Mc 14A Form – Fill Out and Use This PDF

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.

MAIL COMPLETED FORM TO YOUR COUNTY SOCIAL SERVICES AGENCY.

(ADDRESSES ON BACK SIDE OF THIS FORM)

MC 14 A(09/11)

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�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)

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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.

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.

COUNTY USE

� QMB approved

� SLMB approved

� QI-1 approved

� QMB/SLMB/QI-1 denied

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)

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