Qualified Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), And Qualifying Individuals (Qi-1) Application
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1
2
3Department of Health Care Services
State of California–-Health and Human Services Agency
QUALIFIED MEDICARE BENEFICIARY (QMB),
SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (SLMB),
AND QUALIFYING INDIVIDUALS (QI-1) APPLICATION
Name
Social Security Number
Medicare Number
Date
Telephone Number
Date of Birth
Sex
q Married
q Divorced
Marital Status
(
)
q Male q Female
q Separated
q Single
q 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).
yy
Be eligible for Medicare Part B (medical insurance).
yy
Meet the following income requirements
yy
QMB: Net countable income at or below 100% of the Federal Poverty Level (FPL) (at or below
5y
$973* for a single person, or $1,311* for a couple).
SLMB: Net countable income below 120% of the FPL (below $1,167* for a single person, or $1,573*
5y
for a couple).
QI-1: Net countable income below 135% of the FPL (below $1,313* for a single person, or $1,770*
5y
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 $7,160 in nonexempt property for a single person or $10,750 for a couple.
yy
Meet certain requirements and conditions, such as being a resident of California.
yy
IMPORTANT
q Yes q No
You may be eligible for other Medi-Cal programs in addition to the QMB and SLMB programs, such as food
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.
q Yes q No
Do you wish to apply for three months of retroactive coverage for the SLMB and QI-1 programs (there is 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.
Sex
Name
Social Security Number
M=Male
Date of Birth
Relationship to You
F=Female
MAIL COMPLETED FORM TO YOUR COUNTY SOCIAL SERVICES AGENCY.
(ADDRESSES ON BACK SIDE OF THIS FORM)
Page 1 of 3
MC 14A (3/14) ENG
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