Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 20 - Division of County Operations › Rule 016.20.00-021 - Medicare Beneficiaries Application (DCO-808)

Current through Register Vol. 49, No. 6, June, 2024
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.
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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. 2nd
						  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
5th 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. 3rf
						  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
3rd & Hazel
						  Street
P.O. Box 658
Newport, AR72U2
870-523-9828
Jefferson
1222 W. 6th &
						  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. 4th
						  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 2nd
						  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. 2nd
						  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.*