of honesty, as any false statements or omissions can lead to severe penalties, including denial of the application. By adhering to the guidelines and providing the necessary information, applicants can navigate the process more effectively and gain access to essential financial support for their Medicare expenses.

Document Preview

Alabama Medicaid Agency

Application for Medicare Savings Programs

This is NOT an application for full Medicaid.

These programs cover Medicare premiums and deductibles. Medicaid’s drug coverage is limited to the drugs covered under Medicare Part D only. Medicaid will not pay for any excluded drugs under Medicare Part D.

Instructions: Read this application carefully and follow all instructions given throughout the form. Answer each question completely and accurately.

1.Send a copy of your Medicare card to verify your Part A coverage.

2.Send a copy of your Social Security card.

3.Send veriﬁ cation of the gross (before taxes) amount of your monthly income.

4.Sign the application.

5.Mail the application to the District Ofﬁ ce serving your county.

(See attachment for the address of the District Ofﬁces.)

Form 211 (Revised 5/2014)	Alabama Medicaid Agency
	www.medicaid.alabama.gov

Notice to Applicants and Sponsors

Federal and state laws provide both criminal and civil penalties for false statements or material omissions in an application for Medicaid beneﬁ ts or payments. Also, any application found to contain material misstatements or omissions will be denied.

The following statutes are excerpts from the Code of Alabama pertaining to the Medicaid program:

S22-1-11. Making false statement or representation of material fact in claim or application for payments on medical beneﬁ ts from Medicaid agency generally; kickbacks, bribes, etc.; exceptions; multiple offenses.

(a)Any person who, with intent to defraud or deceive, makes, or causes to be made or assists in the preparation of any false statement representation or omission of a material fact in any claim or application for any payment, regardless of amount, from the Medicaid agency, knowing the same to be false; or with intent to defraud or deceive, makes, or causes to be made, or assists in the preparation of any false statement, representation or omission of a material fact in any claim or application for medical beneﬁts from the Medicaid agency, knowing the same to be false; shall be guilty of a felony and upon conviction there of shall be ﬁ ned not more than $10,000.00 or imprisoned for not less than one nor more than ﬁve years, or both.

* * *

(e)Any two or more offenses in violation of this section may be charged in the same indictment in separate counts for each offense and such offense shall be tried together, with separate sentences being imposed for each offense of which defendant is found guilty. (Acts 1980, No. 80-539, p. 837, Sections 1-5.)

S22-6-8, Revocation of eligibility of recipient upon determination of abuse, fraud, or misuse of beneﬁts; when eligibility may be restored.

(a)Upon determination by a utilization review committee of the designated state Medicaid agency that a Medicaid recipient has abused, defrauded, or misused the beneﬁ ts of the program said recipient shall immediately become ineligible for Medicaid beneﬁts.

(b)Medicaid recipients whose eligibility has been revoked due to abuse, fraud or other deliberate misuse of the program shall not be deemed eligible for future Medicaid services for a period of not less than one year and until full restitution has been made to the designated state Medicaid agency.

(c)The provisions of this section shall not be effective if they are found by a court of competent jurisdiction to contravene federal laws or federal regulations applicable to the Medicaid program.

(Acts 1980, No. 80-127, p.190.)

Medicaid Eligibility Policies and Procedures are in compliance with Civil Rights Act of 1964,

Section 504 of the Rehabilitation Act of 1973, Federal Age Discrimination Act of 1975

and the Americans with Disabilities Act of 1990.

Form 211

Application for Medicare Savings Programs

5-2014

Please print clearly using dark ink.

APPLICANT

Name___________________________________________________________________________________

First

Middle/Maiden

Last

Sufﬁx

Mailing Address __________________________________________________________________________

Street or 911 Address

________________________________________________________________________________________

City

State

Zip Code

Phone # (_______)_________________

Other Phone (_______)_________________ Whose? _________________________

email ___________________________________________

Fax ________________________________

Current Resident Address __________________________________________________________________

(If different from Mailing Address)

________________________________________________________________________________________

City

State

Zip Code

County of Residence ______________________________ Date of Birth ____________________________

Social Security # _______________________________

Medicaid # ______________________________

MARITAL STATUS

Marriage Information

I am Married _________________ (Date Married)





If married, does your spouse have Medicare?  Yes

 No

 I am Single (Never Married)





I am Divorced ________________ (Date Divorced)

 I am Widowed _______ (Date Widowed)





I am Separated _______________ (Date Separated)

MEDICARE

Do you have Medicare Part A (Hospital) Coverage?

