This version of the form is not currently in use and is provided for reference only. Download this version of Form MC14A for the current year.

Form MC14A Qualified Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individuals (Qi-1) Application - California

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What Is Form MC14A?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is a Qualified Medicare Beneficiary (QMB)?
A: A Qualified Medicare Beneficiary (QMB) is a person who qualifies for full coverage of Medicare Part A and Part B premiums, as well as deductibles and coinsurance.

Q: What is a Specified Low-Income Medicare Beneficiary (SLMB)?
A: A Specified Low-Income Medicare Beneficiary (SLMB) is a person who qualifies for assistance in paying for Medicare Part B premiums.

Q: What is a Qualifying Individual (QI-1)?
A: A Qualifying Individual (QI-1) is a person who qualifies for assistance in paying for Medicare Part B premiums.

Q: What is the purpose of the MC14A application?
A: The MC14A application is used to apply for the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI-1) programs in California.

Q: Who is eligible for the QMB program?
A: To be eligible for the QMB program, you must be enrolled in Medicare Part A and meet certain income and asset requirements.

Q: Who is eligible for the SLMB program?
A: To be eligible for the SLMB program, you must be enrolled in Medicare Part A and have income and resources below certain limits.

Q: Who is eligible for the QI-1 program?
A: To be eligible for the QI-1 program, you must be enrolled in Medicare Part A and meet certain income and asset requirements.

Q: Are there any fees or costs associated with these programs?
A: No, there are no fees or costs associated with the QMB, SLMB, and QI-1 programs.

Q: What documents do I need to include with my MC14A application?
A: You will need to include proof of your income, assets, and Medicare enrollment with your MC14A application.

Form Details:

Released on April 1, 2015;
The latest edition provided by the California Department of Health Care Services;
Easy to use and ready to print;
Quick to customize;
Compatible with most PDF-viewing applications;
Fill out the form in our online filing application.

Download a fillable version of Form MC14A by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.