Medi Cal Redetermination PDF Template

The Medi-Cal Redetermination Form is a crucial document required by the State of California to assess ongoing eligibility for Medi-Cal benefits. This annual form collects essential information about your income, living situation, and any changes in your household that may affect your coverage. Completing this form accurately is vital to ensure the continuation of your Medi-Cal benefits—click the button below to get started.

Article Guide

The Medi-Cal Redetermination form is a crucial document for individuals seeking to maintain their Medi-Cal benefits in California. This annual form requires you to provide essential information about your household, including income sources, living situation, and any changes in health insurance coverage. Completing the form accurately is vital; it helps ensure that you continue to receive the healthcare services you need. You will need to report various aspects of your financial situation, such as employment income, benefits from social security, and any expenses related to child care or health insurance. Additionally, the form asks about your living situation, including any recent changes in household composition or health status. If applicable, you must disclose any changes in immigration or citizenship status, as this may affect your eligibility. Remember, this form must be signed and returned to your county office to avoid any interruption in your Medi-Cal coverage. Make sure to attach any required documentation to support your claims and use the provided envelope for submission. Keeping track of these details is essential for ensuring continued access to necessary medical care.

Medi Cal Redetermination Preview

State of California—Health and Human Services Agency Department of Health Care Services

MEDI-CAL ANNUAL REDETERMINATION FORM

You must ll out this form and return it to the county to keep your Medi-Cal!

Case Number (optional) Social Security Number (optional)

Print Your Full Name (if you have not moved, put address label here if one is provided) Birth Date (optional) (mm/dd/yyyy)

Current Street Address, Apartment Number ❑ (check here if address is new)

City/State Zip Code

Mailing Address

(if different from above) City/State Zip Code

Use ink and PRINT your answers. Make sure you sign and date the form. Use the postage paid envelope to return it. If you

need more space, attach a separate sheet to this form. If you have any questions or need help lling out this form, call your

worker at the telephone number listed on the Annual Redetermination Notice.

Section 1. Income

(a) Do you or any family member in the home get money from a job, child support or alimony, social

security, veteran benets, unemployment or disability benets, retirement, gifts, or interest or

dividends? ❑ Yes ❑ No

If yes, complete below and list each source of income on a separate line.

Attach most recent pay stubs showing income before taxes or deductions, benefit or award letters,

checks received or signed statement from employer, or last year’s federal income tax return. If income

is from self-employment, send a copy of your most recent tax return or profit and loss statement.

Name of Person with Income

(include rst and last name) Source of Income

Income Amount

(before any

deductions)

How Often Paid

(weekly, monthly,

twice a month)

Hours Worked

(per week or

month)

(b) Do you or any family member in the home get rent, utilities, food, or clothing entirely free? ❑ Yes ❑ No

If yes, who?

What was free?

MC 210 RV (5/11) Page 1 of 4

State of California—Health and Human Services Agency Department of Health Care Services

Section 2. Expenses and Deductions

Do you or any family member in the home pay for child or adult care, health insurance or Medicare

premiums, court-ordered child support or alimony, or educational expenses?

❑ Yes ❑ No

If yes, complete below and list each expense/deduction on a separate line.

Attach proof of expenses/deductions.

Name of Person

with Expense/Deduction

(include rst and last name)

Type of

Expense or

Deduction

Amount of

Payment Paid to Whom

How Often Paid

(weekly, monthly,

twice a month)

Section 3. Other Health Insurance

(a) Did you or any family member have a change in, or get new health, dental, vision, or Medicare

coverage or insurance within the last 12 months?

❑ Yes ❑ No

If yes, who has the coverage/insurance?

Which type of coverage/insurance?

(b) Is any family member living in the home receiving kidney dialysis-related services? ❑ Yes ❑ No

If yes, who?

Section 4. Living Situation

(a) Did anyone move into or out of your home, move in with someone else, get married, or have a baby

within the last 12 months? (Examples: newborn, child, or adult moved in or out of the home, absent

parent returns home.)

❑ Yes ❑ No

If yes, complete below:

Name (include rst and last name) Relationship to You What Changed? Date Changed

(b) Does anyone in the home want Medi-Cal who is not already receiving it?

❑ Yes ❑ No

If yes, who?

City State Country

MC 210 RV (5/11) Page 2 of 4

State of California—Health and Human Services Agency Department of Health Care Services

Section 4. Living Situation

continued

(d) Did anyone in the home get inpatient care in a nursing facility or medical institution?

❑ Yes ❑ No

If yes, who?

(e) Is anyone in the home pregnant? ❑ Yes ❑ No

If yes, who?