 Yes  No

Name on Medicare card _______________________________________________________________

Medicare # ________________________________________________________

RACE

 White

 Black

 American Indian

 Hispanic  Asian 

 Other_________

SEX

 Female

 Male

District Ofﬁ ce Use Only

Date Received ____________

Date Accepted ____________

Medicare Card Received  Yes  No

Income Veriﬁcation Received

 Yes

 No

Form 211 (Revised 5/2014)

Alabama Medicaid Agency

Applicant’s Name __________________________________________ SS # ________________________________

FAMILY SIZE	List names of anyone living in your home
Name	Age	Relationship

_______________________________________________	_______	________________________________________________
_______________________________________________	_______	________________________________________________
_______________________________________________	_______	________________________________________________

SPONSOR (If the applicant is unable to complete the application or provide additional information, the Medicaid sponsor should be the person most familiar with the ﬁ nancial situation of the applicant.) Please complete the Appointment of Representative form on Page 6 of this application.

		Relationship to Applicant ______________________________
		Name ______________________________________________				Home Phone ________________________
		Address ____________________________________________				Work Phone ________________________
	___________________________________________________
	___________________________________________________					Cell Phone _________________________
		City	State		Zip
		email ______________________________________________				FAX ____________________________

8		SPOUSE INFORMATION		(Complete even if divorced, separated or widowed.)
		Name ______________________________________________				Phone # (_______)___________________
		(First, Middle, Last)
		Address ____________________________________________				Date of Birth _______________________
		(Street or Box Number)
	__________________________________________________					SS # ______________________________
		City	State	Zip	County
		email _________________________________________ Spouse’s Medicaid # _______________________

9		FORMER SPOUSE INFORMATION			(Must be completed if you are widowed or divorced.)
		(For all previous marriages, list most recent ﬁrst.)
	1. Former Spouse’s Name ________________________________________						SS # _____________________
		Marriage Began _________________ Ended ______________				Reason  Death  Divorce  Other
			Date		Date
	2. Former Spouse’s Name _______________________________________						SS # ______________________
		Marriage Began _________________ Ended ______________				Reason  Death  Divorce  Other
			Date		Date

Page 2

Applicant’s Name ___________________________________________ SS # ________________________________

10	VETERAN’S STATUS
	Are you a Veteran?  Yes  No
	Are you a dependent of a Veteran?  Yes	 No
	If yes to either of the questions above, complete the following:
	Veteran Name ____________________________________________________________________________
	First			Middle					Last
	Veteran Claim Number __________________________ Relationship to Veteran _______________________
	Have you applied for Veteran’s beneﬁ ts under the new Veterans & Survivor’s Improvement Act?  Yes No
	If no, you must apply and send veriﬁcation.

11	RESIDENCY INFORMATION
	Are you a United States Citizen?  Yes  No			Are you a lawfully admitted alien?  Yes  No
	Are you a United States Citizen?  Yes  No			Are you a lawfully admitted alien?  Yes  No
	Where were you born?______________________________________________________________________
	City		County						State	Country
	Do you live in Alabama and plan to stay?		 Yes					 No
	What language do you usually speak?		 English  Spanish  Other___________________
	Do you or a family member speak English?		 Yes					 No
	Have you ever applied for or received SSI?		 Yes					 No
	If yes, were you terminated from SSI?	When? _____________________________
						Month/Year

12	OTHER INSURANCE
								No

				
	Do you have medical insurance other than Medicare?				Yes				If yes, provide information below:
	1. Name/Address of Health Insurance Company					2. Name/Address of Health Insurance Company
	____________________________________________					_________________________________________
	____________________________________________					_________________________________________
	____________________________________________					_________________________________________
	Policy # ________________________________					Policy # ________________________________
	Group # ________________________________					Group # ________________________________
	3. Name/Address of Health Insurance Company					4. Name/Address of Health Insurance Company
	____________________________________________					_________________________________________
	____________________________________________					_________________________________________
	____________________________________________					_________________________________________
	Policy # ________________________________					Policy # ________________________________
	Group # ________________________________					Group # ________________________________

(You may list other policies on a separate sheet(s) and attach to this application, if needed.)

