Form MC604 IPS HMO "Additional Income and Property Information Needed for Medi-Cal" - California (Hmong)

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State of California Health and Human Services Agency
Department of Health Care Services
XAV TAU COV NTAUB NTAWV QHIA TXOG NYIAJ TXIAG
THIAB VAJ TSE NTXIV RAU MEDI-CAL
Peb tab tom soj ntsuam koj txoj kev tsim nyog rau Medi-Cal thiab xav tau cov ntaub ntawv qhia ntxiv. Thov teb cov nqe
lus nug hauv qab rau txhua tus neeg uas yog koj tsev neeg. Qhov no suav koj, koj tus txij nkawm, thiab cov me nyuam uas
muaj hnub nyoog 21 xyoos rov hauv uas nrog koj nyob los sis ib tug neeg uas tsis nrog koj nyob mus ib ntsus, xws li mus
kawm ntawv los sis ua hauj lwm los sis pw tim tsev kho mob lawm.
Lub Npe Hauv Txooj Xwm (Case):
Zauv Cim Txooj Xwm (Case):
Tus Neeg Lis Ntaub Ntawv Npe:
Tus Neeg Lis Ntaub Ntawv Tus Xov Tooj:
Hnub Xa:
Xa Daim Ntawv Rov Qab Tsis Pub Dhau:
Xav Tau Cov Ntaub Ntawv Qhia Txog Tsev Neeg Ntxiv
Xav tau cov ntaub ntawv qhia nram qab no ntxiv. Tsuas teb yog tias cov nqe lus nug nyob rau nplooj no raug
rau koj los sis ib tug neeg hauv koj tsev neeg.
Thov kos ntawm no yog tias koj, los sis ib tug neeg hauv koj tsev neeg, muaj ntaub ntawv sib yuav tiam sis tam sim no
tsis nrog tus txij nkawm nyob.
Yog tias koj kos lub thawv, thov sau lub npe ntawm tus neeg hauv koj tsev neeg uas tsis nrog tus txij nkawm nyob.
Thov kos ntawm no yog tias koj los sis ib tug neeg hauv tsev neeg yog niam tshiab los sis txiv tshiab.
Yog tias koj kos lub thawv ntawm no, thov sau:
Tus niam tshiab los sis txiv tshiab lub npe:
Tus niam tshiab los sis txiv tshiab cov me nyuam:
Thov kos ntawm no yog tias ib tug neeg hauv tsev neeg yog ib tug me nyuam uas ib tug txheeb ze saib xyuas, dua li
ntawm leej niam leej txiv, uas nyob nrog tsev neeg thiab.
Yog tias koj kos lub thawv no, thov sau:
Tus Txheeb Ze Saib Xyuas lub npe:
Cov me nyuam uas raug saib xyuas:
Page 1 of 7
MC 604 IPS HMO (5/14)
State of California Health and Human Services Agency
Department of Health Care Services
XAV TAU COV NTAUB NTAWV QHIA TXOG NYIAJ TXIAG
THIAB VAJ TSE NTXIV RAU MEDI-CAL
Peb tab tom soj ntsuam koj txoj kev tsim nyog rau Medi-Cal thiab xav tau cov ntaub ntawv qhia ntxiv. Thov teb cov nqe
lus nug hauv qab rau txhua tus neeg uas yog koj tsev neeg. Qhov no suav koj, koj tus txij nkawm, thiab cov me nyuam uas
muaj hnub nyoog 21 xyoos rov hauv uas nrog koj nyob los sis ib tug neeg uas tsis nrog koj nyob mus ib ntsus, xws li mus
kawm ntawv los sis ua hauj lwm los sis pw tim tsev kho mob lawm.
Lub Npe Hauv Txooj Xwm (Case):
Zauv Cim Txooj Xwm (Case):
Tus Neeg Lis Ntaub Ntawv Npe:
Tus Neeg Lis Ntaub Ntawv Tus Xov Tooj:
Hnub Xa:
Xa Daim Ntawv Rov Qab Tsis Pub Dhau:
Xav Tau Cov Ntaub Ntawv Qhia Txog Tsev Neeg Ntxiv
Xav tau cov ntaub ntawv qhia nram qab no ntxiv. Tsuas teb yog tias cov nqe lus nug nyob rau nplooj no raug
rau koj los sis ib tug neeg hauv koj tsev neeg.
Thov kos ntawm no yog tias koj, los sis ib tug neeg hauv koj tsev neeg, muaj ntaub ntawv sib yuav tiam sis tam sim no
tsis nrog tus txij nkawm nyob.
