Fillable QUALIFIED MEDICARE BENEFICIARY (QMB), SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (Department of Health Care Services)

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QUALIFIED MEDICARE BENEFICIARY (QMB), SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (Department of Health Care Services)

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MC 14A (4/15) ENG
Name Social Security Number Medicare Number Date
Telephone Number
( )
Date of Birth Sex
q Male q Female
Marital Status
q Separated
q Married
q Single
q Divorced
q Widowed
Address (number, street) City State Zip Code
q Yes q No
q Yes q No
IMPORTANT
You may be eligible for other Medi-Cal programs in addition to the QMB and SLMB programs, such as food
stamps and/or Medi-Cal with a monthly spenddown (share-of-cost). You may also be eligible for Medi-Cal with
a monthly share-of-cost if you are over the income limits of the QMB, SLMB, and QI-1 programs. This coverage
would include payment of the Medicare Part B premium. If you wish to apply for these other programs, check
yes and the county will send you other forms to complete.
Do you wish to apply for three months of retroactive coverage for the SLMB and QI-1 programs (there is no
retroactive coverage for QMB).
List all persons living in your household (spouse/children). If you have more than three persons living
with you, you may list them on a separate page.
QUALIFIED MEDICARE BENEFICIARY (QMB),
SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (SLMB),
AND QUALIFYING INDIVIDUALS (QI-1) APPLICATION
This information is to help you apply for the Qualied Medicare Beneciary (QMB), Specied Low-Income Medicare
Beneciary (SLMB), or the Qualifying Individual-1 (QI-1) programs. The State will pay Medicare Parts A and B premiums,
deductibles, and coinsurance fees for persons eligible for the QMB program. The State will pay Medicare Part B premiums
for persons eligible for SLMB or QI-1. You may apply for QMB, SLMB, or QI-1 by completing and mailing this form to your
local county social services agency.
To be eligible for QMB, SLMB, or QI-1, you must
yy Be eligible for Medicare Part A (hospital insurance).
yy
Be eligible for Medicare Part B (medical insurance).
yy
Meet the following income requirements
5y QMB: Net countable income at or below 100% of the Federal Poverty Level (FPL) (at or below
$981* for a single person, or $1,328* for a couple).
5y
SLMB: Net countable income below 120% of the FPL (below $1,177* for a single person, or $1,593*
for a couple).
5y
QI-1: Net countable income below 135% of the FPL (below $1,325* for a single person, or $1,793*
for a couple)
*If you have a child living in the home with you, these amounts may be higher. These amounts are expected to increase each year in April.
If you received a Title II Social Security cost of living adjustment in January, this amount will not be counted until April.
yy
Have no more than $7,280 in nonexempt property for a single person or $10,930 for a couple.
yy
Meet certain requirements and conditions, such as being a resident of California.
Name Social Security Number
Sex
M=Male
F=Female
Date of Birth Relationship to You
MAIL COMPLETED FORM TO YOUR COUNTY SOCIAL SERVICES AGENCY. SEE LINK BELOW FOR ADDRESSES.
http://www.dhcs.ca.gov/formsandpubs/forms/Forms/MEB%20Translated%20Forms/mc14a-cntylist-sp.pdf
Page 1 of 4
MC 14A (4/15) ENG
s or certicate(s) of deposit
e. Any other unearned income
f. Total UNEARNED INCOME–add lines a. through e.
f you are married and living with your SPOUSE, ll in the MONTHL
eceived by your spouse:
g. Social Security check
h. VA benets
i. Interest from bank accounts or certicate(s) of deposit
j. Any other unearned income
k. Retirement income
l. Total SPOUSE’S UNEARNED INCOME–add lines g. through k
ill in the MONTHLY earned income received by the QMB/SLMB/Q
nd spouse:
m. Gross earnings for the person who wants to be a QMB,
SLMB,or QI-1
n. Gross earnings for the spouse
o. Total–add lines m. through n.
p. Subtract $65
q. Remainder
r. Divide by 2
otal Income:
dd lines f., I., and r
s. Minus $20 (any income deduction)
b. VA benets
c. Interest from bank account
d. Retirement income
a. Social Security check
$
$
$
$
$
Y
$
$
$
$
$
. $
I-1
$
$
$
$
$
$
$
$
$
u
$ ___________
A. COUNTABLE INCOME
1. Fill in the MONTHLY unearned income received by the QMB/SLMB/QI-1 applicant:
2. I nearned income
r
3. F applicant
a
4. T
A
5. TOTAL COUNTABLE INCOME
6. Potential QMB, SLMB, or QI-1 eligibles:
5 You are potentially eligible as a QMB if your income is at or below 100% of the FPL
(at $981* for a single person, or at $1,328* for a couple).
5 You are potentially eligible as a SLMB if your income is below 120% of FPL
(below $1,177* for a single person, or below $1,593* for a couple).
5 You are potentially eligible as a QI-1 if your income is below 135% of FPL