Page 3

Applicant’s Name _______________________________________					SS # ________________________________

13	GROSS INCOME:	(This means “money coming in” before anything is taken out). Answer the following.
	Do you or your spouse have “money coming in” from any of the sources listed below?					 Yes  No
	If yes, ﬁ ll in the claim number and gross amount. (A copy of most recent check stub or other veriﬁ cation must be
	provided.)
	NOTE: If you are applying on behalf of a married individual, the spouse must also answer these questions.

							How Often
				Applicant	Spouse	Minor Child	Received?
	Type of Income			Gross	Gross	Gross	(Quarterly,
			Claim Number	Amount	Amount	Amount	Annually, etc.)

1.	Social Security
	(include Medicare Premiums)
2.	SSI (Gold Check)

3.	Public Assistance (Welfare)

4.	Railroad Retirement

5.	Veterans Beneﬁts, Pensions,
	Compensation or Insurance

6.	Federal Civil Service Annuity

7.	State Retirement/Pension

8.	Private Pension

9.	Miner’s Beneﬁts

10.	Black Lung Beneﬁts

11.	Cash Contributions (from
	relatives, friends, others)
12.	Rental (land, buildings, or
	from roomer)

13.	Personal loans (relatives,
	friends, others)

14. Unemployment Compensation

15.	Insurance Annuity or Proceeds

16.	Government Payments on land
17.	Coal, Oil, Gravel Rights and
	Timber Leases

18.	Royalties

19.	Court Ordered Support

20.	N/A

21.	Other: Specify ____________

22.	Other: Specify ____________

23.	Legal Settlements

24.	Sheltered Workshop Earnings

25. Wages/Salary

26.	Self Employment

							Page 4

Applicant’s Name ___________________________________________ SS #________________________________

RELEASE OF INFORMATION

*I hereby authorize and give my consent for the Alabama Medicaid Agency to obtain information from any source for the purpose of determining my eligibility for Medicaid beneﬁ ts. I authorize this release form to be in effect for as long as I am on Medicaid regardless of the date that it is signed. I further authorize copies of this document to be used in place of the original. I give my consent for the release of information for those purposes directly related to the administration of the Medicaid program. These purposes include, but are not limited to, establishing eligibility for beneﬁ ts, determination of the amount of medical assistance received, the provision of services, and investigation of program violations.

AFFIRMATION AND AGREEMENT

*I give permission to the Alabama Medicaid Agency to use my Social Security number to get information about my resources and income from banks, ﬁ nancial institutions, employers, and other county, state and federal agencies, and/or to see if I qualify for assistance or to see if I have insurance.

*If I am approved for Medicaid, I assign all insurance and medical support beneﬁ ts to Medicaid. If Medicaid pays my bills, then my insurance or other beneﬁ ts (such as lawsuit settlements) must be used to pay Medicaid back. I agree to help and cooperate with Medicaid in identifying and collecting this money, or I may lose my Medicaid beneﬁ ts. I give permission for my insurance company, employer, and others to give needed information to Medicaid in order to administer the Medicaid program.

*I understand that if this application or other information shows that I may be eligible for payments or beneﬁts from other sources, I am required to apply for them.

*I understand that my case is subject to review by State and Federal Quality Control and that I must cooperate in completing the application process or in any subsequent reviews of my eligibility, including reviews resulting from reported changes, recertiﬁ cation, or as a part of a State or Federal Quality Control Review.

*I understand that resources that have been sold, transferred, disposed of, or given away within the past 60 months will not affect my application for Medicaid for the Medicare Savings Programs, but may affect eligibility for Medicaid in a medical institution.

RESPONSIBILITIES

*I agree to notify the Medicaid District Ofﬁ ce within ten (10) days, if there is a change in my address, living arrangements, family size, income or resources.

FALSE STATEMENTS

I know that anyone who makes or causes to be made a false statement, representation or omission of a material fact in an application or for use in determining eligibility for Medicaid commits a crime punishable under Federal or State law or both. I afﬁ rm under penalty of perjury that all information I give in this document or in support of it is true.

___________________________________________________	Date _________________________
Signature of Applicant or Representative
___________________________________________________	Date _________________________
Signature of Applicant’s Spouse or Representative
___________________________________________________	Date _________________________
Witness’ Signature (If applicable)

Medicaid Eligibility Policies and Procedures are in compliance with the Civil Rights Act of 1964,Section 504 of the Rehabilitation Act of 1973, the Federal Age Discrimination Act of 1975 andthe Americans with Disabilities Act of 1990.

