PM 06-12-01

The Department on Aging (DoA) provides outreach to senior citizens who are potential QMBs. They notify seniors of the availability of QMB benefits and help with the application process. They help seniors who want to apply for QMB only benefits, complete forms and provide proof of Medicare Part A enrollment.

(FCRC) When asked, give Area Agencies on Aging supplies of forms.

  • Application for Payment of Medicare Premiums, Deductibles and Coinsurance (Form 2378M), and
  • Medicaid Payment of Medicare Cost Sharing Expenses (Form 3120).