(below $1,325* for a single person, or below $1,793* for a couple).
*If you have a child in the home, these amounts may be higher.
Applicant’s
unearned
income (line f) $
Spouse’s
unearned
income (line l) +
Any
In
come
deduction -
Net
unearned
income
Net
earned
income
(line r) +
Total
net income
MFBU size
Compare to
QMB/SLMB/QI-1/QI-2
income limit.
If over income limit, is there a
spouse and/or children in the
home? Complete the MC 176-2 A
QMB/SLMB/QI-1 form.
COUNTY USE
Page 2 of 4
State of California–-Health and Human Services Agency
Department of Health Care Services
Date
Signature (or mark) of applicant
County Use
q QMB approved q SLMB approved q QI-1 approved q QMB/SLMB/QI-1-denied
Eligibility Worker’s signature Date
COUNTY USE
B. PROPERTY
A QMB, SLMB, or QI-1 who is not married or not living with his/her spouse may have countable property which is equal
to or less than $7,280. A QMB, SLMB, or QI-1 who is married and living with his/her spouse must have countable prop-
erty which is equal to or less than $10,930.
The following are examples of countable property. Important: The home you and/or a spouse live in does not count. One car
used for transportation does not count. If you apply at the county welfare department as a QMB, SLMB, or QI-1, the county
may treat the property listed on this form differently. There are other types of property which the county welfare department,
will also look at, i. e., certicate(s) of deposit. This other property may or may not count towards the property limit.
Fill in the value of the following property which belongs to you, your spouse, or both of you.
1. Checking accounts $
2. Savings account $
3. Certicate(s) of deposit $
4. Stocks $
5. Bonds $
6. A second car (value mi nus amount owed) $
7. A second home (value minus amount owned) $
8. The cash surrender value of life insurance policies if $
the face val ue of all policies combined exceeds $1,500
(Do not include “term” insurance poli cies)
9. Total PROPERTY- add lines 1 through 8 **$
**This total cannot exceed $7,280 for a single person or $10,930 for a coupl e.
Additional information: You may be eligible for up to three months of retroactive coverage of your Medicare Part B
premiums under the SLMB and QI-1 programs.
NOTE: Individuals enrolled in traditional Medi-Cal, (but not QMB/SLMB/QI-1 programs) may be subject to Estate Recovery.
Medi-Cal benets received by an individual after age 55 may be recoverable by the State. Recovery may be made from
the estate or the distributee/heir of the Medi-Cal beneciary if the beneciary does not leave a surviving spouse, minor
children, or a totally disabled or blind son or daughter. Individuals enrolled in the QMB/SLMB/QI-1 programs (either
in combination with Medi-Cal or without), however, are not subject to Estate Recovery for Medicare premiums,
deductibles or co-payments.
I declare under penalty of perjury, under the laws of the United States of America and the State of California, that
information I have given on this form is true, correct, and complete.
MC 14A (4/15) ENG
Page 3 of 4
MC 14A (4/15) ENG
DHCS PRIVACY STATEMENT
This form is for receiving benets through the Department of Health Care Services (DHCS). The personal
and medical information you provide on it is private and condential. DHCS needs it to identify you and the
other people on this form and to administer our programs. We will share your information with other state,
federal, and local agencies, contractors, health plans, and programs only to administer programs, and with
other state and federal agencies as required by law.
You must answer all of the questions on this form unless they are marked “optional.” If your form is missing
anything that we require, we will contact you to get it. If you do not provide it, we will not be able to make a
decision on your benets. You may have to submit a new application, or services may be denied.
In most cases, you have the right to see personal information about you that is in federal and state records.
You can see it in an alternative format (such as large print) if you need that. For more information, contact
the DHCS Information Protection Unit at:
P.O. Box 997413, MS 4721
Sacramento, CA
95899-7413
Phone: 1-866-866-0602
TTY: 1-877-735-2929
These state laws give us the right to collect and keep the information: CA Welfare and Institutions Code §
14011 and Article 3, Chapters 5 and 7, Parts 2 and 3, Division 9. We must give you this Privacy Statement
under CA Civil Code § 1798.17.
Page 4 of 4
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QUALIFIED MEDICARE BENEFICIARY (QMB), SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (Department of Health Care Services)

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Completed 30 July 2020

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