Page 5

Applicant’s Name _________________________________________ SS# ________________________________

APPOINTMENT OF REPRESENTATIVE

I hereby appoint ________________________________________________________________________ (Sponsor’s Name)

as my legal representative to act in my stead and on my behalf to apply, reapply and make claim for Medicaid beneﬁts under Title XIX of the Social Security Act from the Alabama Medicaid Agency, hereby ratifying and conﬁ rming the acts of my said representative on my behalf. This appointment authorizes my said representative to fully act in my stead in connection with all Medicaid matters involving me, including, but not limited to, making applications, reapplications and claims of all kinds, accepting and giving notice in connection with eligibility determinations and Fair Hearings, requesting information, and presenting and eliciting evidence. This appointment shall remain in full force and effect until I have notiﬁ ed the Alabama Medicaid Agency in writing that this authority has been withdrawn.

Done this the ______________________ day of ________________________________________, 20 __________.

WITNESSES

__________________________________________________ _____________________________________________

(Signature of Medicaid Claimant)

__________________________________________________ _____________________________________________

(Social Security Number)

If claimant cannot sign his/her name but can make a mark; this is acceptable if witnessed by two adults.

The mark may be labeled. Example:

X (Her mark)

Jane Doe

If claimant cannot sign his/her name or make a mark and there is no one legally designated as guardian, conservator, etc., representative must answer the questions below.

What is your relationship to claimant? ________________________________________________________________

Why can’t claimant sign? __________________________________________________________________________

To what extent are you responsible for claimant? ________________________________________________________

If claimant has a legally appointed guardian, conservator or someone with durable power of attorney who will represent him/her for Medicaid purposes, claimant’s signature on this form is not required. Representative should sign the Representative portion of the form only and attach to this form a copy of evidence of legal authority to act on claimant’s behalf (Letter of Conservatorship/Guardianship or Durable Power of Attorney).

ACCEPTANCE OF APPOINTMENT

I hereby accept the foregoing appointment. I certify that I have not been suspended or prohibited from practice before the Alabama Medicaid Agency and am not otherwise disqualiﬁ ed from acting as an appointed representative. I acknowledge that representations and applications made by me on behalf of the claimant are made under an afﬁ rmation which subjects me to penalties for perjury and that false statements may subject me to penalties or fraud.

My relationship to the above is __________________________________________________ (Attorney, relative, etc.)

Done this the ______________________ day of ________________________________________, 20 __________.

WITNESSES

__________________________________________________ _____________________________________________

(Signature of Sponsor/Representative)

__________________________________________________ _____________________________________________

(Address)

__________________________________________________

(City, State, Zip)

__________________________________________________

(Telephone Number)

Page 6

➤ PDF File

Form Specifications

Fact Name	Fact Description
Purpose	The Alabama 211 form is an application for Medicare Savings Programs, not for full Medicaid coverage.
Coverage	This form helps cover Medicare premiums and deductibles, but not all medical expenses.
Drug Coverage	Medicaid's drug coverage is limited to medications covered under Medicare Part D.
Application Requirements	Applicants must send a copy of their Medicare card, Social Security card, and income verification.
Submission Instructions	After completing the form, applicants should mail it to the District Office serving their county.
False Statements Penalty	False statements in the application can lead to criminal and civil penalties under Alabama law.
Governing Laws	Relevant laws include Code of Alabama Sections 22-1-11 and 22-6-8 regarding fraud and eligibility.
Eligibility Revocation	Eligibility can be revoked for abuse, fraud, or misuse of benefits, with a minimum one-year ineligibility period.
Civil Rights Compliance	Medicaid policies comply with various federal civil rights laws, ensuring equal access to benefits.

Alabama 211: Usage Guidelines

Filling out the Alabama 211 form is a straightforward process. You will need to provide personal information, verify your Medicare coverage, and submit necessary documentation. Ensure that all details are accurate to avoid delays in processing your application.

