EXPLANATION The Mabel T. Caverly DEAP Program

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1 EXPLANATION The Mabel T. Caverly DEAP Program The Mabel T. Caverly Senior Services DEAP program is targeted for those Municipality of Anchorage seniors who fall in between the cracks. Applicants must not have any other assistance for the item for which they are applying. DEAP doesn t issue grants to cover deductibles, co-pays, or to be added to the maximum amount that health insurance or Medicaid pays. NOTE: Medicaid covers DEAP items. Therefore, Medicaid recipients aren t eligible for this program. Also note that the standard medigap policy that covers only items that Medicare covers DOES NOT preclude you from applying for DEAP. If you are eligible for Medicare Part D, whether or not you have chosen to participate, DEAP can t be used for prescriptions. However, if you are in the Medicare Part D doughnut hole, you may apply to use DEAP for your prescriptions until such time as Medicare begins to pay again. The DEAP program is designed to reimburse qualifying individuals, ages 55 and over, for some of the amounts these individuals spend on dental work, prescription eyeglasses*, contact lenses*, prescription sunglasses*, hearing aids, and prescription drugs. The total amount available per person SHALL NOT EXCEED $ for dental work or hearing aids or $ for eyeglasses and prescriptions. The reimbursement is NOT applicable to any of the above enumerated expenses for which an applicant has partial or full reimbursement from insurance or other funding source or for which the applicant already receives aid such as a token charge from a pharmaceutical manufacturer, etc. (*Includes eye doctor fee for basic exam for prescription only.) To receive this reimbursement, an individual must be PRE-APPROVED. An approved applicant will receive a letter of approval with confirmation of the beginning and ending dates of the participation period. (PLEASE NOTE: THIS MEANS THAT DEAP DOES NOT REIMBURSE FOR ANY EXPENSES INCURRED BEFORE A PARTICIPANT WAS APPROVED.) Program participants must submit receipts/invoices with their name, the service received, the cost of services, and the date of the expense. RECEIPTS/INVOICES WITHOUT A PROGRAM PARTICIPANT S NAME WILL BE DENIED. The expense MUST BE INCURRED DURING THE 60 DAYS FOR WHICH THE PARTICIPANT HAS BEEN APPROVED. (Note the specified dates on the participation letter.) Expenses incurred before or after the approval period will not

2 Page 2 The Mabel T. Caverly DEAP Program be honored. Payments on account for expenses incurred BEFORE the participation period are not covered EVEN IF the payments are made DURING the participation period. All receipts/invoices must be from an Anchorage provider. All receipts/invoices must be submitted no later than ten (10) days after the end of the participation period. If invoices aren t submitted within the 10 day timeframe, the unused funds will go to the wait list and not be available to the original grantee. Up front payments required by practitioners will be reimbursed if the payment was made during the participation period and if we can confirm that the work was subsequently done or the service provided. Reimbursement checks will be issued no more frequently than 2 times per month, on approximately the middle and last business days in the month. If less than $ $900.00/ in total reimbursable expenditures is submitted during the applicable period, the unused portion goes to the wait list. If you are unable to pay for the expenditure up front and then be reimbursed, contact this office. Assistance for this may be possible. Members of the micro grant application evaluation committee are independent volunteers not affiliated with the Mabel T. Caverly Senior Services or any of its DEAP program donors. The committee will evaluate each application for the greatest level of need while keeping in mind the limited funds available for the program. The decision of the committee on any application is final. The evaluation committee reserves the right to revoke any approval at any time if it becomes aware that the information provided on the application form is not materially accurate. Any applicant whose approval has been revoked is not eligible to reapply for the DEAP program. DEAP participants may re-apply 60 days after their participation period has ended. With the exception of prescription need applications, DEAP applications for 2 nd grants will not be funded while there is a wait list. Prescription need applications may be considered while a wait list exists. Contact Mabel T. Caverly for further information about re-applications. Please see attachment A for the funding parameters. No warranties, expressed or implied, are made as to the length of the DEAP program s existence.

3 Page 3 The Mabel T. Caverly DEAP Program Please sign below to confirm that you have read and understand the information contained herein: I have read and understand the DEAP program information and the information in attachment A. Print name Date Signature

4 Page 4 The Mabel T. Caverly DEAP Program ATTACHMENT A MICRO-GRANT FUNDING PARAMETERS AS OF 2/3/11 Income limits $2, per month for a single individual $3, per month for a married couple The micro grant committee may consider a variance IF there are significant and on going un-reimbursed health care expenses or other extraordinary circumstances.