Yog tias koj kos lub thawv, thov sau lub npe ntawm tus neeg hauv koj tsev neeg uas tsis nrog tus txij nkawm nyob.
Thov kos ntawm no yog tias koj los sis ib tug neeg hauv tsev neeg yog niam tshiab los sis txiv tshiab.
Yog tias koj kos lub thawv ntawm no, thov sau:
Tus niam tshiab los sis txiv tshiab lub npe:
Tus niam tshiab los sis txiv tshiab cov me nyuam:
Thov kos ntawm no yog tias ib tug neeg hauv tsev neeg yog ib tug me nyuam uas ib tug txheeb ze saib xyuas, dua li
ntawm leej niam leej txiv, uas nyob nrog tsev neeg thiab.
Yog tias koj kos lub thawv no, thov sau:
Tus Txheeb Ze Saib Xyuas lub npe:
Cov me nyuam uas raug saib xyuas:
Page 1 of 7
MC 604 IPS HMO (5/14)
Qhia Rau Peb Txog Koj Cov Nyiaj Tau thiab Cov Nuj Nqis
Qhia rau peb txog koj cov nyiaj tau thiab cov nuj nqis rau koj, koj tus txij nkawm thiab cov me nyuam uas muaj hnub
nyoog 21 xyoos rov hauv uas nrog koj nyob los sis ib tug neeg uas tsis nrog koj nyob mus ib ntsus, xws li mus kawm
ntawv los sis ua hauj lwm los sis pw tim tsev kho mob lawm.
Nyiaj Tau
Thov kos Tau los sis Tsis tau yog tias muaj neeg nyob hauv koj tsev neeg tau cov nyiaj raws li nram qab no.
Kos ib lub thawv rau txhua hom nyiaj.
Nyiaj Tsis Taus
Tau
Tsis tau
Nyiaj Qub Tub Rog
Tau
Tsis tau
Nyiaj Yug Me Nyuam
Tau
Tsis tau
Nyiaj Ua Khoom Plig
Tau
Tsis tau
Yog tias koj teb Tau rau ib qho saud, thov muab pov thawj txog qhov nyiaj tau ntawd xa nrog daim ntawv no rov tuaj.
Ib co piv txwv uas yuav siv tau muaj xws li: cov ntawv los sis cov ntawv qhia los ntawm Social Security Administration,
Veteran’s Administration, Employment Development Department, cov ntawv txib los ntawm tsev hais plaub kom them
nyiaj yug me nyuam, los sis lwm cov ntaub ntawv uas muaj cov lus qhia txog qhov nyiaj tau.
Cov Nuj Nqis
Thov kos Them los sis Tsis them yog tias muaj ib tug neeg hauv koj tsev neeg them cov nuj nqis nram qab no.
Kos ib lub thawv rau txhua hom nuj nqis.
Them Nyiaj Yug Me Nyuam
Them
Tsis them
Lwm Cov Nqi Yuav Kev
Tuav Pov Hwm
Them
Tsis them
Cov Nqi Yuav Medicare
Them
Tsis them
Cov Nqi Zov Me Nyuam
Them
Tsis them
Cov Nqi Zov Neeg Laus
Them
Tsis them
Cov Nqi Kawm Ntawv
Them
Tsis them
Yog tias koj teb Them rau ib qho saud, thov muab pov thawj txog qhov nuj nqis ntawd xa nrog daim ntawv no rov tuaj. Ib
co piv txwv uas yuav siv tau muaj xws li: cov ntawv txib los ntawm tsev hais plaub kom them nyiaj yug me nyuam, cov nqi
kawm ntawv, cov ntawv tuaj ntawm Medicare los sis lub tuam txhab tuav pov hwm, cov ntawv qhia nqi los sis cov tw qhia
tias them nqi lawm, los sis lwm cov ntaub ntawv uas muaj cov lus qhia txog qhov nqi.
Page 2 of 7
MC 604 IPS HMO (5/14)
Qhia Rau Peb Txog Koj Tej Tug Thiab Cov Khoom
Thov kos Muaj los sis Tsis muaj yog tias muaj neeg hauv koj tsev neeg muaj los sis yog tswv rau hom teej tug no.
Yuav tsum tau kos ib lub thawv rau txhua nqe 1, 2 thiab 3 hauv qab.
SEEM 1
1. Nyiaj ntsuab los sis cov tshev tsis tau pauv
Muaj
Tsis muaj
Yog tias Muaj sau seb yog pes tsawg rau ntawm no $
2. As khauj sau tshev los sis as khauj tseg nyiaj
Muaj
Tsis muaj
Yog tias Muaj, xa cov qauv ntawm cov ntawv qhia txog tus as khauj uas muaj qhov qhia seb
tshuav nyiaj pes tsawg tam sim no.
