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The Medi-Cal Redetermination form is a crucial document for anyone seeking to maintain their Medi-Cal benefits in California. This annual form requires individuals to provide updated information regarding their income, living situation, and any changes in health insurance or family status. Completing the form involves detailing sources of income, including wages, benefits, and any assistance received, while also documenting expenses that may affect eligibility. It is essential to report any changes in household composition, such as new family members or changes in residency. The form also asks about property ownership and any financial transactions that could impact eligibility. Lastly, individuals must confirm their immigration or citizenship status and declare any disabilities that may affect their ability to work. Accurate completion and timely submission of this form are vital to ensure continued access to necessary health care services.

Form Sample

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?

 

 

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?)

 

(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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⇩ PDF

Document Specifications

Fact Name Details
Purpose of the Form The Medi-Cal Annual Redetermination Form is required to maintain eligibility for Medi-Cal benefits in California.
Submission Requirement Individuals must fill out and return the form to their county office to continue receiving Medi-Cal coverage.
Income Reporting Applicants must disclose all sources of income, including employment, benefits, and support payments.
Expense Documentation Documentation for expenses such as child care or health insurance must be attached to the form if applicable.
Change of Circumstances Any changes in living situation, such as new family members or changes in income, must be reported on the form.
Legal Authority This form is governed by California Welfare and Institutions Code Section 14000 et seq., which outlines Medi-Cal eligibility requirements.
Certification Requirement The individual completing the form must certify that all information provided is true and correct under penalty of perjury.

Steps to Filling Out Medi Cal Redetermination

Completing the Medi-Cal Redetermination form is an essential step to ensure that you maintain your Medi-Cal benefits. After you submit the form, your county will review the information provided and determine your eligibility for continued coverage. It is crucial to be thorough and accurate in your responses to avoid any delays or issues with your benefits.

  1. Begin by writing your case number and social security number at the top of the form. These fields are optional, but including them can help streamline the process.
  2. Print your full name clearly in the designated area. If you have not moved, you can place the address label provided here.
  3. Fill in your birth date in the format (mm/dd/yyyy).
  4. Provide your current street address and apartment number, if applicable. Check the box if this address is new.
  5. Include your city, state, and zip code.
  6. If your mailing address is different from your current address, fill in the mailing address section along with the corresponding city, state, and zip code.
  7. Use ink and print your answers clearly throughout the form.
  8. In Section 1, indicate if you or any family member receives income from various sources by checking yes or no. If yes, list each source of income on a separate line and attach the required documentation.
  9. For any expenses or deductions, go to Section 2. Again, indicate if you or a family member pays for specific expenses by checking yes or no. If yes, provide details and attach proof.
  10. In Section 3, answer questions about other health insurance coverage. Indicate changes in coverage within the last 12 months by checking yes or no.
  11. Section 4 addresses changes in living situations. Respond to each question regarding household changes, and provide details as needed.
  12. Section 5 requires information about real or personal property. Answer the questions and provide details if necessary.
  13. In Section 6, indicate if there has been a change in immigration or citizenship status for anyone in the home.
  14. Section 7 focuses on any disabilities or incapacity. Answer the questions regarding physical or emotional conditions.
  15. In Section 8, you can choose whether to receive information on additional health programs. Check the appropriate boxes.
  16. Finally, in Section 9, read and sign the certification statement. Include your signature, date, and contact numbers. If someone assisted you, have them sign as a witness.
  17. Use the postage-paid envelope provided to return the completed form to your county.

More About Medi Cal Redetermination

What is the Medi-Cal Redetermination form?

The Medi-Cal Redetermination form is a document that you must complete and submit to your county to maintain your Medi-Cal benefits. This form collects information about your income, living situation, and any changes in your health coverage. It helps ensure that you continue to qualify for the program based on your current circumstances.

Who needs to fill out the Medi-Cal Redetermination form?

If you or a family member is currently receiving Medi-Cal benefits, you need to fill out this form. It is essential for anyone whose eligibility may change due to income, family size, or other factors. If you want to keep receiving Medi-Cal, submitting this form on time is crucial.

How do I submit the Medi-Cal Redetermination form?

You can return the completed form using the postage-paid envelope provided with your notice. Make sure to sign and date the form before sending it. If you need more space for your answers, feel free to attach an additional sheet. It's important to submit the form promptly to avoid any disruption in your benefits.

What happens if I don’t submit the form on time?

If you fail to submit the Medi-Cal Redetermination form by the deadline, you risk losing your Medi-Cal benefits. It’s essential to be aware of the due date mentioned in your Annual Redetermination Notice and to act before that date. If you have concerns about the deadline, reach out to your county worker for assistance.

