KC-1500 Form Kansas — Medical Assistance Application for Medicare Savings
What the KC-1500 Is
Form KC-1500 — titled "Medical Assistance Application for the Elderly and Persons with Disabilities" — is the paper application that Kansas uses for non-MAGI Medicaid programs, including all three Medicare Savings Program tiers (QMB, LMB, ELMB). It is the entry point for low-income seniors and adults with disabilities applying through the KanCare Clearinghouse.
The same form covers long-term care Medicaid and HCBS waiver services. For families applying only for Medicare premium assistance, the key is selecting the right boxes and skipping sections that trigger unnecessary verification.
How to Fill It Out for Medicare Savings Programs
In the program selection section, check "Medicare Savings Programs / Premium Assistance" and leave the long-term care and waiver sections blank. This tells the Clearinghouse to evaluate the application under MSP rules — higher resource limits ($9,950 single / $14,910 couple), no lookback period, and no estate recovery.
Checking the long-term care box by mistake can trigger additional asset verification steps, extending processing time.
The identity and income sections are straightforward: personal information, Social Security claim number, gross monthly benefit amounts, pension income if any, and a list of financial accounts with current balances. Kansas counts gross Social Security before the Part B premium deduction, with a $20 general disregard subtracted.
Documents to Attach
The Clearinghouse verifies income and resources. Submitting these up front prevents the most common delay — an evidence request notice with a 10-to-15-day response window:
- Social Security COLA Award Letter (shows the gross benefit)
- Most recent statements for every bank account, CD, and investment account
- Pension or annuity documentation
- Medicare card (Parts A and B status)
- Life insurance face sheets if total face value exceeds $1,500
Free Download
Get the Kansas — Medicare Savings Program Eligibility Checklist
Everything in this article as a printable checklist — plus action plans and reference guides you can start using today.
The KC-6100: Authorizing a Family Representative
If an adult child manages the application, Form KC-6100 (Medical Representative Authorization) must be on file. Without it, the Clearinghouse cannot release case details to anyone except the applicant.
The KC-6100 grants authority to sign forms, receive copies of state notices, and communicate directly with Clearinghouse staff about the case. If the applicant cannot sign due to physical or cognitive limitations and uses a mark ("X"), two independent witnesses must co-sign.
A related but narrower form — KC-6200 (Facilitator Authorization) — is for community health workers or navigators. It expires after six months or when the pending application cycle ends. For family members managing ongoing care, the KC-6100 is the right choice.
An existing financial Power of Attorney also works in place of the KC-6100, provided the POA document explicitly grants authority over health benefits and government claims. Social Security Representative Payee status alone is not enough — it covers SSA benefits management but does not extend to state Medicaid files.
Where to Submit
- Mail: KanCare Clearinghouse, P.O. Box 3599, Topeka, KS 66601
- Fax: 1-844-264-6285
- In person: DCF offices in Wichita, Topeka, Kansas City, and smaller cities accept paper drop-offs (staff scan and forward to the Clearinghouse)
- Online: applyforKanCare.ks.gov submits the same information electronically
- Phone: 1-800-792-4884 — an agent takes the information verbally and files the electronic KC-1500
Processing takes up to 45 calendar days from receipt. If a disability determination is needed, the window extends to 90 days.
Other Forms You May Encounter
KC-1600 (Pre-Populated Elderly and Disabled Review): the annual renewal form. Arrives pre-filled; review, correct, attach bank statements, and return within 30 days.
KC-1700: passive renewal approval notice — no action needed. The Clearinghouse verified eligibility electronically.
KC-1105 (E&D Supplemental Application): used only when a family has already filed a MAGI application (KC-1100) for children and needs to add MSP coverage for a senior parent.
The Kansas Medicare Savings Programs & Extra Help Guide includes a field-by-field KC-1500 walkthrough and a document assembly checklist so nothing is missed before submission.
Get Your Free Kansas — Medicare Savings Program Eligibility Checklist
Download the Kansas — Medicare Savings Program Eligibility Checklist — a printable guide with checklists, scripts, and action plans you can start using today.