Form Mc 14 A PDF Details

Navigating the complexities of healthcare coverage can be daunting, especially for those on Medicare who may find themselves needing additional support to cover premiums, deductibles, and coinsurances. This is where forms like the MC 14A come into play, a vital tool for individuals seeking financial help through the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) programs. Offered by the State of California—Health and Human Services Agency, the MC 14A form acts as an application for these programs, aiming to alleviate some of the financial burdens associated with Medicare. The form requires essential information such as name, social security number, and detailed income and property information, ensuring that the state can accurately determine eligibility for the QMB program, which covers Parts A and B premiums, deductibles, and coinsurance fees, or the SLMB and QI-1 programs, which assist with Part B premiums. Applicants must meet specific criteria regarding their Medicare Part A and B eligibility, reside in California, and their income and property must fall below certain thresholds. The importance of accurately completing this form cannot be overstated, as it opens the door to potential financial assistance for Medicare beneficiaries who might otherwise struggle to afford their healthcare costs.

QuestionAnswer
Form NameForm Mc 14 A
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesMERCED, California, mc14a spanish, FPL

Form Preview Example

State of California—Health and Human Services Agency

Department of Health CARE Services

QUALIFIED MEDICARE BENEFICIARY (QMB),

SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (SLMB),

AND QUALIFYING INDIVIDUALS (QI) APPLICATION

 

 

 

 

 

 

 

 

 

Name

 

 

Social security number

Medicare number

 

Date

 

 

 

 

 

 

 

 

Telephone number

Date of birth

 

Sex

Marital status

Married

Divorced

(

)

 

 

Male Female

Separated

Single

Widowed

 

 

 

 

 

 

 

 

Address (number, street)

 

 

City

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

This information is to help you apply for the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (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:

Be eligible for Medicare Part A (hospital insurance).

Be eligible for Medicare Part B (medical insurance).

Meet the following income requirements:

QMB: Net countable income at or below 100% of the Federal Poverty Level (FPL) (at or below $908* for a single person, or $1,226* for a couple).

SLMB: Net countable income below 120% of the FPL (below $1,089* for a single person, or $1,471* for a couple).

QI-1: Net countable income below 135% of the FPL (below $1,226* for a single person, or $1,655* 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.

Have no more than $6,680 in nonexempt property for a single person, or $10,020 for a couple.

Meet certain requirements and conditions, such as being a resident of California.

IMPORTANT:

 

 

You may be eligible for other Medi-Cal programs in addition to the QMB and SLMB programs, such as food

Yes

No

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

Yes

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.

Name

 

Sex

 

 

 

M=Male

 

 

Social Security Number

F=Female

Date of Birth

Relationship to You

MAIL COMPLETED FORM TO YOUR COUNTY SOCIAL SERVICES AGENCY. (Addresses at the bottom of this form)

MC 14 A(09/11)

Page 1 of 3

A. COUNTABLE INCOME

1. Fill in the MONTHLY unearned income received by the QMB/SLMB/QI-1 applicant:

a.

Social security check

$_______________

b.

VA benefits

$_______________

c.

Interest from bank accounts or certificate(s) of deposit

$_______________

d.

Retirement income

$_______________

e.

Any other unearned income

$_______________

f.

Total UNEARNED INCOME—add lines a. through e.

$_______________

2.If you are married and living with your SPOUSE, fill in the MONTHLY unearned income received by your spouse:

g.

Social security check

$_______________

h.

VA benefits

$_______________

i.

Interest from bank accounts or certificate(s) of deposit

$_______________

j.

Any other unearned income

$_______________

k.

Retirement income

$_______________

l.

Total SPOUSE’S UNEARNED INCOME—add lines g. through k.

$_______________

3.Fill in the MONTHLY earned income received by the QMB/SLMB/QI applicant and 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. and n.

$_______________

p.

Subtract $65

$_______________

q.

Remainder

$_______________

r.

Divide by 2

$_______________

s.

Total EARNED AND UNEARNED INCOME—

$_______________

 

add lines f., l., and r.

