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The Medi-Cal Annual Redetermination Form is an essential document that individuals in California must complete to maintain their Medi-Cal benefits. This form serves several key functions, ensuring that beneficiaries report their current income, expenses, living situation, and any changes in health coverage or personal circumstances. The form is divided into multiple sections that require detailed information about various aspects of the applicant's life, including income sources from jobs, child support, and disability benefits. Additionally, it seeks information on current living arrangements, expenses related to childcare or healthcare, and any new health insurance coverage received in the past year. Importantly, beneficiaries must also declare any changes in immigration status or disability and provide verification if certain criteria apply. Finally, the form requires signatures to certify that the information provided is accurate and complete. Failure to submit this form on time may result in a loss of Medi-Cal benefits, underscoring its importance in the benefits renewal process.

Medi Cal Redetermination Example

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

MC 210 RV (5/11)

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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

 

MC 210 RV (5/11)

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Get Medi Cal Redetermination PDF Form

Form Characteristics

Fact Name Description
Purpose of the Form This form is required to maintain eligibility for Medi-Cal benefits by providing updated information about income, expenses, and living situations.
Submission Requirement The completed form must be returned to the appropriate county office to ensure continued Medi-Cal coverage.
Important Sections The form includes sections on income, expenses, changes in living situation, and other relevant personal information.
Governing Laws The Medi-Cal program operates under California Welfare and Institutions Code, Sections 14000-14087.
Documentation Needed Applicants must attach proof of income and expenses, such as pay stubs or benefit letters, to this form.
Signature Requirement The individual completing the form is required to sign and date it, confirming the accuracy of all provided information.
Changes in Status Any changes in citizenship, income, or family composition within the last 12 months must be reported on this form.
Assistance for Completion If individuals encounter difficulties while filling out this form, they are advised to contact their case worker for assistance.

Guidelines on Utilizing Medi Cal Redetermination

Completing the Medi-Cal Redetermination Form is a vital step to ensure the continuation of your Medi-Cal benefits. Follow these simple steps to accurately fill out the form and submit it to your county office.

  1. Begin by writing your Case Number and Social Security Number in the designated areas at the top of the form. If you do not have these numbers, you can leave them blank.
  2. Print your Full Name clearly in the next box. If your address hasn’t changed and a label is provided, you may affix it here.
  3. Provide your Birth Date in the format (mm/dd/yyyy), followed by your Current Street Address, including apartment number if applicable. If you have moved, be sure to check the appropriate box.
  4. Indicate your City, State, and Zip Code. If you have a Mailing Address that is different from your current address, fill that out as well.
  5. Use a pen to fill in all answers clearly and legibly. Be sure to sign and date the form at the end, following the provided instructions.
  6. Move to Section 1: Income. Answer whether you or any family member receive various types of income. If you select "Yes," list each source of income and attach the appropriate documentation.
  7. For Section 2: Expenses and Deductions, indicate if you have expenses such as child care or health insurance. If "Yes," document these with the necessary details and proof.
  8. In Section 3: Other Health Insurance, provide information about health coverage or any kidney dialysis-related services received by members of your household.
  9. Section 4: Living Situation will ask about any changes in your home such as new members or births. Fill out this section carefully, providing details as required.
  10. Proceed to Section 5: Real or Personal Property. Disclose assets held by family members and answer questions regarding recent monetary or property transactions.
  11. In Section 6: Immigration or Citizenship Status Change, indicate if there have been changes in status for anyone receiving or applying for Medi-Cal.
  12. Section 7 addresses any disabilities or incapacity among household members. Respond as appropriate.
  13. If applicable, answer the questions in Section 8: Other Health Program Information and Referrals, choosing whether or not to receive additional health program information.
  14. Lastly, Section 9 requires your signature and verification that all provided information is true. If someone assisted you in filling the form, their signature should also be included here.

After completing the form, carefully review your answers for accuracy. Use the postage-paid envelope to send it back to the county. If you need more space for answers, don’t hesitate to attach an additional sheet. Should you have any questions during this process, reach out to your designated worker for assistance.

What You Should Know About This Form

What is the purpose of the Medi-Cal Redetermination form?

The Medi-Cal Redetermination form is used to assess an individual's ongoing eligibility for Medi-Cal benefits. It collects information about your income, expenses, living situation, health coverage, and changes in circumstances that may impact your eligibility. Completing this form is crucial to ensure continued access to necessary healthcare services.

