New HRA QMB recertification form - Sample

HRA has revised the recertification form it will be sending to QMB recipients.  The form previously in use did not state on it that it was intended to be used for QMB referring only to Medicaid.  This was very confusing for recipients who have QMB, but not Medicaid.  Many QMB only recipients discarded the form because they did not understand that it was also intended for QMB only cases.

The new recertification form states that it is intended for Medicaid and QMB.  Clients receiving recertifcation packets in January 2010 should be receiving this new form.  When this new recertification form is issued to recipients it will be prepopulated with their information.

Please feel free to contact Legal Aid Society at 212-577-3394, if you have any problems reinstating QMB for clients who received  the old form and did not understand that it applied to them.

ALSO ON RENEWALS OF QMB -- See

12ADM-04 - Automated Medicaid Renewal Expansion: Medicare Savings Program (MSP) Individuals with Fixed Incomes (7/2012)


This article was authored by the Health Law Unit of the Legal Aid Society.  1/21/10

The Legal Aid Society



Article ID: 104
Last updated: 11 Nov, 2013
Revision: 2
Medicare Savings Program -> New HRA QMB recertification form - Sample
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