What should I do if I have questions while filling out the form?

If you encounter any difficulties or have questions while completing the form, don’t hesitate to contact your caseworker. The telephone number for your worker is listed on your Annual Redetermination Notice. They can provide guidance and help clarify any sections of the form.

What information do I need to provide on the form?

You will need to provide details about your income, expenses, living situation, and any changes in health coverage. Be prepared to list sources of income, any free assistance you receive, and details about your household. Supporting documents, like pay stubs or tax returns, may also be required to verify your information.

Can I include other family members on the form?

Common mistakes

  1. Failing to provide accurate personal information. Ensure that your name, address, and case number are correctly filled out. Any errors can delay processing.

  2. Not including all sources of income. Be thorough when listing income from jobs, benefits, or other sources. Missing information can lead to a denial of benefits.

  3. Neglecting to attach required documentation. Always include pay stubs, tax returns, or other proof of income and expenses. Incomplete submissions may result in processing delays.

  4. Overlooking changes in living situation. Report any new family members, moves, or significant life changes. This information is crucial for accurate eligibility assessment.

  5. Not checking for changes in health insurance. If you or a family member has new coverage, it must be reported. Failing to do so can affect your Medi-Cal eligibility.

  6. Forgetting to sign and date the form. A missing signature will lead to automatic rejection of the application.

  7. Using illegible handwriting. Fill out the form clearly and in ink. If the information is hard to read, it may not be processed correctly.

  8. Ignoring the deadline for submission. Late forms can result in loss of coverage. Always send your form back as soon as possible.

  9. Not following up with the county. If you do not receive confirmation of your application, reach out to ensure it was received and is being processed.

  10. Failing to report all assets. Be transparent about cash, property, and other resources. Underreporting can lead to penalties or loss of benefits.

Documents used along the form

The Medi-Cal Redetermination form is an essential document for maintaining eligibility for Medi-Cal benefits. Along with this form, several other documents may be required to ensure a smooth redetermination process. Below is a list of common forms and documents that are often used in conjunction with the Medi-Cal Redetermination form.

  • Income Verification Documents: This includes recent pay stubs, benefit letters, or tax returns that confirm your income sources and amounts.
  • Expense Verification Documents: Proof of expenses such as child care, health insurance premiums, or educational costs may be needed to determine eligibility.
  • Property Supplement Form: If there are changes in assets or property ownership, this form must be completed and submitted.
  • Immigration Status Documentation: If there has been a change in immigration status, proof of the new status is required.
  • Medical Records: Documentation of any significant medical conditions or disabilities affecting household members may be necessary.
  • Child Health and Disability Prevention Program (CHDP) Application: This form provides information about health services for children under 21.
  • Women, Infants, and Children Program (WIC) Application: This document is used to apply for nutritional support for pregnant women and young children.
  • Personal Care Services Program (PCSP) Application: This form is for those seeking in-home care services for disabled or elderly individuals.
  • Important Information for Persons Requesting Medi-Cal (MC 219): This document outlines rights and responsibilities for Medi-Cal applicants.
  • Annual Redetermination Notice: A notice that provides specific instructions and reminders about the redetermination process.

Gathering these documents can help streamline the redetermination process and ensure that all necessary information is available for review. If you have questions about any of these forms, don’t hesitate to reach out for assistance.

Similar forms

The Medi-Cal Redetermination form is similar to the Food Stamp Application, which also requires applicants to provide detailed information about their household income and expenses. Both forms aim to assess eligibility for government assistance programs. Applicants must report any changes in their financial situation, such as income from employment or other sources. This ensures that benefits are allocated based on current needs and circumstances.

Another document with similarities is the Temporary Assistance for Needy Families (TANF) application. Like the Medi-Cal Redetermination form, the TANF application requires information about household composition, income, and expenses. Both documents emphasize the importance of reporting changes in living situations, such as new household members or changes in income, to determine continued eligibility for assistance.

The Supplemental Security Income (SSI) application shares common elements with the Medi-Cal Redetermination form. Both require applicants to disclose their financial status, including income and assets. Additionally, both forms necessitate the reporting of any changes in health status or living arrangements that could affect eligibility for benefits.

The Unemployment Insurance (UI) claim form is also comparable to the Medi-Cal Redetermination form. Both documents require individuals to provide information regarding their employment history and current financial situation. Applicants must report any income received during the claim period, ensuring that benefits are accurately distributed based on real-time circumstances.