Who needs to complete the Medi-Cal Redetermination form?

How do I submit the completed Redetermination form?

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

If you encounter any difficulties or have questions while completing the Medi-Cal Redetermination form, you can contact your assigned worker using the telephone number listed on your Annual Redetermination Notice. They can provide assistance and clarify any points of confusion.

What information is required about my income?

What happens if I fail to submit the Redetermination form?

Can I report changes in my circumstances after submitting the form?

What types of expenses should I report on the form?

Common mistakes

Filling out the Medi-Cal Redetermination form requires attention to detail. One common mistake individuals make is not providing their Case Number or Social Security Number. Although these fields are designated as optional, including them helps the county process the application more efficiently.

Another frequent error is failing to update the Current Street Address. If an individual's address has changed, it is crucial to check the box indicating a new address and accurately fill it in. Inaccurate addresses can lead to delays in communication and processing.

One may also overlook attaching the necessary documentation for income verification. Commonly, individuals forget to include pay stubs, benefit letters, or tax returns. Each source of income should be listed separately, along with the relevant proof. This documentation is vital for assessing eligibility.

Another mistake involves the income section since some people might not report all sources of income, such as cash gifts or freelance work. Accurate reporting is essential because any unreported income may affect eligibility negatively.

In Section 2, individuals sometimes fail to provide details regarding expenses and deductions. For instance, not stating payments for health insurance or child support can result in an incomplete application. Each expense must be documented thoroughly and accurately.

People may also forget to disclose any changes in their health insurance coverage in Section 3. Reporting new coverage or changes is essential for the county to determine the correct Medi-Cal benefits. Additionally, some applicants fail to indicate if any family members have had kidney dialysis or organ transplants, which can also impact their eligibility.

When addressing changes in living situations in Section 4, individuals sometimes neglect to mention temporary occupants or new babies. This information is crucial for providing the appropriate health care coverage for all household members.

A common oversight occurs when applicants do not list their assets under Section 5. Important items often left unreported include bank accounts, vehicles, or property. Accurate disclosure is vital to ensure eligibility and to avoid potential issues down the line.

In Section 6, changes in immigration or citizenship status are sometimes ignored. This information can significantly influence eligibility and potential benefits. Applicants must ensure they report any relevant changes accurately.

Lastly, individuals sometimes sign the form without reviewing all the information provided. A signature attests to the accuracy of the information, and errors or omissions could lead to complications. It is vital to double-check everything before submission.

Documents used along the form

The Medi-Cal Redetermination form is essential for maintaining health coverage in California. However, several additional forms and documents might be needed to provide comprehensive information during this process. Below is a list of commonly used forms and documents that assist in the redetermination. Each serves a specific purpose to ensure that the eligibility criteria are thoroughly evaluated.

  • Income Verification Documents: Recent pay stubs, benefit letters, or tax returns that verify the income of all household members. These are crucial to assess the financial eligibility for Medi-Cal.
  • Property Supplement Form: This form is required if there are changes in assets, such as selling or giving away property. It ensures that all relevant property information is accurately reported.
  • Self-Employment Documentation: Profit and loss statements or recent tax returns for individuals who are self-employed, providing insight into fluctuating incomes.
  • Change of Address Form: A document to report any change in residence. Keeping the mailing address updated is vital for continued communication.
  • Verification of Health Insurance Coverage: Proof of any changes or new health insurance coverage obtained within the last 12 months, which can impact Medi-Cal eligibility.
  • Citizenship and Immigration Status Documentation: Required proof if there has been a change in immigration status of any household member, affecting eligibility for Medi-Cal benefits.
  • Disability Verification Form: Should there be someone in the household with a disability, this form is important to provide necessary information about any limitations affecting work capability.

Each of these documents plays an important role in the Medi-Cal Redetermination process. It is advisable to gather and submit all necessary forms promptly to avoid any interruptions in healthcare coverage. Ensuring that you provide accurate and complete information is key to a smooth redetermination experience.