 

4. Potential QMB, SLMB, or QI-1 eligibles:

COUNTY USE

Applicant’s

 

unearned

 

income

 

(line f)

$____________

Spouse’s

 

unearned

 

income

 

(line l)

+____________

 

____________

Any

 

income

 

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 form.

You are potentially eligible as a QMB if your income is at or below 100% of the FPL (at $908* for a single person, or at $1,226* for a couple.

You are potentially eligible as a SLMB if your income is below 120% of FPL (below $1,089* for a single person, or below $1,471* for a couple).

You are potentially eligible as a QI-1 if your income is below 135% of FPL (below 1,226* for a single person, or below $1,655* for a couple).

*If you have a child in the home, these amounts may be higher.

MC 14 A (09/11)

Page 2 of 3

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 $6,600. A QMB, SLMB, or QI-1 who is married and living with his/her spouse must have countable property which is equal to or less than $9,910.

The following are examples of countable property. Important: The home you and/or a spouse live in doesnotcount. 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., certificates 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 accounts

$_______________

3.

Certificate(s) of deposit

$_______________

4.

Stocks

$_______________

5.

Bonds

$_______________

6.

A second car (value minus amount owed)

$_______________

7.

A second home (value minus amount owed)

$_______________

8.The cash surrender value of life insurance policies if the face value of all policies combined exceeds $1,500

(Do not include “term” insurance policies)

$_______________

9. Total PROPERTY—add lines 1 through 8

**$_______________

**This total cannot exceed $6,680 for a single person or $10,020 for a couple.

COUNTY USE

Additional information: You may be eligible for up to three months of retroactive coverage of your Medicare Part B premiums under the SLMB and QIprograms.

NOTE: Individuals enrolled in traditional Medi-Cal, in addition to the QMB/SLMB/QIprograms, may be subject to Estate Recovery. Medi-Cal benefits 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 beneficiary if the beneficiary does not leave a surviving spouse, minor children, or a totally disabled or blind son or daughter.

Individuals enrolled in only the QMB/SLMB/QIprograms, however, are not subject to Estate Recovery.

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.

Signature (or mark) of applicant

Date

COUNTY USE

QMB approved

SLMB approved

QI-1 approved

QMB/SLMB/QI-1 denied

Eligibility Worker’s signature

Date

Privacy Statement

This information given in this application is private and confidential under Welfare and Institutions Code 14100.2. This information will be disclosed only in accordance with those laws.

Sections 14011 and 14012 of the Welfare and Institutions Code allow county welfare departments to get certain facts from you, or the person(s) you represent, so that you can get Medi-Cal benefits. You must provide these facts to get some or all of your Medicare costs paid by Medi-Cal. You are required to provide your Social Security Number under the Social Security Act, Section 1137(a)(1) and the Welfare and Institutions Code, Section14011.2.

MC 14A (09/11)

Page 3 of 3

Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary

(SLMB)/Qualifying Individual (QI) Counties’ List

Mail completed form to your county listed below:

ALAMEDA COUNTY (01)

Social Services Agency

QMB/SLMB/QI Program

7751 Edgewater Drive

Oakland, CA 94621

(510)383-8749

(510)569-5017 FAX

ALPINE COUNTY (02) Health and Human Services QMB/SLMB/QI Program

75 Diamond Valley Road Markleeville, CA 96120 (530) 694-2235

AMADOR COUNTY (03)

Department of Social Services

QMB/SLMB/QI Program

1003 Broadway

Jackson, CA 95642

(209)223-6550

(209)223-6208 FAX

BUTTE COUNTY (04) Department of Social Welfare QMB/SLMB/QI Program P.O. Box 1649

Oroville, CA 95965 (530) 879-3521

CALAVERAS COUNTY (05) Calaveras Works and Human

Services Agency

QMB/SLMB/QI Program

891 Mountain Ranch Road San Andreas, CA 95249 (209)754-6444

(209) 754-6543 FAX

COLUSA COUNTY (06)