The Medicare Savings Program application is another document similar to the Medi-Cal Redetermination form. Both require applicants to provide details about their income and expenses to determine eligibility for assistance. The focus on household income and expenses ensures that individuals receive the appropriate level of support based on their financial needs.

The Housing Assistance application aligns with the Medi-Cal Redetermination form in that it requires detailed information about household income and expenses. Both forms assess eligibility based on current living situations and financial resources, ensuring that assistance is provided to those who truly need it.

The Child Care Subsidy application shares similarities with the Medi-Cal Redetermination form, particularly in its focus on household income and expenses. Both documents require applicants to report any changes in financial circumstances that could impact their eligibility for assistance, emphasizing the need for accurate and up-to-date information.

The Low-Income Home Energy Assistance Program (LIHEAP) application is another document that resembles the Medi-Cal Redetermination form. Both require applicants to disclose their income and expenses to determine eligibility for assistance. The emphasis on financial disclosure ensures that aid is directed to those facing financial hardships.

The Women, Infants, and Children (WIC) Program application is similar to the Medi-Cal Redetermination form in that it requires information about household composition and income. Both forms aim to provide assistance based on current financial needs, ensuring that eligible families receive the necessary support for health and nutrition.

Finally, the State Disability Insurance (SDI) claim form shares commonalities with the Medi-Cal Redetermination form. Both require individuals to provide detailed information about their income and living situation. This information helps determine eligibility for benefits and ensures that individuals receive the appropriate level of support based on their current circumstances.

Dos and Don'ts

When filling out the Medi-Cal Redetermination form, it's important to follow certain guidelines to ensure your application is processed smoothly. Here are some do's and don'ts to keep in mind:

  • Do use black or blue ink to fill out the form.
  • Do print your answers clearly and legibly.
  • Do attach any necessary documents, such as proof of income or expenses.
  • Do sign and date the form before submitting it.
  • Don't leave any required fields blank; provide information for all applicable sections.
  • Don't forget to check the box if your address has changed.
  • Don't submit the form without verifying that all information is accurate.
  • Don't use correction fluid or tape on the form; if you make a mistake, simply cross it out and write the correct information.

Following these tips will help ensure that your Medi-Cal Redetermination form is completed correctly and submitted on time.

Misconceptions

Understanding the Medi-Cal Redetermination form is crucial for maintaining eligibility. However, several misconceptions can lead to confusion. Here are five common misconceptions explained:

  • Misconception 1: The form is optional.

    • Many people believe that filling out the Medi-Cal Redetermination form is optional. In reality, it is mandatory to submit this form to keep your Medi-Cal benefits active. Failure to do so can result in losing coverage.

  • Misconception 2: You can skip questions if you don’t have the information.

    • Some individuals think they can leave questions blank if they don’t have all the information. However, it is important to provide as much information as possible. If you need more space, attach a separate sheet rather than leaving questions unanswered.

  • Misconception 3: You don’t need to provide proof of income or expenses.

    • Another common belief is that proof of income or expenses is not necessary. In fact, you must attach documentation such as pay stubs or benefit letters to support the information you provide on the form.

  • Misconception 4: You can submit the form without a signature.

    • Some people think they can submit the form without signing it. A signature is required to certify that the information is accurate. Submitting an unsigned form may lead to delays or denial of benefits.

  • Misconception 5: Changes in circumstances do not need to be reported immediately.

    • Many believe that changes in income or living situation can wait until the next redetermination. However, you must report any changes within ten days to ensure continued eligibility for Medi-Cal.

Key takeaways

Completing the Medi-Cal Redetermination form is a crucial process for maintaining eligibility for Medi-Cal benefits. Here are key takeaways to consider:

  • Timeliness is essential. Submit the form before the deadline to avoid a lapse in coverage.
  • Accurate information is vital. Ensure that all personal details, including name and address, are correct.
  • Document income sources. List all income from various sources and attach necessary proof, such as pay stubs or tax returns.
  • Report changes in living situation. Include any recent changes, such as new family members or relocations.
  • Disclose all expenses. Provide information about any relevant expenses that could affect eligibility, such as child care or health insurance costs.
  • Include property details. Report any assets, including bank accounts and real estate, that may impact your Medi-Cal status.
  • Seek assistance if needed. Contact your caseworker for help with completing the form if you have questions.
  • Use the correct format. Fill out the form in ink and ensure it is legible to avoid processing delays.
  • Sign and date the form. Your signature certifies that the information provided is accurate and complete.
  • Keep a copy. Retain a copy of the completed form for your records, along with any attachments submitted.

Understanding these points can facilitate a smoother redetermination process and help maintain necessary health coverage.