Summary of Changes: Application for Medicare Savings Programs (MSP)

Summary of changes to MSP model form:
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Added spouse as a person who can apply.
Simplified language describing types of Medicaid coverage.
Added language to clarify that the application can be used by an individual or a married
couple.
Added information about contacting Medicaid agency for Extra Help benefit.
Added more details about inapplicability of estate recovery.
Modified ‘what you may need to apply’ section to simplify language and add documents
that may be needed for non-citizens.
Added statement to ‘attach additional pages’ as needed.
Modified ‘ways to apply’ section.

Page 2:
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Modified section about getting help with Medicare, added phone number to find local SHIP.

Page 3:
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Added additional marital status categories to clarify status.
Modified citizenship status section to fully align with single streamline application.
Removed sex from household member section and added language to clarify information
needed based on whether they are applying for MSPs.

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Simplified language in income section.

Page 4:
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Simplified real property language.
Modified life insurance policy section to include all policies with combined value over
$1,500.
Added option to request help from Medicaid agency to find value of life insurance policy.

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Added language authorizing the state Medicaid agency to contact applicants’ life insurance
company on their behalf.
Modified appeal rights language.

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Added representative email address.
Added additional accessibility information.
Added optional section for race/ethnicity.
Added optional section for gender/sexual orientation.