Form Mc 008 - Qualified Medicare Beneficiary Program Information Notice printable pdf download

Form Mc 008 - Qualified Medicare Beneficiary Program Information Notice

State of California–Health and Human Services Agency

Department of Health Care Services

QUALIFIED MEDICARE BENEFICIARY PROGRAM

INFORMATION NOTICE

This notice is to help you decide whether to apply for the Qualified Medicare Beneficiary (QMB)

Program. People eligible for this program will have their expenses for Medicare Part A and Part B

premiums, coinsurance and deductibles paid by the Medi-Cal program. You may apply for the QMB

program at your local county department of social services.

There are four requirements which you must meet if you want to be a QMB.

HERE ARE THE FOUR REQUIREMENTS:

1. A QMB must be eligible for Medicare Part A (Hospital Insurance).

2. A QMB must have income which is equal to or less than $908 if he/she is a single person or

$1,226 if he/she is married and living with a spouse.

3. A QMB must have property which is equal to or less than $6,680 if he/she is single or equal to or

less than $10,020 if he/she is married and living with a spouse.

4. A QMB must meet cert ain other requirement s and conditions which are p art of the Medi-Cal

program, such as being a California resident.

The following gives more information about the four QMB requirements.

A QMB must be eligible for Medicare Part A (Hospital Insurance).

REQUIREMENT 1

I already have Medicare Part A (Hospital Insurance).

I do not have Medicare Part A (Hospital Insurance) but I underst and I must apply for Part A at

the Social Security Administration before March 31st. I underst and that I can make a

"conditional application” for Part A so that I will only receive it if the premium is p aid by

the Medi-Cal program.

I have already applied for Medicare Part A (Hospital Insurance).

I will apply before March 31st.

A QMB who is not married or not living with a spouse must have count able

REQUIREMENT 2

income which is equal to or less than $908. A QMB living with a spouse must have count able

income which is equal to or less than $1,226. These amount s are expected to increase sometime

in April.

The following are examples of some types of income that count towards the QMB income limit.

When a person applies to be a QMB at the county department of social services, the county will also

look at other types of income and may treat the income dif ferently from what is on this sheet. For

example, if there is a minor child or children in the home, there may be deductions allowed which

would reduce the amount of countable income.

Fill in the amounts to see if you are close to the limit.

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MC 008 Information Notice (10/11)

Form Mc 008 - Qualified Medicare Beneficiary Program Information Notice