3. Koj los sis ib tug neeg hauv koj tsev neeg puas muaj ntau tshaj ib lub tsheb
(tsheb, tsheb nees zab, tsheb thauj khoom)?
Muaj
Tsis muaj
4. Koj los sis ib tug neeg hauv koj tsev neeg puas muaj nkoj, cov tsheb caij ua si los sis tsheb cab?
Muaj
Tsis muaj
Yog tias koj teb Muaj rau nqe lus nug 3 los sis 4, thov xa cov qauv ntawm cov ntawv ua tswv
los sis cov ntawv rau npe tias yog tswv uas tshiab tshaj, cov ntawv yuav, cov tw yuav, los sis cov
kev kwv yees seb raug nqi pes tsawg.
5. Thov soj ntsuam cov teej tug nram qab no.
Kos lub thawv no yog tias ib tug neeg hauv koj tsev neeg yog tswv rau los sis muaj npe nyob hauv ib los sis ntau
tshaj ib qho khoom nram qab no.
Vaj tse dua li ntawm lub tsev koj nyob (cov tsev, cov tsev uas ib yig yuav ib chav nyob hauv ib lub tuam tsev
(condominiums), cov tuam tsev, cov tsev txawb, cov teej tug uas yus yog tswv mus tag lub neej (life estates), cov
tsev nyob thaum mus ua si (timeshares), cov nyiaj tso ua lag luam (stock), nyiaj mutual funds, Individual Retirement
Accounts (IRAs), Keoghs, los sis cov nyiaj tso rau yav laus tom hauj lwm (pension funds), cov cuab tam tseem ceeb
(trusts), cov as khauj uas thaiv lawm los sis cov kev cog lus (uas tuav qhov nyiaj los sis vaj tse rau lwm tus neeg hauv
tsev neeg uas nyob hauv lub tsev), cov kev lees them nqi (judgments), cov kev cog lus them nyiaj hauv ib rooj plaub
(settlement agreements), cov ntawv txib kom them nyiaj, cov kev cog lus ua ntej sib yuav los sis cov kev cog lus tom
qab sib yuav, cov ntawv cog lus them qhov nyiaj txais rov qab, cov ntawv txais nyiaj yuav tsev los sis ntawv ua ib tug
tswv ntawm vaj tse (deeds of trust), cov as khauj ua lag luam, vaj tse ua lag luam, cov cai rau roj thiab mineral, cov
khoom coj ntawm cev xws li qhwv ntsej, saw caj dab, saw tes, nplhaib uas raug nqi ntau tshaj $100.00 (tiam tsis sis
yog cov nplhaib sib yuav, cov nplhaib sib qhaib, los sis cov puav pheej ntawm tsev neeg (heirlooms)), lwm cov vaj tse
los sis khoom ntawm ntiag tug, cuab tam, los sis cov khoom uas raug nqi $500 los sis ntau dua ntawd.
Yog tias koj YEEJ kos lub thawv, thov mus rau SEEM 2 (hauv qab).
Yog tias koj TSIS kos lub thawv no, mus rau SEEM 3 nyob rau nplooj 6.
SEEM 2
Yog tias koj kos lub thawv nyob hauv Nqe 5 saud, thov teb seem no thiab teb TAG NRHO cov nqe lus nug. Thov muab
cov ntaub ntawv nrog rau daim ntawv no rau cov pawg hauv qab no uas koj teb Muaj rau. Ib co piv txwv ntawm cov ntaub
ntawv no muaj xws li: cov ntawv yuav kev tuav pov hwm (policies), cov ntawv cog lus, cov cuab tam tseem ceeb (trusts), cov
ntawv cog lus yuav, cov ntawv txib los ntawm tsev hais plaub, cov ntawv cog lus them nqi hauv ib rooj plaub (settlement
agreements), cov ntawv qhia nyiaj, cov ntawv ua se rau lag luam, cov nqi, cov tw nqi, cov ntawv tso cai, cov ntawv qhia txog
cov kev tau peev thiab poob peev, los sis lwm cov ntawv qhia tias yog tswv los sis lwm cov ntaub ntawv raws cai tias yog tswv.
6. Nyiaj Tso Ua Lag Luam (Stock) los sis Mutual Funds
Yog tias Muaj, thov xa ib daim qauv ntawm cov ntawv qhia, los sis cov ntawv ua pov thawj
tso nyiaj ua lag luam los sis mutual fund uas qhia tias muaj pes tsawg qhov shares
Muaj
Tsis muaj
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MC 604 IPS HMO (5/14)
7. Individual Retirement Accounts (IRAs), Keoghs, Cov Nyiaj Tso Rau Yav Laus Tom Hauj Lwm
los sis cov nyiaj tso rau yav laus tom hauj lwm, xws li cov as khauj 401k los sis 457.