Department of Social Welfare

QMB/SLMB/QI Program

251 East Webster Street

Colusa, CA 95932

(530)458-0250

(530)458-0492 FAX

CONTRA COSTA COUNTY (07) Employment and Human Services

Department QMB/SLMB/QI Program 40 Douglas Drive Martinez, CA 94553 (866) 663-3225

DEL NORTE COUNTY (08) Department of Social Services QMB/SLMB/QI Program 880 Northcrest Drive Crescent City, CA 95531 (707) 464-3191

EL DORADO COUNTY (09) Department of Social Services QMB/SLMB/QI Program 3057 Briw Road Placerville, CA 95667

(530) 642-7300

FRESNO COUNTY (10) Employment and Temporary

Assistance Department QMB/SLMB/QI Program P.O. Box 1912

Fresno, CA 93750 (559) 253-9051

GLENN COUNTY (11)

Human Resources Agency

QMB/SLMB/QI Program

420 East Laurel Street

P.O. Box 611

Willows, CA 95988

(530)934-6514

(530)934-6521 FAX

HUMBOLDT COUNTY (12) Department of Social Services QMB/SLMB/QI Program 929 Koster Street

Eureka, CA 95501 (707) 445-7706

IMPERIAL COUNTY (13) Department of Social Services QMB/SLMB/QI Program

2995 South Fourth Street, Suite 105 El Centro, CA 92243

(760) 337-6820

INYO COUNTY (14) Department of Social Services QMB/SLMB/QI Program 914 North Main Street Bishop, CA 93514

(760) 872-1394

KERN COUNTY (15) Department of Human Services QMB/SLMB/QI Program

100 East California Avenue Bakersfield, CA 93302 1-888-506-2200

KINGS COUNTY (16)

Human Services Agency

QMB/SLMB/QI Program

1200 South Drive

Hanford, CA 93230

(559)582-3241

(559)585-0346 FAX

LAKE COUNTY (17)

Department of Social Services

QMB/SLMB/QI Program

15975 Anderson Ranch Parkway

P.O. Box 9000

Lower Lake, CA 95457

(707)995-4200

(707)995-4204 FAX

LASSEN COUNTY (18) Department of Social Services QMB/SLMB/QI Program 720 Richmond Road

P.O. Box 1359 Susanville, CA 96130 (530) 251-8152

LOS ANGELES COUNTY (19) Department of Social Services QMB/SLMB/QI Program

17171 East Gale Avenue City of Industry, CA 91745 (626) 854-4987

MADERA COUNTY (20) Department of Social Services QMB/SLMB/QI Program

720 East Yosemite Avenue P.O. Box 569

Madera, CA 93639 (559) 675-2300

MARIN COUNTY (21) Department of Health and Human

Services

3501 Civic Center Branch P.O. Box 4160

San Rafael, CA 94913 (415) 499-7089

MC 14 A (05/07) COUNTIES LISTING

Page 1(a)

Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary

(SLMB)/Qualifying Individual (QI) Counties’ List

Mail completed form to your county listed below:

MARIPOSA COUNTY (22) Department of Human Services QMB/SLMB/QI Program 5186 Highway 49 North

P.O. Box 7 Mariposa, CA 95338 (209) 966-3609

MENDOCINO COUNTY (23) Department of Social Services QMB/SLMB/QI Program 747 South State Street P.O. Box 8508

Ukiah, CA 95482 (707) 463-7828

MERCED COUNTY (24)

Human Services Agency

QMB/SLMB/QI Program

2115 West Wardrobe Avenue

P.O. Box 112

Merced, CA 95341-0112

(209)385-3000

(209)725-3583 FAX

MODOC COUNTY (25) Department of Social Services QMB/SLMB/Qi Program 120 North Main Street Alturas, CA 96101

(530) 233-6501

MONO COUNTY (26) Department of Social Services QMB/SLMB/QI Program P.O. Box 2969 Bridgeport, CA 93517

(619) 932-7291

MONTEREY COUNTY (27)

Department of Social Services

QMB/SLMB/QI Program

1000 South Main Street, Suite 208

Salinas, CA 93901

(831)755-4407/755-4400

(831)755-8408 FAX

NAPA COUNTY (28) Department of Social Services QMB/SLMB/QI Program 2261 Elm Street

