Qualified Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), And Qualifying Individuals (Qi-1) Application Page 2

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Department of Health Care Services
State of California–-Health and Human Services Agency
A. COUNTABLE INCOME
COUNTY USE
1. Fill in the MONTHLY unearned income received by the QMB/SLMB/QI-1 applicant:
Applicant’s
unearned
a. Social Security check
$
income (line f) $
b. VA benefits
$
Spouse’s
c. Interest from bank accounts or certificate(s) of deposit
$
unearned
income (line l) +
d. Retirement income
$
e. Any other unearned income
$
f.
Total UNEARNED INCOME–add lines a. through e.
$
2. If you are married and living with your SPOUSE, fill in the MONTHLY unearned income
Any
received by your spouse:
Income
deduction
-
g. Social Security check
$
h. VA benefits
$
Net
unearned
i.
Interest from bank accounts or certificate(s) of deposit
$
income
j.
Any other unearned income
$
Net
k. Retirement income
$
earned
income
l.
Total SPOUSE’S UNEARNED INCOME–add lines g. through k.
$
(line r)
+
3. Fill in the MONTHLY earned income received by the QMB/SLMB/QI-1 applicant
Total
a
nd spouse:
net income
m. Gross earnings for the person who wants to be a QMB,
SLMB,or QI-1
$
MFBU size
n. Gross earnings for the spouse
$
o. Total–add lines m. through n.
$
Compare to
p. Subtract $65
$
QMB/SLMB/QI-1/QI-2
income limit.
q. Remainder
$
r.
Divide by 2
$
If over income limit, is there a
spouse and/or children in the
4. Total Income:
home? Complete the MC 176-2 A
QMB/SLMB/QI-1 form.
Add lines f., I., and r
$
s. Minus $20 (any income deduction)
$
5. TOTAL COUNTABLE INCOME
$ ___________
6. Potential QMB, SLMB, or QI-1 eligibles:
You are potentially eligible as a QMB if your income is at or below 100% of the FPL
5
(at $973* for a single person, or at $1,311* for a couple).
You are potentially eligible as a SLMB if your income is below 120% of FPL
5
(below $1,167* for a single person, or below $1,573* for a couple).
You are potentially eligible as a QI-1 if your income is below 135% of FPL
5
(below $1,313* for a single person, or below $1,770* for a couple).
*If you have a child in the home, these amounts may be higher.
Page 2 of 3
MC 14A (3/14) ENG

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