Muaj
Tsis muaj
Yog tias Muaj, thov xa cov ntawv qhia tshiab tshaj los ntawm koj qhov chaw ua hauj lwm,
tuam txhab tso nyiaj, los sis chaw tso nyiaj ua lag luam (brokerage) uas qhia seb koj tshuav
pes tsawg thiab tau paj li cas los sis qhov nyiaj ntsuab tshuav (cash value) hauv tus as khauj
(tom qab them rau cov kev nplua vim rho nyiaj tawm ntxov).
8. Nyiaj them ib xyoos ib zaug (annuities) los sis Kev Tuav Pov Hwm Txoj Sia.
Muaj
Tsis muaj
9. Chaw Faus, Cuab Tam Tseem Ceeb (Trusts), Ntawv Cog Lus Faus los sis Kev Tuav Pov Hwm Faus.
Muaj
Tsis muaj
10. Cov cuab tam tseem ceeb (trusts), cov as khauj uas thaiv lawm los sis cov kev cog lus
(uas tuav qhov nyiaj los sis vaj tse rau lwm tus neeg hauv tsev neeg uas nyob hauv lub tsev).
Muaj
Tsis muaj
11. Cov kev lees them nqi (judgments), cov kev cog lus them nyiaj hauv ib rooj plaub (settlement
agreements), cov ntawv txib kom them nyiaj, cov kev cog lus ua ntej sib yuav los sis cov kev
cog lus tom qab sib yuav.
Muaj
Tsis muaj
12. Cov ntawv cog lus them qhov nyiaj txais rov qab, cov ntawv txais nyiaj yuav tsev los sis ntawv
ua ib tug tswv ntawm vaj tse (deeds of trust).
Muaj
Tsis muaj
Yog tias koj teb Muaj rau cov nqe lus nug 6 txog 12 (saud), thov muab cov qauv ntawm cov
ntawv yuav kev tuav pov hwm (policies), cov ntawv cog lus, cov cuab tam tseem ceeb
(trusts), cov ntawv cog lus yuav, cov ntawv txib los ntawm tsev hais plaub, cov ntawv cog
lus them nqi hauv ib rooj plaub (settlement agreements), los sis cov ntawv qhia txog tus
as khauj uas qhia tias them li cas, tam sim no raug nqi li cas, tau nyiaj ntsuab li cas yog tias
tsis yuav lawm, tshuav pes tsawg, cov kev ua lag luam (investments), thiab distributions.
13. Cov khoom coj ntawm cev xws li qhwv ntsej, saw caj dab, saw tes, nplhaib uas raug nqi ntau
tshaj $100.00 (tiam sis sis yog cov nplhaib sib yuav, cov nplhaib sib qhaib, los sis cov puav
pheej ntawm tsev neeg).
Muaj
Tsis muaj
Yog tias Muaj, thov xa cov qauv ntawm cov ntawv yuav, cov ntawv qhia tias raug nqi pes tsawg,
cov ntawv kwv yees tias raug nqe li cas los sis cov ntawv tuav pov hwm.
14. Cov As Khauj Ua Lag Luam Thiab Vaj Tse
Muaj
Tsis muaj
Yog tias Muaj, thov xa cov ntawv ua se, cov nqi, cov tw them, cov ntawv tso cai, cov ntawv
qhia txog qhov tau peev thiab poob peev, los sis lwm cov ntawv uas qhia tias yog tswv, cov
ntawv qhia txog nyiaj tau thiab/los sis cov nqi.
15. Tam sim no koj puas muaj ib lub tsev yuav, cov tsev uas ib yig yuav ib chav nyob hauv ib lub
tuam tsev, cov tsev uas muaj ntau yim nyob, tshav yug tsiaj, av, tsev txawb, los sis cov teej
tug uas yus yog tswv mus tag lub neej (life estate) (muaj cai siv) hauv lub tsev uas tam sim
no yog koj lub tsev los sis tau yog koj lub tsev yav dhau los?
Muaj
Tsis muaj
Yog tias Muaj, koj puas nyob hauv lub tsev tam sim no?
Yog tias Muaj, thov sau qhov chaw nyob ntawm lub tsev rau ntawm no thiab mus rau
nqe lus nug 16.
Yog tias koj tsis nyob hauv lub tsev tam sim no, koj puas tau nyob hauv yav dhau los thiab
koj puas xav tias yuav siv lub tsev ntawd ua koj lub tsev nyob ib hnub tom ntej no?