Number of babies expected Due date:

Section 5. Real or Personal Property

(a) Indicate the total amount of cash and uncashed checks held by any family member in the home $

(b) Does anyone have a checking or savings account, life insurance, long-term care insurance,

motor vehicle, court-ordered settlement or judgement, stocks, bonds, retirement funds, trusts

where money or property is held for the benet of any family member in the home, real estate,

motor vehicles for a business, business accounts or property, promissory notes, mortgages,

deeds of trust, recreational vehicles, burial trusts or funds, annuities, jewelry (not heirloom or

wedding), or oil or mineral rights?

❑ Yes ❑ No

past 12 months, or have any of the items listed in this section been spent or used as security

for medical costs? ❑ Yes ❑ No

Note: If you have answered “yes” to questions (b) or (c), you will also have to fill out a property

supplement form, submit the form to the county and provide verification.

Section 6. Immigration or Citizenship Status Change

Has there been a change in immigration or citizenship status for anyone in the home that has Medi-Cal

or wants Medi-Cal within the last 12 months? (If your immigration status has changed, you might qualify for

full scope Medi-Cal benets.)

❑ Yes ❑ No

If yes, list the name(s) below and send proof of new status.

Name of Person

(include rst and last name)

Status Change

(send proof of status)

Section 7. Blindness/Disability/Incapacity

(a) Do you or any family member in the home have a physical or emotional condition that makes it

difcult to work, take care of personal needs, or take care of your children?

❑ Yes ❑ No

If yes, who?

(b) Was the physical, mental, or health condition a result of an injury or accident? ❑ Yes ❑ No

If yes, explain

MC 210 RV (5/11) Page 3 of 4

State of California—Health and Human Services Agency Department of Health Care Services

Section 8. Other Health Program Information and Referrals

(a) Check this box if you do not want your child’s information shared with the low-cost Healthy

Families Program if your child gets Medi-Cal with a share of cost. ❑

(b) Do you want information on the no-cost health program for children under 21 (Child Health

and Disability Prevention Program, also known as CHDP?)

❑ Yes ❑ No

feeding women and children under 5 (Women, Infants, and Children Program, also known

as WIC)? ❑ Yes ❑ No

(d) Do you want information on the Personal Care Services Program, an in-home care program

for aged, blind, or disabled persons (also known as In-Home Supportive Services)?

❑ Yes ❑ No

Section 9. SignatureandCertication

Person completing this form must read and sign below.

➤ I have received and read a copy of the Important Information for Persons Requesting Medi-Cal form (MC 219).

➤ I am aware of, understand, and agree to meet all my responsibilities as described on the MC 219 form.

➤ I certify that I will report all income, property, and/or other changes that may affect Medi-Cal eligibility within

ten days of the change.

➤ I understand that all of the statements, including benefit and income information, that I have made on this

form, may be subject to investigation and verification.

➤ I declare, under penalty of perjury, under the laws of the State of California that all information provided on this

form is true and correct.

Signature Date

Daytime or Message Telephone Number

Home Telephone Number

❑ (check here if new number)

Signature of Witness (if signed by a mark), Interpreter or Person Assisting

— County Use Only —

Referrals Follow-up Forms

❑ HF

❑ CHDP

❑ WIC

❑ PCSP

❑ MC 13

❑ MC 210 PS

❑ DDSD Packet

❑ Other:

MC 210 RV (5/11) Page 4 of 4

↓ Medi Cal Redetermination

File Properties

Fact Name	Description
Purpose	The Medi-Cal Redetermination form is used to assess ongoing eligibility for Medi-Cal benefits in California. It must be completed and submitted annually to ensure continued coverage.
Required Information	Applicants must provide personal details, income sources, expenses, and changes in living situations. This information is crucial for determining eligibility and benefits.
Submission Process	The completed form should be returned to the appropriate county office using the provided postage-paid envelope. Failure to submit the form may result in loss of benefits.
Governing Laws	The Medi-Cal program operates under California Welfare and Institutions Code, Sections 14000-14088, which outline eligibility and benefits for low-income residents.
Assistance Availability	If assistance is needed while completing the form, applicants can contact their designated caseworker using the phone number listed on the Annual Redetermination Notice.

Instructions on Utilizing Medi Cal Redetermination

Completing the Medi-Cal Redetermination form is a crucial step in maintaining your eligibility for Medi-Cal benefits. Once you have filled out the form accurately, it must be returned to your county office. Be sure to include any required documentation to support your answers.

Begin by writing your Case Number and Social Security Number at the top of the form (both are optional).
Print your full name clearly. If your address has not changed, you can place an address label here.
Fill in your birth date in the format (mm/dd/yyyy).
Provide your current street address, including apartment number, and check the box if your address is new.
Complete the city, state, and zip code for your current address.
If you have a different mailing address, fill that in as well, including the city, state, and zip code.
Use ink to answer all questions and print your responses clearly.
Sign and date the form at the bottom, ensuring that you include your daytime or message telephone number and home telephone number, checking the box if it is a new number.
If you need additional space for any section, attach a separate sheet to the form.
Return the completed form using the postage-paid envelope provided.

