Department of Health Care ServicesState of CaliforniaHealth and Human Services AgencyQUALIFIED MEDICARE BENEFICIARY (QMB), SPECIFIED LOWINCOME MEDICARE BENEFICIARY (SLMB), AND QUALIFYING INDIVIDUALS.

How it works
  • Open form

    Open form follow the instructions

  • Easily sign form

    Easily sign the form with your finger

  • Share form

    Send filled & signed form or save

How to fill out the CA DHCS MC 14A online

The CA DHCS MC 14A form is used to apply for the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI-1) programs in California. This guide will walk you through the steps needed to complete the form effectively and accurately online.

Follow the steps to fill out the CA DHCS MC 14A online.

  1. Click ‘Get Form’ button to access the CA DHCS MC 14A application form and open it in your document management tool.
  2. Fill in your name, Social Security number, and Medicare number in the corresponding fields at the top of the form.
  3. Enter your date of birth and contact information, including your telephone number, to ensure the authorities can reach you if needed.
  4. Specify your gender and marital status by checking the appropriate boxes provided.
  5. Provide your complete address including number, street, city, state, and zip code.
  6. Indicate whether you would like to apply for retroactive coverage for SLMB and QI-1 programs by selecting 'Yes' or 'No'.
  7. List all persons living in your household, including their names, Social Security numbers, dates of birth, and relationships to you.
  8. Fill out the section regarding countable income. Input monthly income sources, including Social Security, VA benefits, retirement income, and any other unearned income.
  9. Complete the property section, detailing the value of your checking and savings accounts, stocks, and other relevant assets.
  10. After filling out all required fields, review the form for accuracy. Ensure all necessary information is complete before proceeding.
  11. Once the form is complete, you can save your changes, download a copy, print it, or share it as needed.

Complete your CA DHCS MC 14A application online today to ensure your eligibility for essential Medicare programs.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Related content

MC14A-ENG.pdf - DHCS

This information is to help you apply for the Qualified Medicare Beneficiary (QMB)...

Learn more
Overview of the Medi-Cal Program - fall in the

15 Jul 2008 — DHCS, Form MC 210, available at...

Learn more
A Curriculum for Developing Culturally and...

This project was developed by the UC Davis Center for Reducing Health Disparities in...

Learn more
Questions & Answers

Get answers to your most pressing questions about US Legal Forms API.

Contact support

What does SLMB mean in Medicare?

The Specified Low-Income Medicare Beneficiary (SLMB) program is one of four Medicaid-administered Medicare Savings Programs (MSPs). What does SLMB mean in Medicare? This MSP pays for the Medicare Part B premium, which is $164.90 per month for most people in 2023. States may have different SLMB income limits.

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.

Medicare Savings Programs (MSPs) are Medicaid-administered programs for people on Medicare who have limited income and resources. These programs help those qualified to afford Medicare.

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

To qualify for QMB, your monthly income cannot exceed $1,215 if you are single ($14,580/year) or $1,643 ($19,720/year) if you are part of a couple. Note: A $20 “disregard” is subtracted from your monthly income (earned or unearned).

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.

What Does SLMB Cover? Because the SLMB program is for people with higher incomes, SLMBs get fewer benefits than QMBs. The SLMB program pays the Medicare Part B monthly premium, but doesn't pay any Medicare deductibles or coinsurance amounts.

If your income is slightly too high for you to qualify for QMB benefits, you may still be eligible for another state medical assistance program: Specified Low-Income Medicare Beneficiary (SLMB). The resource limits for SLMB eligibility are the same as for a QMB, but the income limits are 20% higher.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

If you believe that this page should be taken down, please follow our DMCA take down process here.

Get CA DHCS MC 14A