PDF AP-2, Universal Application for PAAD, Senior Gold and Other ...

New Jersey Department of Human Services Division of Aging Services

State Health Insurance Programs for the Aged and Disabled P.O. Box 715

Trenton, NJ 08625-0715 humanservices

NJSave APPLICATION FOR MEDICARE SAVINGS PROGRAMS (MSP), PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED (PAAD), LIFELINE UTILITY ASSISTANCE

(LIFELINE), SENIOR GOLD PRESCRIPTION DISCOUNT PROGRAM (SENIOR GOLD), AND OTHER SPECIAL BENEFITS PROGRAMS

The attached NJSave application is a source of help offered by the State of New Jersey that can save you up to $5,000 per year in prescription, Medicare and other costs.

Please complete and return the application, along with all requested documents, in the self-addressed postage paid envelope provided. This one application gives you access to numerous programs and other special benefits including the following:

Medicare Savings Programs (Specified Low-Income Medicare Beneficiary (SLMB) and SLMB Qualified Individual (SLMBQI-1) programs). If eligible, these programs pay for your monthly Medicare Part B premium, which currently costs most people $134.00 per month; and

Pharmaceutical Assistance to the Aged and Disabled (PAAD) program or the Senior Gold Prescription Discount program. The PAAD program helps with the cost of your prescribed medications, including the payment of certain Medicare Part D premiums and deductibles. Senior Gold is a prescription discount program for individuals not eligible for PAAD; and

Lifeline Utility Credit/Tenants Lifeline Assistance program. This program offers an annual $225 utility benefit on electric and gas utility bills provided you meet the PAAD eligibility requirements; and

Hearing Aid Assistance to the Aged and Disabled (HAAAD) program. This program provides a $100 reimbursement to help offset the purchase of a hearing aid if you meet the PAAD eligibility requirements; and

Screening for Extra Help with Medicare Part D. This program covers Medicare Part D prescription drug plan costs, for those individuals eligible for PAAD; and

Screening for benefits provided by the Universal Service Fund (USF) and the Low-Income Home Energy Assistance Program (LIHEAP). These are two more programs that help pay for utility costs, if eligible; and

Reduced motor vehicle fees. This benefit is available through the Division of Motor Vehicles to those individuals eligible for PAAD and Lifeline; and

Property tax freeze. This benefit is available through the Division of Taxation to all eligible individuals.

NJSave 10/18

For more information, visit aging. or call 1-800-792-9745

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Program

Eligibility Requirements

Medicare Savings Programs (MSP) (Specified Low-income Medicare Beneficiary (SLMB)/Specified Lowincome Medicare Beneficiary/Qualified Individual 1 (SLMB/QI1)

To be eligible for MSP, you must: 1. Be a resident of the State of New Jersey 2. Be eligible for or enrolled in Medicare Part A (Hospital) and Medicare Part B (Medical) 3. Have income at or below $16,389 (single) and $22,221 (married) 4. Have liquid resources of no more than $7,560 (single) or $11,340 (married)

Benefits

Payment of Medicare Part B monthly premium and any late enrollment penalty for Medicare Part B.

Pharmaceutical Assistance to the Aged and Disabled Program (PAAD)

To be eligible for PAAD, you must: 1. Be a resident of the State of New Jersey 2. Be age 65 or older OR between 18 and 64 AND

receiving Social Security Disability benefits 3. Have income:

less than $27,951 (single) or less than $34,268 (married)

PAAD co-pay is: $5 per PAAD covered generic drug. $7 per PAAD covered brand name drug.

Premium payment for certain Medicare Part D prescription drug plans.

Lifeline Utility Credit Program and Tenants Lifeline Assistance Program

Same as PAAD

Annual $225 benefit applied to utility bill, or for tenant's benefit, in the form of a check.

