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Blank Medi Cal Redetermination Form

The Medi-Cal Redetermination Form is a crucial document that individuals must complete to maintain their Medi-Cal benefits. This form collects essential information about your income, living situation, and any changes in your health coverage. Timely submission ensures continued access to necessary healthcare services.

Outline

The Medi-Cal Redetermination form is a crucial document for individuals and families seeking to maintain their Medi-Cal benefits in California. This annual form ensures that the Department of Health Care Services has up-to-date information regarding your income, expenses, living situation, and any changes in health coverage. It requires you to provide personal details such as your name, address, and Social Security number, although some of these fields are optional. The form also includes sections where you must disclose various sources of income, from employment to social security benefits, and outline any expenses that may affect your eligibility. Additionally, it addresses changes in your household, such as new members or significant life events, and asks about other health insurance coverage. Completing the form accurately is essential; it not only helps in determining continued eligibility but also ensures that you receive the benefits you need. Remember to sign and date the form before submitting it, and if you have questions, assistance is readily available through your county worker. Keeping your information current is key to enjoying uninterrupted access to Medi-Cal services.

Sample - Medi Cal Redetermination Form

State of California—Health and Human Services Agency

Department of Health Care Services

MEDI-CAL ANNUAL REDETERMINATION FORM

You must fill 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 filling 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 benefits, unemployment or disability benefits, 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 first 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?⁜
(c) Was the free rent, utilities, food, or clothing received in exchange for work done?			❑ Yes ❑ No

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State of California—Health and Human Services AgencyDepartment 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 first 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?⁜
(c) Has any family member living in the home received an organ transplant within the last 2 years?					❑ 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 first 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?⁜ ؠ

(c) If a new baby is in home, where was the baby’s place of birth?		⁜ \|		\|
	City		State		Country

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State of California—Health and Human Services AgencyDepartment 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?⁜
		❑ Yes ❑ No
(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 benefit 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

(c)Did you or any family member in the home sell or give away any money or property in the 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 benefits.)	❑ Yes ❑ No
If yes, list the name(s) below and send proof of new status.

Name of Person

(include first 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
	difficult 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

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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			❑ Yes ❑ No
	and Disability Prevention Program, also known as CHDP?)		❑ Yes ❑ No
(c) Do you want information on the no-cost supplemental food program for pregnant or breast
	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 Certification

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	❑⁜WIC	❑⁜MC 13	❑⁜MC 210 PS	❑⁜Other:
❑⁜CHDP	❑⁜PCSP		❑⁜DDSD Packet

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Form Information

Fact Name	Description
Purpose	The Medi-Cal Redetermination form is required to maintain eligibility for Medi-Cal benefits.
Filing Requirement	Individuals must complete and submit the form annually to their county office.
Information Needed	The form collects personal details, income sources, expenses, and changes in living situations.
Optional Information	Case number and Social Security number are optional but can help streamline the process.
Submission Method	Forms can be returned using a postage-paid envelope provided with the form.
Proof of Income	Applicants must attach documentation such as pay stubs or tax returns to verify income.
California Law	The form is governed by California Welfare and Institutions Code Section 14000 et seq.
Signature Requirement	A signature is required to certify that all information provided is true and correct.

Detailed Guide for Filling Out Medi Cal Redetermination

Completing the Medi-Cal Redetermination form is essential for maintaining your Medi-Cal benefits. After you submit the form, the county will review your information to determine your continued eligibility. Make sure to provide accurate and complete information to avoid delays in processing.

Gather your documents, including income statements, proof of expenses, and any relevant identification.
Fill in your case number and social security number at the top of the form (these are optional).
Print your full name and birth date in the designated areas.
Provide your current street address and check the box if it is a new address.
If your mailing address is different, fill it in as well.
In Section 1, indicate if you or any family member receives income from various sources and list them accordingly. Attach necessary proof, such as pay stubs or tax returns.
In Section 2, report any expenses or deductions you or your family members incur. Include proof of these expenses.
Section 3 requires you to disclose any changes in health insurance or coverage. Answer the questions and provide details as needed.
In Section 4, note any changes in your living situation over the past 12 months, including new births or anyone moving in or out.
Section 5 asks about your cash and property holdings. Provide accurate figures and answer questions regarding any sales or transfers of property.
If there have been changes in immigration or citizenship status, fill out Section 6 with the relevant details.
In Section 7, indicate if you or any family member has a disability or condition affecting daily living.
Section 8 allows you to opt-in for additional health programs. Check the boxes as applicable.
Finally, sign and date the form in Section 9. Ensure you provide a daytime phone number and check if your number has changed.
Use the postage-paid envelope to return the completed form to the county.