Xav
Tsis xav
Yog koj teb tias Xav, mus rau nqe lus nug 16.
Page 4 of 7
MC 604 IPS HMO (5/14)
Yog tias koj teb Tsis xav, puas muaj ib los sis ntau tshaj ib tug neeg hauv koj tsev neeg,
raws li cov hauv qab no, nyob hauv lub tsev ntawd tam sim no?
• Koj tus txij nkawm
• Ib tug me nyuam muaj hnub nyoog 21 xyoos rov hauv
• Ib tug tub los sis ntxhais tsis taus
• Ib tug txheeb ze uas yus yug noj yug haus (dependent) uas nyob hauv cov ntawv ua se
• Ib tug nus muag uas yog tswv rau lub tsev thiab tau nyob ntawd mus yam tsawg ib xyoos
ua ntej koj mus rau tim tsev laus
• Lwm tus neeg hauv tsev neeg uas tau nyob hauv lub tsev mus yam tsawg ob xyoos
nrog koj los saib xyuas koj kom koj thiaj li nyob tau hauv tsev ua ntej koj mus rau
tim tsev laus
Muaj
Tsis muaj
Yog tias koj teb Muaj, mus rau nqe lus nug 16.
Yog tias koj teb Tsis muaj, thov xa daim ntawv qhia tias se yuav raug li cas uas tshiab tshaj
plaws, los sis ib qho kev ntsuam xyuas tias raug nqi pes tsawg los ntawm ib tug neeg
ntsuam xyuas vaj tse uas tsim nyog. Peb yuav siv qhov lub tsev muaj nqis tsawg tshaj.
16. Lwm cov vaj tse uas koj yog tswv rau tiam sis tsis nyob hauv (piv txwv li, cov tsev uas ib yig yuav
ib chav nyob hauv ib lub tuam tsev, cov tsev ua txheej, cov tsev txawb, cov teej tug uas yus yog
tswv mus tag lub neej (life estate), cov tsev nyob thaum mus ua si (timeshares).
Muaj
Tsis muaj
Yog tias Muaj, puas tau nyiaj ntawm cov vaj los?
Yog tias Muaj, thov xa cov qauv ntawm cov tw them nqi tsev xauj thiab cov nqi rau hluav taws
xob thiab nkev, cov se rau vaj tse, kev tuav pov hwm, nqi tu kom zoo thiab cov nqi kho.
17. Cov Cai Rau Roj thiab Mineral.
Muaj
Tsis muaj
Yog koj teb tias Muaj rau cov nqe lus nug 15, 16 los sis 17, thov xa cov qauv ntawm cov nqi tsev,
daim ntawv qhia tias se yuav raug li cas uas tshiab tshaj plaws, cov ntawv rau npe tias yog tswv,
thiab cov ntawv yog tswv.
18. Lwm cov vaj tse los sis khoom, cuab tam, los sis yam muaj uas seb raug nqi $500 los sis ntau
tshaj ntawd.
Muaj
Tsis muaj
Yog tias Muaj, thov xa cov ntawv qhia txog lub vaj tse thiab raug nqi pes tsawg.
19. Puas tau muab cov khoom nyob hauv cov nqe lus nug hauv 2 txog 18 coj los siv kom pab
txais tau nyiaj los sis los ua ib qho lees them nqi rau cov kev pab kho mob?
Tau
Tsis tau
Yog tias Tau, thov piav qhia hauv seem sau “Cov lus xav hais los sis cov lus qhia ntxiv” uas
nyob rau ntu kawg hauv daim ntawv no, thiab muab pov thawj txog qhov nqi tiv, nyiaj
txais los sis cov ntaub ntawv txog security.
Tau
Tsis tau
20. Koj puas tiv nyiaj rau cov khoom uas tau sau saud hauv cov nqe lus nug 2 txog 18?
Tiv
Tsis tiv
Yog tias Tiv, thov xa cov qauv ntawm cov nqi tiv, nyiaj txais, los sis cov ntaub ntawv
txog security.
21. California Kev Sib Koom Tes rau Kev Kho Mob Mus Ntev (California Partnership for
Long-Term Care) Phau Ntawv Tuav Pov Hwm Uas Tau Kev Pom Zoo
Muaj
Tsis muaj
Yog tias Muaj, thov xa ib daim qauv ntawm koj phau ntawv tuav pov hwm tuaj. Yog tias
koj tau txais kev pab hauv phau ntawv tuav pov hwm, thov xa koj daim qauv ntawm koj
daim ntawv qhia tshiab tshaj txog qhov kev pab.
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MC 604 IPS HMO (5/14)