Begin by printing the form clearly using dark ink.
Fill in your name, including first, middle, last, and suffix.
Provide your mailing address and current resident address if different.
Enter your phone number and any additional contact numbers.
Include your email address and fax number if applicable.
Indicate your date of birth and Social Security number.
Specify your marital status and provide details if married, divorced, or widowed.
Confirm whether you have Medicare Part A coverage by marking yes or no.
Complete the race and sex sections by selecting the appropriate options.
List the names, ages, and relationships of anyone living in your home.
If applicable, fill out the sponsor section with details of the person assisting you.
Provide information about your spouse, including their name, phone number, and date of birth.
If you are divorced or widowed, list details of your former spouse(s).
Indicate your veteran status and provide details if you are a veteran or a dependent of one.
Answer questions regarding your residency and citizenship status.
If you have other medical insurance, provide the names and addresses of the insurance companies.
Attach copies of your Medicare card, Social Security card, and proof of income.
Sign the application at the designated area.
Mail the completed application to the appropriate District Office for your county.

Your Questions, Answered

What is the Alabama 211 form?

The Alabama 211 form is an application for Medicare Savings Programs offered by the Alabama Medicaid Agency. It is specifically designed to help individuals cover their Medicare premiums and deductibles. However, it is important to note that this form does not apply for full Medicaid benefits.

Who should fill out the Alabama 211 form?

This form is intended for individuals who have Medicare and need assistance with paying their Medicare premiums and deductibles. If you are eligible for Medicare and your income is within certain limits, you may qualify for these savings programs.

What documents do I need to submit with the form?

When submitting the Alabama 211 form, you must include several important documents. These include a copy of your Medicare card to verify your Part A coverage, a copy of your Social Security card, and verification of your gross monthly income before taxes. Additionally, don’t forget to sign the application before mailing it.

Where do I send my completed application?

After completing the form and gathering the necessary documents, you should mail your application to the District Office that serves your county. The address for your District Office can be found in the attachment provided with the application.

What happens if I provide false information on the application?

Providing false statements or omitting important information on the Alabama 211 form can lead to serious consequences. Both federal and state laws impose penalties for such actions, including potential fines and imprisonment. Applications found to contain inaccuracies will be denied.

Can I apply for the Alabama 211 form if I am not a U.S. citizen?

You can apply for the Alabama 211 form if you are a lawfully admitted alien. However, you must provide proof of your residency status and confirm that you live in Alabama and plan to stay. This information is essential for determining your eligibility.

What if I have other health insurance besides Medicare?

If you have additional health insurance coverage beyond Medicare, you must provide details about that insurance on the form. Include the name and address of the insurance companies, along with your policy and group numbers. This information helps the Medicaid agency assess your overall coverage.

Is there any assistance available if I need help completing the form?

If you find it challenging to complete the application on your own, you can have someone assist you. This person, known as a sponsor, should be familiar with your financial situation. Make sure to fill out the Appointment of Representative form included in the application if you need assistance.

How can I check the status of my application after submission?

After you mail your application, you can contact the District Office where you submitted it to check on the status. Be sure to have your personal information handy, such as your name and Social Security number, to help them locate your application quickly.

Common mistakes

Incomplete Information: Many applicants forget to fill out all required fields. Missing information can delay processing or lead to denial.
Incorrect Medicare Card Submission: Failing to send a copy of the Medicare card can result in the application being rejected. Ensure that this is included to verify Part A coverage.
Omitting Income Verification: Not providing proof of gross monthly income is a common mistake. This documentation is crucial for determining eligibility.
Unsigned Application: Forgetting to sign the application is another frequent oversight. An unsigned application is considered incomplete and cannot be processed.
Incorrect Mailing Address: Sending the application to the wrong District Office can lead to delays. Always double-check the address based on your county.
Failure to Read Instructions: Skipping the instructions can result in errors. It’s important to read through all guidelines to ensure compliance with the application process.
Inaccurate Personal Information: Providing incorrect information, such as Social Security numbers or marital status, can lead to significant issues. Double-check all entries for accuracy.

Documents used along the form

The Alabama 211 form is an essential document for individuals seeking assistance with Medicare premiums and deductibles through the Medicare Savings Programs. Alongside this form, several other documents and forms are commonly used to ensure a complete application process. Below is a list of these documents, each serving a specific purpose in the application process.

Medicare Card: A copy of the Medicare card is required to verify that the applicant has Part A coverage, which is crucial for eligibility.
Social Security Card: This document helps confirm the identity of the applicant and is necessary for processing the application.
Income Verification: Documentation showing the gross monthly income before taxes is needed to determine financial eligibility for the program.
Appointment of Representative Form: If the applicant needs assistance completing the application, this form designates a representative who can act on their behalf.
Veteran’s Benefits Verification: If applicable, this document confirms the applicant's status as a veteran or dependent, which may influence eligibility for additional benefits.
Other Insurance Information: If the applicant has other medical insurance, this information is necessary to assess overall coverage and benefits.
District Office Address: This attachment provides the mailing address for the District Office where the application must be sent, ensuring it reaches the correct location.