Obtain Answers on Medi Cal Redetermination

What is the Medi-Cal Redetermination form?

The Medi-Cal Redetermination form is a document that individuals must complete annually to maintain their eligibility for Medi-Cal, California's Medicaid program. It collects updated information about income, expenses, living situations, and other relevant factors affecting eligibility.
Who needs to fill out the form?

Anyone currently receiving Medi-Cal benefits must complete the Redetermination form. This ensures that the information on file is current and accurate, which is essential for continued eligibility.
How do I submit the form?

You can submit the completed form by mailing it to your county's Medi-Cal office using the postage-paid envelope provided. Ensure that you sign and date the form before sending it. If you need more space for your answers, attach additional sheets as necessary.
What happens if I don’t submit the form?

If you fail to submit the Redetermination form by the deadline, you may lose your Medi-Cal benefits. It is crucial to complete and return the form on time to avoid any interruption in your healthcare coverage.
What information is required on the form?

The form requires various details, including:
- Personal information such as name, address, and date of birth.
- Income sources and amounts.
- Expenses and deductions.
- Changes in living situation.
- Information about any other health insurance.
What if my income or living situation has changed?

If there have been changes in your income or living situation, you must report these on the Redetermination form. Changes can affect your eligibility and the level of benefits you may receive.
Can I get help filling out the form?

Yes, assistance is available. You can contact your Medi-Cal worker using the phone number provided on your Annual Redetermination Notice. They can guide you through the process and answer any questions you may have.
What should I do if I have new family members?

If someone has moved into your home or if there are new family members, such as a newborn, you must include their information on the form. This ensures that all eligible individuals receive the appropriate benefits.
What if I need more space for my answers?

If the space provided on the form is insufficient for your answers, you can attach additional sheets. Make sure to reference the section number on the form to which your additional information pertains.
What is the deadline for submitting the form?

The deadline for submitting the Redetermination form is typically indicated in your Annual Redetermination Notice. It is essential to adhere to this deadline to maintain your Medi-Cal benefits.

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. For instance, when listing income sources, it’s essential to include every type of income received, whether it’s from a job, social security, or even gifts. Omitting any source can raise questions and complicate the review process.

Another common mistake is failing to attach necessary documentation. The form requires proof of income, such as pay stubs or tax returns, to verify the information provided. Without these documents, the application may be deemed incomplete, resulting in a denial or delay. Always double-check that you’ve included all required attachments before submitting the form.

Many individuals also forget to update their living situation. If someone has moved in or out of the household, this change must be reported. Not doing so can lead to inaccuracies in determining eligibility. Similarly, if there has been a change in marital status or if a new baby has been born, it is crucial to reflect these changes on the form.

Another mistake is neglecting to sign and date the form. A missing signature can halt the processing of the application. Ensure that you have signed in the designated area, as this confirms that you understand the responsibilities associated with Medi-Cal.

Some applicants overlook the importance of providing accurate contact information. If there are any changes to phone numbers or addresses, these need to be updated on the form. This ensures that the county can reach you if there are questions or if additional information is required.

Additionally, people often fail to read the instructions carefully. The Medi-Cal Redetermination form includes specific guidelines on how to fill it out, including which boxes to check and how to provide information. Skipping this step can lead to errors that could have been easily avoided.

Another common oversight is not reporting all assets. The form asks about various types of property, including bank accounts and vehicles. If any of these assets are not reported, it may lead to complications in eligibility determination. Transparency is key in this process.

Moreover, some individuals do not keep a copy of the submitted form for their records. Having a copy can be helpful if there are questions later on or if you need to follow up with your caseworker. Always make a copy before mailing it in.

Lastly, many applicants miss the deadline for submission. It’s crucial to return the form by the specified date to avoid any lapse in coverage. Setting a reminder can help ensure that you don’t overlook this important deadline.

Documents used along the form

The Medi-Cal Redetermination form is essential for maintaining eligibility for Medi-Cal benefits. Along with this form, several other documents may be required to provide a complete picture of an individual's 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 that prove income sources. They help establish the financial status of the applicant and their household.
Expense Documentation: Proof of monthly expenses, such as child care, health insurance, or educational costs, is necessary. This documentation helps assess eligibility based on financial obligations.
Property Supplement Form: If there are changes in property ownership or significant transactions, this form is required. It provides additional details about assets that may affect eligibility.
Proof of Citizenship or Immigration Status: Documentation proving citizenship or legal residency is crucial. This includes passports, green cards, or other legal documents that verify status.
Medical Records: For individuals with disabilities or chronic health conditions, medical documentation may be needed. This helps in assessing the need for specific health services.
Change of Address Form: If there has been a change in residence, this form must be submitted. It ensures that communication from Medi-Cal is sent to the correct address.
Application for Additional Benefits: If an applicant is seeking other assistance programs, this application may be required. It allows for a comprehensive review of available benefits.
Authorization for Release of Information: This form allows Medi-Cal to obtain necessary information from other agencies or providers. It ensures that all relevant data is available for the redetermination process.

