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This version of the form is not currently in use and is provided for reference only. Download this version of
Form MC14 A
for the current year.
Form MC14 A Qualified Low-Income Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individuals (Qi) Application - California (Hmong)
This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California.
The document is provided in Hmong. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is the MC14 form?
A: The MC14 form is an application for Qualified Low-Income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI) programs in California.
Q: Who is eligible for the QMB program?
A: Eligibility for the QMB program is based on income and resources. Individuals with income below a certain level and limited resources may qualify.
Q: Who is eligible for the SLMB program?
A: Eligibility for the SLMB program is also based on income and resources. Individuals with income slightly higher than the QMB program limits may qualify.
Q: Who is eligible for the QI program?
A: The QI program is for individuals who do not qualify for the QMB or SLMB programs but still need help paying for Medicare Part B premiums.
Q: What does the MC14 form allow you to apply for?
A: The MC14 form allows you to apply for the QMB, SLMB, and QI programs in California.
Q: Are there any fees to submit the MC14 form?
A: No, there are no fees to submit the MC14 form.
Q: What documents do I need to include with the MC14 form?
A: You may need to include documents such as proof of income, resources, and Medicare Part A and B enrollment.
Form Details:
- Released on March 1, 2021;
- The latest edition provided by the California Department of Health Care Services;
- Easy to use and ready to print;
- Available in Spanish;
- Quick to customize;
- Compatible with most PDF-viewing applications;
Download a fillable version of Form MC14 A by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.
Download Form MC14 A Qualified Low-Income Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individuals (Qi) Application - California (Hmong)
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