After submitting your form, the county will review your information. If any additional documentation is needed, they will reach out to you. It’s important to keep track of any communication from your county office to ensure your Medi-Cal benefits remain uninterrupted.

Important Facts about Medi Cal Redetermination

What is the Medi-Cal Redetermination form and why is it important?

The Medi-Cal Redetermination form is a crucial document that individuals must complete to maintain their Medi-Cal benefits. This annual process ensures that the information on file is current and accurate. By submitting this form, you confirm your eligibility for the program, which provides essential health care coverage for low-income individuals and families in California. Failure to complete the redetermination can result in a loss of benefits, making it vital to return the form on time.

How do I fill out the Medi-Cal Redetermination form?

To fill out the form, start by providing your personal information, including your full name, address, and case number if available. Carefully read each section and answer the questions about your income, expenses, living situation, and any changes in health insurance or immigration status. Use ink and print your answers clearly. If you need more space, you can attach additional sheets. Finally, don’t forget to sign and date the form before sending it back using the provided postage-paid envelope.

What should I do if I have questions while completing the form?

If you encounter any difficulties or have questions while filling out the Medi-Cal Redetermination form, you can reach out to your assigned worker. Their contact number is listed on the Annual Redetermination Notice you received. They can provide assistance and clarify any uncertainties, ensuring that you complete the form correctly and submit it on time.

What happens if my income or living situation changes after I submit the form?

If your income or living situation changes after you have submitted the Medi-Cal Redetermination form, it is your responsibility to report these changes. You must do so within ten days of the change. This is important because such changes can affect your eligibility for Medi-Cal benefits. By keeping the county informed, you help ensure that you continue to receive the appropriate level of coverage based on your current circumstances.

What should I include as proof of income and expenses?

When completing the form, you need to provide proof of your income and any relevant expenses. For income, include recent pay stubs, benefit letters, or tax returns. If you are self-employed, a profit and loss statement or your most recent tax return will suffice. For expenses, attach documentation such as receipts or statements for child care, health insurance premiums, or educational costs. Providing accurate proof helps verify your information and supports your continued eligibility for Medi-Cal.

Common mistakes

Filling out the Medi-Cal Redetermination form can be a straightforward process, but many people make common mistakes that can lead to delays or even loss of benefits. One frequent error is not providing complete information. When answering questions about income, expenses, or living situations, it’s essential to include all relevant details. For instance, if you receive multiple sources of income, each one should be listed separately. Omitting any source can raise questions and complicate your application.

Another mistake is failing to attach necessary documentation. The form requires proof of income and expenses, such as pay stubs or tax returns. If these documents are not included, the county may delay processing your application or request additional information. Always double-check that you have attached everything required before sending in your form.

Some individuals overlook the importance of updating their contact information. If you have moved or changed your phone number, it’s crucial to provide your current address and contact details. This ensures that the county can reach you if they have questions or need to send important information regarding your Medi-Cal status. Failing to do so can result in missed communications that might affect your benefits.

Another common error is not signing and dating the form. It may seem like a small detail, but your signature certifies that the information provided is accurate and complete. Without it, the form may be considered incomplete, leading to unnecessary delays in processing.

Lastly, many people do not seek assistance when needed. The form can be complex, and it’s perfectly acceptable to ask for help. If you’re unsure about how to answer a question or what documents to provide, don’t hesitate to reach out to your caseworker. They are there to help you navigate the process and ensure that you maintain your Medi-Cal benefits.

Documents used along the form

The Medi-Cal Redetermination form is a crucial document for maintaining eligibility for California's Medi-Cal program. Alongside this form, several other documents may be required to provide comprehensive information about your circumstances. Below is a list of commonly used forms and documents that often accompany the Medi-Cal Redetermination form.

Income Verification Documents: These include recent pay stubs, benefit letters, or tax returns. They help confirm the income sources and amounts reported on the redetermination form.
Property Supplement Form: If there are changes in property ownership or if assets were sold or given away, this form is necessary to provide details about the property.
Proof of Health Insurance: Documentation showing any changes in health coverage, such as insurance cards or policy statements, is essential for determining eligibility.
Citizenship or Immigration Status Documentation: If there has been a change in immigration status, proof must be submitted to ensure compliance with eligibility requirements.
Expense Verification Documents: Receipts or statements related to child care, health insurance, or other expenses may be needed to validate deductions claimed on the form.
Medical Records: If applicable, records confirming any disabilities or medical conditions may be required to support claims for additional benefits.
Child Health and Disability Prevention Program (CHDP) Referral: If applicable, a referral form may be needed for children under 21 to access preventive health services.