Gathering these documents alongside the Alabama 211 form can streamline the application process and improve the chances of a successful outcome. Each document plays a vital role in verifying eligibility and ensuring that applicants receive the assistance they need.

Similar forms

The Alabama 211 form is essential for individuals seeking assistance with Medicare premiums and deductibles. It shares similarities with various other forms and applications related to health insurance and assistance programs. Below is a list of documents that are similar to the Alabama 211 form, along with explanations of how they relate:

Medicaid Application Form: This form is used to apply for full Medicaid benefits, covering a wider range of medical services compared to the Alabama 211 form, which focuses solely on Medicare Savings Programs.
Medicare Application for Benefits: This document is used by individuals to enroll in Medicare. Like the Alabama 211 form, it requires personal information and proof of eligibility, such as Social Security numbers and income verification.
Supplemental Security Income (SSI) Application: Similar to the Alabama 211 form, the SSI application collects detailed information about income and resources to determine eligibility for benefits, particularly for low-income individuals.
Veterans Affairs Health Care Application: This application is for veterans seeking health care benefits. It requires personal and financial information, akin to the Alabama 211 form's requirements for income verification and residency status.
Social Security Disability Insurance (SSDI) Application: This form is used to apply for disability benefits and requires extensive personal information and documentation, similar to the Alabama 211 form's focus on financial status and household composition.
Food Assistance Program Application: This document helps individuals apply for food assistance benefits. It also requires income and household information, paralleling the Alabama 211 form's need for detailed applicant data.
Low-Income Home Energy Assistance Program (LIHEAP) Application: This application assists low-income households with energy costs. It requires financial documentation, reflecting the income verification process found in the Alabama 211 form.
Children's Health Insurance Program (CHIP) Application: This form is for families applying for health insurance for children. It gathers similar information about household income and residency, much like the Alabama 211 form.
State Health Insurance Assistance Program (SHIP) Application: This application provides assistance with Medicare and Medicaid questions. It shares the same focus on eligibility verification and personal information as the Alabama 211 form.

Dos and Don'ts

When filling out the Alabama 211 form, it's crucial to approach the task with care and attention. Here are seven important dos and don'ts to keep in mind:

Do read the entire application carefully before starting to fill it out.
Do provide accurate and complete information for each question.
Do send a copy of your Medicare card to verify your Part A coverage.
Do include a copy of your Social Security card.
Do sign the application before mailing it to the appropriate District Office.
Don't leave any questions unanswered; incomplete applications may be delayed or denied.
Don't provide false information or omit details, as this can lead to severe penalties.

By following these guidelines, applicants can ensure a smoother process when applying for Medicare Savings Programs through the Alabama Medicaid Agency.

Misconceptions

Misconceptions about the Alabama 211 form can lead to confusion and errors in the application process. Here are five common misconceptions clarified:

This form is an application for full Medicaid. In reality, the Alabama 211 form is specifically for Medicare Savings Programs. It does not serve as an application for full Medicaid benefits.
Medicaid covers all prescription drugs. Many believe that Medicaid will pay for any medication. However, coverage is limited to drugs covered under Medicare Part D, excluding any drugs not listed.
Only low-income individuals can apply. While income is a factor, the form is designed for those who have Medicare and need assistance with premiums and deductibles, regardless of their overall income level.
All applications are automatically approved. This is not true. Applications may be denied if they contain false statements or omissions. It’s crucial to provide accurate information.
You do not need to provide verification documents. Many applicants think they can skip this step. In fact, you must submit copies of your Medicare card, Social Security card, and proof of income to complete the application.

Key takeaways

Key Takeaways for Filling Out and Using the Alabama 211 Form:

This form is specifically for applying to Medicare Savings Programs, not for full Medicaid coverage.
Ensure you send a copy of your Medicare card, Social Security card, and verification of your monthly income.
Complete all sections of the application accurately to avoid denial due to false statements or omissions.
Sign and mail your application to the appropriate District Office for your county; the address is provided in the attachment.
Understand that penalties exist for providing false information, including potential criminal charges and loss of benefits.