Senior Gold Prescription Discount Program

To be eligible for Senior Gold, you must: 1. Be a resident of the State of New Jersey 2. Be age 65 or older OR between 18 and 64 AND receiving Social Security Disability benefits 3. Have income: between $27,951 and $37,951 (single) or between $34,268 and $44,268 (married)

Senior Gold applicants do not qualify for the Lifeline Utility Credit/Tenants Lifeline Assistance Program or the Hearing Aid Assistance to the Aged and Disabled Program and, therefore, do not need to answer questions related to these programs.

Senior Gold co-pay for Senior Gold covered drugs is $15 + 50% of the remaining cost of the prescription or actual drug cost, whichever is less. (Co-pay will change with change in drug price.)

Catastrophic cap: $2,000 (single) $3,000 (married) Once the beneficiary's annual out of pocket expenses reach the catastrophic cap, co-pay is $15 for the balance of that eligibility period.

Revised 10-2018 NJSave 10/18

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Department of Human Services Pharmaceutical Assistance to the Aged and Disabled (PAAD),

Lifeline and Special Benefits Programs Senior Gold Prescription Discount Program (Senior Gold) Specified Low-income Medicare Beneficiary Program (SLMB) and Specified Low-income Medicare Beneficiary Qualified Individual 1 (SLMB QI1) Program

This form will be scanned for computerized data capture. Please follow these instructions to ensure that your application is processed quickly and accurately.

Use blue or black ink. Do not use red ink or pencil. Print clearly in uppercase block letters (see examples below). Print only one number or letter in each box. Stay inside boxes. Correct errors with white correction fluid.

AB C DE F G HI J K L M N O P Q R S T U V WX Y Z

1 2 3 45 67 890

If you have questions or need help filling out this form, call our toll free number at 1-800-792-9745.

This form must be completed and returned to:

PAAD/Senior Gold PO Box 637

Trenton, NJ 08625-9826

DO NOT SEND ORIGINAL SUPPORTING DOCUMENTS. SEND COPIES. ORIGINALS WILL NOT BE RETURNED.

NUJAS-1ave 1O0C/1T816

J01900208

Prescription Assistance

New Jersey Department of Human Services Pharmaceutical Assistance to the Aged and Disabled (PAAD), Lifeline and Special Benefits Programs Senior Gold Prescription Discount Program (Senior Gold) Specified Low-income Medicare Beneficiary (SLMB) and Specified Low-income Medicare Beneficiary Qualified Individual (SLMB QI1) PO Box 715, Trenton, NJ 08625-0715 Toll Free Hotline 1-800-792-9745

I am applying for:

Lifeline Utility Benefit

Medicare Savings Programs (SLMB/QI)

PLEASE PRINT YOUR NAME ON THE TOP OF EACH PAGE.

1. Enter your name, date of birth and sex. List your Social Security number. Use CAPITAL LETTERS. Print only one letter or number in each box. List date of birth verified by Social Security.

Last Name

Suffix

(Jr., Sr.,

etc.)

First Name

Middle Initial

Sex Male/Female

Social Security

- -

Number

Month / Day / Year Date of

Birth / /

2. If your spouse is also applying, both of you must complete separate applications. Even if your spouse is not applying, we need all of the questions answered and signatures for both of you, if married and living together.

Spouse's Last

Suffix (Jr., Sr.,

Name

etc.)

First Name

Middle Initial

Sex Male/Female

Spouse's

Social Security

- -

Number

Date of Birth

Month / Day / Year

/ /

3. Please identify your current marital status. Please X only one box.

Married

Separated*

Widowed

Divorced

3a. Has your marital status changed in the last year?

YES NO

List the date of change

Single

/ /

Month / Day / Year

*If you are separated from your spouse, call the toll free number above to request an `Affidavit of Separation' form which MUST accompany this application.

3b. Are you or your spouse, if married, residing in a long-term care facility (nursing home)? If YES, submit a letter from the facility indicating the date admitted.

YOU: YES SPOUSE: YES

NO NO

1

2

3

4

5

6

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