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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 (Thai)
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 Thai. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form MC14?
A: Form MC14 is an application for the Qualified Low-Income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI) programs in California.
Q: What are the QMB, SLMB, and QI programs?
A: The QMB, SLMB, and QI programs are California state programs that help eligible individuals pay for certain Medicare costs, such as premiums, deductibles, and copayments.
Q: Who is eligible for the QMB program?
A: To be eligible for the QMB program, you must meet certain income and asset requirements and be enrolled in Medicare Part A.
Q: Who is eligible for the SLMB program?
A: To be eligible for the SLMB program, you must meet certain income and asset requirements, not be eligible for Medicaid, and be enrolled in Medicare Part A.
Q: Who is eligible for the QI program?
A: To be eligible for the QI program, you must meet certain income and asset requirements, not be eligible for Medicaid, and be enrolled in Medicare Part A.
Q: What costs do the QMB, SLMB, and QI programs help with?
A: The QMB, SLMB, and QI programs help with paying for Medicare Part A premiums, deductibles, and copayments.
Q: Can I apply for the QMB, SLMB, and QI programs using Form MC14?
A: Yes, Form MC14 is the application form for the QMB, SLMB, and QI programs in California.
Q: Is Form MC14 available in languages other than English?
A: Yes, Form MC14 is available in Thai in California.
Q: Are there any fees for submitting Form MC14?
A: No, there are no fees for submitting Form MC14.
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 (Thai)
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