Gathering these documents can streamline the redetermination process and help ensure that you maintain your Medi-Cal benefits without interruption. Always check with your local county office for any specific requirements or additional forms that may be necessary.

Similar forms

Medicaid Application Form: Like the Medi-Cal Redetermination form, the Medicaid application requires detailed personal and financial information. Both forms assess eligibility for health care benefits based on income and household composition.
Food Stamp Application: The food stamp application also necessitates information about income and expenses. Similar to the Medi-Cal form, it aims to determine eligibility for assistance programs based on financial need.
Temporary Assistance for Needy Families (TANF) Application: This application shares a focus on household income and living situation. Both forms evaluate the financial status of applicants to provide necessary assistance to families in need.
Supplemental Security Income (SSI) Application: The SSI application requires information about income, resources, and living arrangements. Much like the Medi-Cal Redetermination form, it assesses eligibility based on financial criteria and personal circumstances.
Health Insurance Marketplace Application: This application collects similar information regarding income and household size. It is designed to determine eligibility for health insurance subsidies, paralleling the Medi-Cal form's purpose of assessing health care coverage eligibility.

Dos and Don'ts

When filling out the Medi-Cal Redetermination form, it’s essential to approach the process with care. Here’s a list of things to keep in mind, including actions you should and shouldn't take.

Do use black or blue ink. This ensures that your answers are clear and legible.
Do provide accurate information. Double-check your details to avoid delays in processing.
Do sign and date the form. Your signature is crucial for the validity of your submission.
Do attach necessary documents. Include any required proof of income or expenses to support your application.
Do keep a copy of the completed form. Having a record can be helpful for future reference.

Don't leave any sections blank. If a question does not apply, indicate that clearly.
Don't forget to check for updates. If your address or contact information has changed, be sure to reflect that.
Don't rush the process. Take your time to ensure accuracy in your responses.
Don't hesitate to ask for help. If you have questions, reach out to your caseworker for assistance.

By following these guidelines, you can help ensure that your Medi-Cal Redetermination form is completed correctly and efficiently. This will aid in maintaining your coverage without unnecessary complications.

Misconceptions

Misconceptions about the Medi-Cal Redetermination form can lead to confusion and delays in receiving benefits. Here are seven common misconceptions, along with clarifications for each.

The form is optional. Many believe that completing the Medi-Cal Redetermination form is optional. In reality, submitting this form is mandatory to maintain eligibility for Medi-Cal benefits.
Address changes do not need to be reported. Some think that if they move, they do not have to inform the county. However, any change in address must be reported to ensure that communications regarding benefits are received.
Income does not need to be reported if it is below a certain amount. A common misconception is that only income above a specific threshold needs to be reported. All sources of income must be disclosed, regardless of the amount.
Proof of income is not necessary. Many individuals assume that they can simply state their income without providing documentation. In fact, attaching proof, such as pay stubs or tax returns, is required to verify income claims.
Changes in living situation are irrelevant. Some believe that their living situation does not affect their Medi-Cal eligibility. However, any changes, such as new household members or marital status, must be reported.
Failure to report changes has no consequences. There is a misconception that not reporting changes will not impact benefits. In truth, failing to report changes can lead to penalties, including loss of Medi-Cal coverage.
The form can be submitted without a signature. Some individuals think they can submit the form without signing it. However, a signature is required to certify that the information provided is accurate and complete.

Key takeaways

Filling out the Medi-Cal Redetermination form is an important step to maintain your Medi-Cal coverage. Here are some key takeaways to keep in mind:

Complete the Form Accurately: Make sure to fill out all required sections completely and accurately. This helps avoid delays in processing your application.
Use Ink: Always use ink to fill out the form. This ensures that your answers are clear and legible.
Sign and Date: Don’t forget to sign and date the form before returning it. An unsigned form may be considered incomplete.
Provide Supporting Documents: Attach necessary documents, such as pay stubs or tax returns, to verify your income and expenses.
Check for Changes: Be sure to report any changes in your living situation, income, or family members that could affect your eligibility.
Use the Provided Envelope: Return the completed form using the postage-paid envelope provided. This makes it easier for you to send it back.
Ask for Help: If you have questions while filling out the form, don’t hesitate to call your worker for assistance.
Keep a Copy: Make a copy of the completed form for your records before sending it in. This can be helpful if you need to reference it later.
Respond Promptly: Submit the form by the deadline indicated in your notice to avoid any interruption in your Medi-Cal benefits.
Stay Informed: Review the Important Information for Persons Requesting Medi-Cal form to understand your responsibilities and rights.

By following these guidelines, you can help ensure a smooth redetermination process for your Medi-Cal coverage.