Napa, CA 94558 (707) 253-4106

NEVADA COUNTY (29)

Department of Public Social Services

Adult and Family Services

950 Maidu Avenue

P.O. Box 1210

Nevada City, CA 95959

(530)265-1340

(530)265-7062 FAX

ORANGE COUNTY (30) Social Services Agency QMB/SLMB/QI Program

888 North Main Street, #158C P.O. Box 1772 (92702-1772) Santa Ana, CA 92701-3518 (714) 541-7750

PLACER COUNTY (31) Health and Human Services QMB/SLMB/QI Program 11519 B Avenue Auburn, CA 95603

(530) 889-7609

PLUMAS COUNTY (32) Department of Social Services QMB/SLMB/QI Program

270 County Hospital Road, Room 207

Quincy, CA 95971 (530) 283-6350

RIVERSIDE COUNTY (33)

Department of Public Social Services

QMB/SLMB/QI Program

731 Palmyrita Avenue

Riverside, CA 92507

(Call Local Department of Social

Services)

SACRAMENTO COUNTY (34)

Department of Human Assistance

QMB/SLMB/QI Program

1725 28th Street

Sacramento, CA 95816

(916)874-2580

(916)874-2565 FAX

SAN BENITO COUNTY (35) Human Services Agency QMB/SLMB/QI Program 1111 San Felipe Road, #206 Hollister, CA 95023

(831) 636-4180

SAN BERNARDINO COUNTY (36)

Human Services System Traditional

Assistance Department

QMB/SLMB/QI Program

825 East Hospitality Lane

San Bernardino, CA 92415-0079

(Call Local Department of Social

Services)

SAN DIEGO COUNTY (37)

Health and Human Services Agency QMB/SLMB/QI Program

7947 Mission Center Court San Diego, CA 92108 (619) 767-5022

SAN FRANCISCO COUNTY (38) Medi-Cal Health Connections QMB/SLMB/QI Program

P.O. Box 7988

San Francisco, CA 94120 (415) 558-1855

SAN JOAQUIN COUNTY (39) Human Services Agency QMB/SLMB/QI Program 333 East Washington

P.O. Box 201056 Stockton, CA 95201-3006 (209) 468-1453

SAN LUIS OBISPO COUNTY (40) Department of Social Services QMB/SLMB/QI Program

P.O. Box 8119

San Luis Obispo, CA 93403-8119 (805) 781-1885

SAN MATEO COUNTY (41) Department of Social Services QMB/SLMB/QI Program

400 Harbor Boulevard, Building C Belmont, CA 94002

(650) 595-7570

SANTA BARBARA COUNTY (42) Department of Social Services QMB/SLMB/QI Program

1100 West Laurel Avenue Lompoc, CA 93436 (805) 737-7056

MC 14 A (05/07) COUNTIES LISTING

Page 2(a)

Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary

(SLMB)/Qualifying Individual (QI) Counties’ List

Mail completed form to your county listed below:

SANTA CLARA COUNTY (43)

Social Services Agency

QMB/SLMB/QI Program

1725 Technology Drive

San Jose, CA 95110-1305

(408)441-5590

(408)436-5493 FAX

SANTA CRUZ COUNTY (44) Human Resources Agency QMB/SLMB/QI Program 1320 Emeline Street Santa Cruz, CA 95061 (831) 454-4260

SHASTA COUNTY (45) Department of Social Services QMB/SLMB/QI Program P.O. Box 496005 Redding, CA 96049

(530) 225-5767

SIERRA COUNTY (46)

Human Services

QMB/SLMB/QI Program

202 Front Street

P.O. Box 1019

Loyalton, CA 96118

(530)993-6725

(530)993-6767 FAX

SISKIYOU COUNTY (47)

Human Services

QMB/SLMB/QI Program

818 South Main

Yreka, CA 96097

(530)938-5100

(530)938-5116 FAX

SOLANO COUNTY (48) Health and Social Services

Department. QMB/SLMB/QI Program 1745 Enterprise Drive Fairfield, CA 94533 1-800-400-6001

