DHS 1100 Application for Hawaii Medicare Savings Programs
The Two Forms You Need
Hawaii's Medicare Savings Program application requires two forms submitted together:
DHS 1100 is the general health coverage application — it covers everything from ACA Medicaid to Medicare Savings Programs. The form runs up to 16 pages because it is designed for multiple coverage types. For an MSP-only application, several sections are irrelevant, which is why families find it confusing.
DHS 1100B is the supplemental form specifically for non-MAGI applicants — anyone applying based on age (65+), blindness, or disability rather than income-only ACA rules. This is where Med-QUEST collects Medicare claim numbers, a detailed breakdown of unearned income, and a full asset inventory. Without DHS 1100B, Med-QUEST cannot process the MSP determination.
Both forms are available at any Med-QUEST eligibility office, through the DHS website, or integrated into the online KOLEA portal at medical.mybenefits.hawaii.gov.
What to Fill Out on DHS 1100
For a senior applying specifically for Medicare Savings Programs, focus on these sections:
Personal information. Full legal name, date of birth, Social Security number, Hawaii residential address, and mailing address if different. If an adult child is helping, the child's contact information goes in the authorized representative section — but also file DHS 1127 separately for full representative authority.
Household composition. Provide the household information requested on the form. For MSP eligibility under the Aged, Blind, and Disabled (non-MAGI) rules, an adult child's income is not counted.
Medicare status. Confirm enrollment in Medicare Part A and/or Part B. Include the Medicare Beneficiary Identifier (MBI) from the red, white, and blue card.
Income section. Report all sources of gross monthly income — Social Security benefits (the gross amount from the award letter, not the net deposit), private pensions, VA benefits, and annuity payments. Med-QUEST uses gross income to calculate countable income after applicable disregards and deductions.
Signature. If no DHS 1127 or other state-recognized authorization is on file, the applicant must sign; a designated representative may sign under that authorization. Follow Med-QUEST's instructions if the applicant is legally incapacitated.
Some questions cover programs beyond MSP. Follow the form instructions and answer each required item; if an item does not apply to an MSP-only application, confirm the correct response with Med-QUEST.
What DHS 1100B Adds
The supplemental form asks for details the general form does not cover:
Medicare claim number and coverage dates. The specific Part A and Part B enrollment dates, which Med-QUEST uses to determine retroactive coverage eligibility (SLMB and QI allow up to three months retroactive).
Itemized asset declaration. Checking accounts, savings accounts, CDs, stocks, mutual funds, bonds, and any real property besides the primary home. The primary residence, one vehicle, household goods, burial spaces, and irrevocable prepaid funeral contracts are exempt. Revocable burial funds are excluded up to $1,500 per spouse.
Detailed income breakdown. This section separates earned and unearned income more granularly than the DHS 1100. Pension names, VA benefit types, and any regular financial contributions from family members go here.
Free Download
Get the Hawaii — Medicare Savings Program Eligibility Checklist
Everything in this article as a printable checklist — plus action plans and reference guides you can start using today.
Submission Options
Online through medical.mybenefits.hawaii.gov — the KOLEA portal walks through both forms interactively and accepts document uploads during the same session.
Fax to the Med-QUEST eligibility office for your parent's island. Fax provides immediate confirmation and avoids mail transit delays.
Mail to the island office's mailing address. Allow extra time for delivery, especially when mailing from the mainland.
In person at any Med-QUEST eligibility office.
Our Hawaii Medicare Savings Programs & Extra Help Guide provides a page-by-page walkthrough of both forms with annotations showing which sections to complete for each MSP tier, sample entries for common income scenarios, and a pre-submission checklist to ensure nothing is missing before you file.
Get Your Free Hawaii — Medicare Savings Program Eligibility Checklist
Download the Hawaii — Medicare Savings Program Eligibility Checklist — a printable guide with checklists, scripts, and action plans you can start using today.