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NDIVIDUALS (QI-1) APPLICATION Name Social Security Number Medicare Number Telephone Number ( ) Date of Birth Sex Marital Status Address (number, street) City State Zip Code q Male q Female Date q Separated q Married q Single q Divorced q Widowed 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, d.

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Full Duals and Qualified Medicare Beneficiary (QMB) Only The Qualified Medicare Beneficiary (QMB) program helps District residents who are eligible for Medicare pay for their Medicare costs. This means that Medicaid will pay for the Medicare premiums, co-insurance and deductibles for Medicare covered services.

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).

Is QMB Full Medicaid? While QMB is administered by your state Medicaid agency, it's a separate program from Medicaid and provides different coverage. For example, Medicaid covers vision and dental, but QMB doesn't. Qualifying for QMB does not mean you automatically qualify for Medicaid.

Full Duals and Qualified Medicare Beneficiary (QMB) Only The Qualified Medicare Beneficiary (QMB) program helps District residents who are eligible for Medicare pay for their Medicare costs. This means that Medicaid will pay for the Medicare premiums, co-insurance and deductibles for Medicare covered services.

The Qualified Medicare Beneficiary (QMB) program provides Medicare coverage of Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries.

Benefits of the QMB program include: Medicare Part A & B premiums paid back in your Social Security Check. Medicare Part D premium reduced or covered through the Low-Income Subsidy (LIS) / Extra Help program. Medication costs reduced to $0 – $10 for most medications through the LIS / Extra Help program.

Qualified Medicare Beneficiary Plus (QMB+) offers the same benefits as QMB Only except for one big difference: People with QMB+ also have full Medicaid benefits. This means that people with QMB Plus may be eligible to receive supplies through Medicaid. Coverage and plan availability will vary by state.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232