Similar forms

  • Application for Health Coverage: Similar to the Medi-Cal Redetermination form, this application requires personal information, income details, and proof of expenses to assess eligibility for health benefits.
  • Food Stamp Application: This document requests household information, income, and expenses to determine eligibility for Supplemental Nutrition Assistance Program (SNAP) benefits, paralleling the income and expense disclosures found in the Medi-Cal form.
  • Medicare Enrollment Form: Like the Medi-Cal Redetermination, this form asks for personal details and any changes in health status or insurance coverage to continue receiving benefits.
  • WIC Application: Women, Infants, and Children (WIC) applications require information similar to that of the Medi-Cal form, including family composition and income verification to assess eligibility for nutritional support.
  • California's Covered California Enrollment Form: This enrollment form demands personal, income, and household information, much like the Medi-Cal Redetermination, to determine eligibility for health coverage under the Affordable Care Act.
  • Housing Assistance Application: This type of application seeks information about income, assets, and family composition, mirroring the Medi-Cal form's requirements for proving financial need and household status.
  • CalWORKs Application: Much like the Medi-Cal Redetermination form, the CalWORKs application involves submitting details about income, living situation, and family members to qualify for cash aid.
  • Child Care Subsidy Application: This document assesses eligibility for financial support in child care, requiring similar information about income and family size as the Medi-Cal form.
  • Unemployment Benefits Application: Just as with the Medi-Cal form, applicants must provide documentation of income and employment history to qualify for unemployment assistance.
  • Temporary Assistance for Needy Families (TANF) Application: This form requests information about personal circumstances, income, and family situation, akin to the requirements of the Medi-Cal Redetermination process.

Dos and Don'ts

When completing the Medi-Cal Redetermination form, keep the following points in mind:

  • Use black or blue ink: Always fill out the form using either black or blue ink to ensure readability.
  • Attach necessary documents: Include all required proofs of income and expenses. Missing documents may delay your application.
  • Double-check your information: Review the form for any inaccuracies or omissions before sending it. Errors can lead to processing issues.
  • Sign and date the form: Ensure that you sign and date the form before submission.

Conversely, avoid the following errors:

  • Do not leave sections blank: Every question needs an answer, even if the answer is "no." Leaving blanks can cause delays.
  • Avoid using pencil: Filling out the form in pencil can lead to unreadable answers and may not be accepted.
  • Do not submit without a signature: Failing to sign the form means it won’t be processed.
  • Do not ignore instructions: Carefully follow all directions on the form to avoid complications.

Misconceptions

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

    • This form is mandatory for individuals who wish to maintain their Medi-Cal benefits. Failure to submit it may lead to the termination of those benefits.

  • Misconception 2: Providing the Social Security Number is required.

    • The form states that providing a Social Security Number is optional. However, submitting it can help process the application more efficiently.

  • Misconception 3: Only income from jobs needs to be reported.

    • The form requires reporting all sources of income, including child support, unemployment benefits, disability income, and any other financial contributions.

  • Misconception 4: You do not need to report changes in living situations.

    • The form explicitly asks about any changes in living arrangements. Reporting such changes is crucial for accurate eligibility determination.

  • Misconception 5: New health insurance does not need to be reported.

    • Any changes in health insurance must be reported within the specified timeframe. This includes gaining new coverage or experiencing a lapse in existing coverage.

  • Misconception 6: The form can be filled out without proof of income.

    • The instructions clarify that attaching proof of income is necessary. This may include pay stubs, tax returns, or other documentation to verify reported amounts.

  • Misconception 7: It is okay to submit the form without a signature.

    • The form requires the certifying signature of the person completing it. Submitting an unsigned form may delay processing or result in denial of benefits.

  • Misconception 8: The Redetermination form can be submitted late without consequences.

    • Timely submission is critical. Late submissions may lead to a gap in coverage or a complete denial of benefits.

  • Misconception 9: Changes in immigration status do not affect eligibility.

    • Changes in immigration status can impact Medi-Cal eligibility. Individuals are advised to report any such changes to maintain compliance.

Key takeaways

Here are some important points to consider when filling out and using the Medi-Cal Redetermination form:

  • Complete the Form Accurately: Ensure you provide all required information. Missing details can delay your Medi-Cal eligibility.
  • Income Reporting: Clearly list all sources of income for you and any family members in your household. This includes jobs, benefits, and any other financial support.
  • Documentation is Key: Attach relevant proof of income, such as pay stubs and tax returns. This documentation supports the claims you make on the form.
  • Changes in Living Situation: If there have been new arrivals or departures within your household, document these changes. They can impact your benefits.
  • Stay Updated: Notify your county office of any changes in health insurance or other relevant coverage. Keeping your information current is crucial.
  • Sign and Date: Don’t forget to sign and date the form before submission. An unsigned form may not be processed.

By following these tips, you can help ensure that your Medi-Cal application stays on track and that your benefits continue without interruption.

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