Gathering these documents can facilitate a smoother redetermination process and help ensure that all necessary information is provided for a thorough review of eligibility. It is important to stay organized and submit all required materials promptly.

Similar forms

The Medi-Cal Redetermination form shares similarities with several other documents that individuals may encounter in various contexts, particularly those related to health care and social services. Below is a list of nine documents that are similar to the Medi-Cal Redetermination form, along with a brief explanation of how they are alike.

Medicaid Application Form: This form is used to apply for Medicaid benefits. Like the Medi-Cal Redetermination form, it requires personal information, income details, and documentation to determine eligibility.
Food Stamp Application: Individuals seeking food assistance must fill out this form. Similar to the Medi-Cal Redetermination, it asks for income and household information to assess eligibility for benefits.
WIC Program Application: The Women, Infants, and Children (WIC) program application requests information about income, family size, and nutritional needs, paralleling the Medi-Cal form's focus on financial and household circumstances.
Health Insurance Marketplace Application: This application is for those seeking health insurance under the Affordable Care Act. It requires income and household information, similar to the Medi-Cal Redetermination form.
Supplemental Security Income (SSI) Application: This form assesses eligibility for SSI benefits based on income and resources. Like the Medi-Cal form, it requires detailed financial disclosures.
Unemployment Benefits Application: Individuals applying for unemployment benefits must provide personal and financial information. This mirrors the requirements of the Medi-Cal Redetermination form in terms of verifying income and household composition.
Child Care Assistance Application: This document is used to apply for financial assistance with child care costs. It similarly requires information about income and family circumstances.
Housing Assistance Application: Individuals seeking housing aid must provide details about their financial situation and household, much like the information requested in the Medi-Cal Redetermination form.
Medicare Savings Program Application: This application helps determine eligibility for assistance with Medicare costs. It requests income and asset information, paralleling the Medi-Cal form’s focus on financial details.

Dos and Don'ts

When filling out the Medi-Cal Redetermination form, there are important guidelines to follow. Here is a list of things you should and shouldn't do:

Do use blue or black ink to complete the form.
Do provide accurate and complete information for each section.
Do sign and date the form before submission.
Do attach any necessary documentation, such as pay stubs or proof of expenses.
Don't leave any required fields blank; if a question does not apply, indicate that clearly.
Don't forget to use the postage-paid envelope for returning the form.
Don't submit the form late; ensure it is sent back before the deadline.
Don't hesitate to contact your worker if you have questions or need assistance.

Misconceptions

Misconception 1: The Medi-Cal Redetermination form is optional.

This form is not optional. It must be completed and returned to the county to maintain Medi-Cal eligibility. Failing to submit the form could result in losing benefits.

Misconception 2: Only income from employment needs to be reported.

All sources of income must be reported. This includes child support, social security, veteran benefits, and any other financial support. It is important to provide a complete picture of your financial situation.

Misconception 3: You can submit the form without supporting documents.

Misconception 4: Changes in living situation do not need to be reported.

Any changes in your living situation, such as someone moving in or out, getting married, or having a baby, must be reported. These changes can affect eligibility and should be documented on the form.

Misconception 5: The form can be submitted without a signature.

A signature is required to certify that the information is true and correct. Submitting the form without a signature could lead to delays or denial of benefits.

Key takeaways

Filling out the Medi-Cal Redetermination form is a crucial step to maintain your Medi-Cal benefits. Here are some key takeaways to help you navigate the process effectively:

Complete All Sections: Ensure that you fill out every section of the form. Missing information can delay your benefits.
Provide Accurate Information: Double-check your answers for accuracy. Mistakes could lead to complications in your eligibility.
Attach Necessary Documentation: Include required documents such as pay stubs, tax returns, and proof of expenses. This helps verify your information.
Use the Provided Envelope: Make sure to return the form using the postage-paid envelope included with your notice. This simplifies the submission process.
Ask for Help if Needed: If you have questions or need assistance, don’t hesitate to contact your worker. They can provide guidance tailored to your situation.
Sign and Date the Form: Remember to sign and date the form before sending it. An unsigned form may be considered incomplete.

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