Tip for State-specific MSP form

QMB pays Part A and B premiums, deductibles, coinsurance, and copayments — the most comprehensive help

Tip for State-specific MSP form

SLMB pays only the Part B premium. QI also pays the Part B premium (apply by year-end as funding is limited)

Tip for State-specific MSP form

MSP enrollment automatically qualifies you for Extra Help (LIS) with Part D drug costs

Medicarehard

Medicare Savings Program Application

State-specific MSP form · State Medicaid Agencies

Application for QMB, SLMB, or QI programs that help pay Medicare premiums, deductibles, and copays. Over 6 million eligible but unenrolled.

Form Details

Total fields: 55
Auto-fillable: 30 (55%)
Time without BeneFill: 60 minutes
Time with BeneFill: 15 minutes
Time saved: 45 minutes
Filled by: patient
Frequency: annual
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Apply through your state Medicaid agency

https://www.medicare.gov/basics/costs/help/medicare-savings-programs

Application processes vary by state. Contact your state Medicaid office.

🏢

At your local Medicaid or Department of Social Services office

📬

Mail to your state Medicaid agency

Request an application by calling your state Medicaid office.

Required Attachments

📎 Proof of Medicare enrollment (Medicare card)
📎 Proof of income (Social Security benefit letter, pension statements, tax return)
📎 Proof of resources/assets (bank statements, investment statements)
📎 Proof of identity and residency

Processing Time

Up to 45 days for eligibility determination.

What Happens Next

If approved, your state will pay some or all of your Medicare premiums, deductibles, and copays depending on the program level (QMB, SLMB, QI, QDWI).

Tips for This Form

✓ QMB pays Part A and B premiums, deductibles, coinsurance, and copayments — the most comprehensive help
✓ SLMB pays only the Part B premium. QI also pays the Part B premium (apply by year-end as funding is limited)
✓ MSP enrollment automatically qualifies you for Extra Help (LIS) with Part D drug costs
✓ Income limits are updated annually — check even if you were denied in the past

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid Agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.