SONOMA COUNTY (49) Human Services Department QMB/SLMB/QI Program 520 Mendocino Avenue P.O. Box 1539

Santa Rosa, CA 95402 (707) 565-5304

STANISLAUS COUNTY (50) Comm. Services Agency QMB/SLMB/QI Program 251 East Hackett Road Modesto, CA 95358

P.O. Box 42

Modesto, CA 95347-5351 1-800-962-4468

(209) 558-2189 FAX

SUTTER COUNTY (51)

Welfare and Social Services

QMB/SLMB/QI Program

190 Garden Highway

P.O. Box 1535

Yuba City, CA 95992-1535

(530) 822-7230 Ext. 218

TEHAMA COUNTY (52) Department of Social Services QMB/SLMB/QI Program 22840 Antelope Building P.O. Box 1515

Red Bluff, CA 96080 (530) 527-1911

TRINITY COUNTY (53) Department of Health and Human

Services QMB/SLMB/QI Program P.O. Box 1470 Weaverville, CA 96093 (530) 623-1265

TULARE COUNTY (54)

Health and Human Services

QMB/SLMB/QI Program

5957 South Mooney Boulevard

Visalia, CA 93277

(209)737-4660

(209)737-4694 FAX

TUOLUMNE COUNTY (55) Department of Social Services QMB/SLMB/QI Program 20075 Cedar Road North Sonora, CA 95370

(209) 533-5711

VENTURA COUNTY (56) Human Services Agency QMB/SLMB/QI Program 505 Poli Street Ventura, CA 93001 (805) 652-7522

YOLO COUNTY (57) Department of Employment and

Social Services

QMB/SLMB/QI Program

500 A Jefferson Boulevard, Suite 100 West Sacramento, CA 95605 (916) 375-6214

YUBA COUNTY (58) Human Services Agency QMB/SLMB/QI Program

6000 Lindhurst Avenue, #504 P.O. Box 2320 Marysville, CA 95901 (530) 749-6311

MC 14 A (05/07) COUNTIES LISTING

Page 3(a)

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Part number 1 in filling in NEVADA

2. Soon after completing this section, go on to the next stage and complete all required details in these blank fields - IMPORTANT You may be eligible for, List all persons living in your, Name, Social Security Number, Sex, MMale, FFemale, Date of Birth, Relationship to You, MAIL COMPLETED FORM TO YOUR COUNTY, Addresses at the bottom of this, MC A, and Page of.

Part no. 2 for completing NEVADA

3. In this specific stage, have a look at Fill in the MONTHLY unearned, COUNTY USE, a Social security check, b VA benefits, Interest from bank accounts or, d Retirement income, e Any other unearned income, f Total UNEARNED INCOMEadd lines a, Applicants unearned income line f, Spouses unearned income line l, If you are married and living with, g Social security check, h VA benefits, Any income deduction, and Interest from bank accounts or. All of these are required to be completed with utmost precision.

d Retirement income, Applicants unearned income line f, and If you are married and living with of NEVADA

4. The next part will require your involvement in the subsequent parts: m Gross earnings for the person, SLMB or QI, n Gross earnings for the spouse, o Totaladd lines m and n, p Subtract, q Remainder, r Divide by, s Total EARNED AND UNEARNED INCOME, add lines f l and r, Potential QMB SLMB or QI eligibles, Total net income, MFBU size, Compare to QMBSLMBQIQI income limit, If over income limit is there a, and You are potentially eligible as a. Make sure you enter all needed details to go further.

How you can fill in NEVADA stage 4

5. The very last section to finalize this form is critical. Ensure that you fill in the displayed blanks, for example Checking accounts, Savings accounts, Certificates of deposit, Stocks, Bonds, A second car value minus amount, A second home value minus amount, The cash surrender value of life, the face value of all policies, Total PROPERTYadd lines through, This total cannot exceed for a, Additional information You may be, I declare under penalty of perjury, and Date, before submitting. Failing to do this could give you an incomplete and possibly incorrect form!

How you can fill in NEVADA part 5

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