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Effective Date: 
12/2006

Documents

Instructions

Updated: 2/2002

Purpose

  • To notify the client of his eligibility status as a Qualified Medicare Beneficiary (QMB).
  • To notify the client of his eligibility status as a Qualified Disabled and Working Individual (QDWI).
  • To notify the client of his eligibility status as a Specified Low-Income Medicare Beneficiary (SLMB).
  • To notify the client or the responsible party of the right to appeal.

When to Prepare

Prepare Form H1207 when a decision is made about the client's eligibility for QMB, QDWI, or SLMB.

Number of Copies

Prepare the original and two copies.

Transmittal

Send the original and first copy to the client at his address or that of his responsible party. Enclose a prepaid return envelope.

File the second copy in the case record.

Form Retention

Keep the copy according to the retention requirements of the case record.

Detailed Instructions

This form may be typed or legibly handwritten.

Inside Address — Enter the name of the client and his mailing address or that of his responsible party.

Date — Self-explanatory.

Worker — Self-explanatory.

Office Address and Telephone Number — Enter the caseworker's complete office address and telephone number. Include the TDD telephone number if the office is equipped with TDD.

I have determined that ... — Check the appropriate box to indicate whether the client is eligible as a QMB, QDWI, or SLMB.

You are eligible to receive Qualified Medicare Beneficiary (QMB) benefits beginning ... — If this box is checked, enter the effective date of QMB benefits. Unless ensuring continuous QMB coverage for type program transfers or for clients who were receiving QMB benefits out-of-state, this date will always be the first day of the month following the month in which the Form H1201, MAO Worksheet, is signed.

You are eligible to receive Qualified Disabled and Working Individuals (QDWI) benefits beginning ... — If this box is checked, enter the effective date of QDWI benefits.

You are eligible to receive Specified Low-Income Medicare Beneficiaries (SLMB) benefits beginning ... — If this box is checked, enter the effective date of SLMB benefits. This date may be up to three calendar months prior to the month in which the application was filed, if all criteria are met.

Page 2: Worker, Mail Code, Office Address, and Telephone Number — Enter the caseworker's name, mail code, complete office address, and telephone number. Include the TDD telephone number if the office is equipped with TDD.