Qualified Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), And Qualifying Individuals (Qi-1) Application Page 3
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3Department of Health Care Services
State of California–-Health and Human Services Agency
B. PROPERTY
A QMB, SLMB, or QI-1 who is not married or not living with his/her spouse may have countable property which is equal
to or less than $7,160. A QMB, SLMB, or QI-1 who is married and living with his/her spouse must have countable prop-
erty which is equal to or less than $10,750.
The following are examples of countable property. Important: The home you and/or a spouse live in does not count. One car
used for transportation does not count. If you apply at the county welfare department as a QMB, SLMB, or QI-1, the county
may treat the property listed on this form differently. There are other types of property which the county welfare department,
will also look at, i. e., certificate(s) of deposit. This other property may or may not count towards the property limit.
COUNTY USE
Fill in the value of the following property which belongs to you, your spouse, or both of you.
1. Checking accounts
$
2. Savings account
$
3. Certificate(s) of deposit
$
4. Stocks
$
5. Bonds
$
6. A second car (value minus amount owed)
$
7. A second home (value minus amount owned)
$
8. The cash surrender value of life insurance policies if
$
the face value of all policies combined exceeds $1,500
(Do not include “term” insurance policies)
9. Total PROPERTY- add lines 1 through 8
**$
**This total cannot exceed $7,160 for a single person or $10,750 for a couple.
Additional information: You may be eligible for up to three months of retroactive coverage of your Medicare Part B
premiums under the SLMB and QI-1 programs.
NOTE: Individuals enrolled in traditional Medi-Cal, (but not QMB/SLMB/QI-1 programs) may be subject to Estate Recovery.
Medi-Cal benefits received by an individual after age 55 may be recoverable by the State. Recovery may be made from
the estate or the distributee/heir of the Medi-Cal beneficiary if the beneficiary does not leave a surviving spouse, minor
children, or a totally disabled or blind son or daughter. Individuals enrolled in the QMB/SLMB/QI-1 programs (either
in combination with Medi-Cal or without), however, are not subject to Estate Recovery for Medicare premiums,
deductibles or co-payments.
I declare under penalty of perjury, under the laws of the United States of America and the State of California, that
information I have given on this form is true, correct, and complete.
Date
Signature (or mark) of applicant
County Use
q QMB approved
q SLMB approved
q QI-1 approved
q QMB/SLMB/QI-1-denied
Eligibility Worker’s signature
Date
Privacy Statement
This information given in this application is private and confidential under Welfare and Institutions Code 14100.2. This information will be
disclosed only in accordance with those laws.
Sections 14011 and 14012 of the Welfare and Institutions Code allow county welfare departments to get certain facts from you, or the
person(s) you represent, so that you can get Medi-Cal benefits. You must provide these facts to get some or all of your Medicare costs
paid by Medi-Cal. You are required to provide your Social Security Number under the Social Security Act, Section 1137(a)(1) and the
Welfare and Institutions code, Section 14011.2.
Page 3 of 3
MC 14A (3/14) ENG
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