Hawaii Medicare Savings Program Documents Needed for Your Application

The Two Required Forms

Every Hawaii Medicare Savings Program application starts with two state forms filed together:

Form DHS 1100 ("Application for Health Coverage & Help Paying Costs") is the core statewide application. It covers both MAGI and non-MAGI programs in one document — the form runs up to 16 pages because it asks questions for multiple coverage types. For an MSP application, your parent fills out the sections relevant to Medicare beneficiaries aged 65 or older (or under 65 with Medicare through disability).

Form DHS 1100B ("Supplemental Form for Applying for Coverage Other Than MAGI or LTC") is the required supplement. This is the form where Med-QUEST collects the details specific to Medicare Savings Programs: Medicare claim numbers, itemized unearned income sources, and a full asset declaration. Skipping this form is the most common reason applications stall — Med-QUEST cannot process an MSP determination without it.

Both forms are available at any Med-QUEST eligibility office, downloadable from the DHS website, or completed online through the KOLEA portal at medical.mybenefits.hawaii.gov.

Supporting Documents Checklist

Med-QUEST verifies eligibility against documentation in four categories. Submitting everything upfront avoids the back-and-forth requests that delay processing.

Medicare enrollment proof. The red, white, and blue Medicare card showing Part A and/or Part B enrollment, or an SSA Benefit Verification Letter confirming Medicare status. If your parent enrolled through Conditional Part A (common for those lacking 40 work quarters), include the SSA conditional enrollment receipt.

Identity and Hawaii residency. A Hawaii driver's license or state ID card. If neither is current, official mail delivered to a Hawaii residential address — a utility bill, bank statement, or government notice — works as residency proof.

Income documentation. The Social Security Benefit Award Letter, pension or annuity statements, VA benefit letters, and any other income evidence Med-QUEST requests. Med-QUEST uses gross monthly income to calculate countable income after applicable disregards and deductions, so provide documents showing the gross amount before deductions.

Asset documentation. Bank statements for checking, savings, and CD accounts, plus stock or mutual fund statements and documentation for real property other than the primary home. One vehicle is exempt. The primary residence is fully exempt from the MSP resource test regardless of value.

Common Mistakes That Delay Processing

Sending only the DHS 1100 without the DHS 1100B. Med-QUEST requires the supplemental form for Medicare Savings Program applicants and may request it before completing the determination.

Submitting net Social Security deposit amounts instead of gross. The bank deposit is net of the Part B premium deduction ($202.90/month in 2026). Med-QUEST needs the gross figure from the SSA award letter.

Missing signatures. If an adult child fills out the forms without state-recognized representative authority, the senior applicant must sign the DHS 1100. A designated representative may sign under that authorization; follow Med-QUEST's instructions if the applicant is legally incapacitated.

Forgetting the authorized representative form. If an adult child — especially one on the mainland — needs to receive notices, submit documents, and speak with caseworkers on the parent's behalf, Form DHS 1127 ("Appointment of Authorized Representative") must be filed alongside the application. Without it, Med-QUEST cannot share case information with the child.

Our Hawaii Medicare Savings Programs & Extra Help Guide includes a printable document checklist organized by category, a page-by-page walkthrough of the DHS 1100 and 1100B forms, and a submission tracker so you know what you sent and when Med-QUEST should respond.

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