MAP-205 and MAP-14 Kentucky Forms: Medicare Savings Program Application

What the MAP-205 Is

Form MAP-205 — titled "Application for Medicaid or Medicare Savings Programs" — is Kentucky's paper application for Medicare Savings Programs, including QMB, SLMB, and QI. It's shorter and more targeted than the general Medicaid application forms (KHBE-I10 or KHBE-I11), because it collects only the information DCBS needs for an MSP determination: income, resources, Medicare enrollment status, and household composition.

You can get MAP-205 at any DCBS county office across Kentucky's 120 counties, or request one by calling the DCBS Family Support line at 1-855-306-8959.

What MAP-205 Asks For

The form walks through several sections:

Personal information: Name, date of birth, Social Security number, address, and citizenship or immigration status. If you're married and your spouse lives with you, their information goes here too — DCBS evaluates couples jointly.

Medicare details: Your Medicare Beneficiary Identifier (MBI), Part A and Part B effective dates, and whether you pay a Part A premium. Attach a copy of your red, white, and blue Medicare card.

Income: Gross Social Security benefit (the amount before Part B premiums or tax withholding — this is on your SSA award letter or SSA-1099, not the net deposit amount), pensions, annuities, VA payments, and any earned income from work.

Resources: Checking and savings account balances, CDs, stocks, IRAs, 401(k) balances, life insurance face value and cash surrender value, and vehicle information. Your home, one car, household goods, and designated burial reserves are excluded.

Signature: The applicant (or authorized representative) signs and dates the form. For a phone application, the DCBS call center representative records an electronic signature.

Where to Submit

Mail the completed MAP-205 with supporting documents to the Office of the Kentucky Health Benefit Exchange, 12 Mill Creek Park, Frankfort, KY 40601, or return it to your local DCBS office. You can also fax it to the DCBS Centralized Mail Room at 502-573-2005 or 502-573-2007.

Keep copies of everything you submit so you can quickly resubmit anything DCBS says is missing.

Form MAP-14: Interested Party Authorization

If an adult child, family member, or caregiver is acting as the beneficiary's authorized representative, submit Form MAP-14 or an accepted Power of Attorney or court-ordered guardianship document with the application. MAP-14 lets the applicant choose the representative's authority, including whether they may:

• Apply and report changes
• Recertify
• Receive copies of notices

Without an authorized representative on file who is permitted to receive notices, DCBS sends notices — including renewal packets and denial letters — only to the applicant. If your parent has difficulty reading or responding to official mail, this can lead to missed deadlines and benefit termination.

MAP-205 vs. Applying Online Through kynect

The information is identical — MAP-205 collects the same data points as the kynect online application. The advantage of paper is that seniors who aren't comfortable with online portals can complete it at their own pace, and rural applicants without reliable broadband can submit by mail or in person.

The advantage of kynect is speed: digital submissions are typically processed faster because document uploads are immediately attached to the case file, while mailed documents require manual scanning and indexing at the processing center.

For complete guidance on filling out each section — including the income and resource calculations DCBS performs behind the scenes — the Kentucky Medicare Savings Programs & Extra Help Guide walks through the process field by field.

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