5 Mabel T. Caverly Senior Center A friendly place providing stepping stones over deep water 325 E. Third Ave. Anchorage AK Phone: Fax DEAP APPLICATION PAGE 1 Micro grants for dental work, eyeglasses, hearing aids, and prescription drugs. Date Where did you hear about the program? Name of Applicant Male Female Date of Birth Address City Zip SS# Phone Number of persons residing in household Do you have: Health insurance yes no Medicaid (or CHOICE waiver) yes no Previous applicant? yes no Previously approved? yes no Do you have any other assistance for DEAP items? yes no Name of other source Other source covers: Prescription Drugs Prescription Eyeglasses Hearing Aids Dental work ATTACH PROOF OF INCOME EXCEPT FOR SENIOR Benefit assistance. Total previous three (3) months of gross income (If your income is the same every month, you need only put down one month s income.) Wages Social Security Pension Senior Benefit Disability payments Unemployment compensation Alimony or spousal support Other TOTAL DIVIDED BY 3 = per month

6 DEAP APPLICATION PAGE 2 Total previous three (3) months out of pocket medical, dental, hearing, vision expenses (good faith estimate): Physician Lab Prescription Dentist Eyeglasses Hearing Aid Other TOTAL DIVIDED BY 3 = PER MONTH Own home Rent Amount for mortgage or rent per month Does above include utilities? yes no Besides your current place of residence, do you: Own a cabin? yes no Own a condominium? yes no Own a timeshare? yes no How many working vehicles do you own? Make and year of each Do you own: a recreational vehicle? yes no camper yes no boat yes no snowmachine/atv yes no Do you have a checking account? Yes No Savings account? Yes No Name of financial institution(s) Current checking account(s) balance(s) Current savings account(s) balance(s) (include certificates of deposits) Current value of stocks, bonds, mutual funds, etc

7 DEAP APPLICATION PAGE 3 If your application is approved, for which covered expense will you seek reimbursement? Choose ONE only. Dental work Prescription eyeglasses Hearing aid Prescription drugs (Note: You must contact Mabel T. Caverly for approval to change this item.) Other information of which you would like the micro grant committee to be aware that might better help them understand your circumstances. For instance, you are supporting adult children or grandchildren, how long it has been since you ve had new eyeglasses, the cost of your anticipated dental work, your current glasses are giving you headaches, you have a toothache, you need new glasses to get a job, etc Where do you get your healthcare? (check one) I have a private practice medical home (almost always go to the same health care provider) I use Anchorage Neighborhood Heallth for my primary care I occasionally/usually use a walk in storefront clinic. I go to the emergency room. I don t go to a doctor or other healthcare provider. Where do you get your dental care? (check one) I regularly go to a private practice dentist. I regularly use Anchorage Neighborhood Health Center I go to UAA s hygienist school for cleanings but otherwise don t get much dental care. I rarely get dental care.

8 DEAP APPLICATION Page 4 Please note: If the information provided herein is found to not be materially accurate, then any approval will be immediately revoked and the applicant will be prohibited from reapplying for the DEAP program. I hereby confirm that all the information contained herein is accurate to the best of my knowledge. X Signature date

9 DEAP APPLICATION PAGE 4 FOR STATISTICAL PURPOSES ONLY Name Age M F Income range: Circle one: less than $5,000 per year $5,000 - $9,999 per year $10,000 14,999 per year $15,000 - $20,000 per year $20,001 - $26,000 per year $26,001+ Alaska Native Caucasian Hispanic Asian Native American African American Other I am retired. A homemaker Working less than 20 hours/week Working hours/week Employed full time I hereby authorize the Mabel T. Caverly Senior Center to compile all information contained in this application WITH THE EXCEPTION OF MY NAME, ADDRESS, PHONE NUMBER, AND SOCIAL SECURITY NUMBER, in order to provide the statiscal documentation necessary for the accurate reporting of the results of this program to grantors and for use in future grant requests. Signature Date

10 READ THE EXPLANATION. THEN SIGN & SUBMIT THE SIGNATURE PAGE ONLY FILL OUT THE APPLICATION COMPLETELY, SIGN AND RETURN INCOMPLETE APPLICATIONS ARE NOT PROCESSED. PROVIDE PROOF OF INCOME THIS PROGRAM CAN T BE USED IN COMBINATION WITH HEALTH INSURANCE OR MEDICAID. IF HEALTH INSURANCE, MEDICAID OR OTHER ASSISTANCE WILL PAY PART OF THE COST OF THE ITEM FOR WHICH YOU ARE APPLYING, YOU AREN T ELIGIBLE FOR DEAP.