To submit this form, you can use the following methods: Email: submit@medicaid.gov, Fax: 1-800-555-1234, Online Submission Form: www.medicaid.gov/submit-form, Physical Address: Medicaid Office, 123 Medicaid Lane, City, State, ZIP. Ensure you have completed all sections of the form and included any required documentation. Double-check the accuracy of the information before submission. My advice is to keep copies of all submitted documents for your records and follow up with the Medicaid office to confirm receipt and processing of your form.

For the years 2024 and 2025, it is important to remember that eligibility for Extra Help is determined annually. Ensure you meet your spenddown amount within the required periods to qualify for Medicaid and Extra Help. Note that individuals who qualify for Medicaid through spenddown in the last six months of a year are eligible for Extra Help for the rest of the current year and the entire following year.

The purpose of this form is to guide Medicare beneficiaries through the process of applying for Medicaid Spenddown and Extra Help programs. These programs are designed to assist individuals with high medical expenses by lowering their out-of-pocket Medicare drug costs. By understanding and completing this form, beneficiaries can access the financial support they need to manage their healthcare expenses.

• 1. Personal Information: This section requires the beneficiary's personal details, including name, address, and Social Security number.
• 2. Medical Expense Documentation: Here, the beneficiary must provide documentation of medical expenses, such as receipts and bills.
• 3. Income Information: This section requires details about the beneficiary's income, including sources and amounts.
• 4. Medicaid Spenddown Calculation: In this section, the beneficiary calculates their spenddown amount based on medical expenses and income.
• 5. Signature and Date: The beneficiary must sign and date the form to certify the accuracy of the information provided.

If you fail to submit this form, you may not qualify for Medicaid Spenddown or Extra Help programs. This could result in higher out-of-pocket Medicare drug costs and additional financial strain.

• Ineligibility for Medicaid: Without submitting the form, you may not qualify for Medicaid benefits.
• Loss of Extra Help: Failure to submit the form may result in losing eligibility for Extra Help, increasing your Medicare drug costs.
• Higher Medical Expenses: Not submitting the form can lead to higher out-of-pocket medical expenses that could have been covered by Medicaid.

• 1. High Medical Expenses: When your medical expenses exceed your available income, use this form to apply for assistance.
• 2. Qualifying for Medicaid: Use this form to determine if you qualify for Medicaid through the spenddown process.
• 3. Reducing Medicare Costs: If you want to reduce your Medicare drug costs, this form helps you apply for Extra Help.
• 4. Annual Eligibility Review: Complete this form annually to ensure ongoing eligibility for Medicaid and Extra Help programs.
• 5. Caregiver Support: Caregivers can use this form to assist Medicare beneficiaries in managing their medical expenses.