Form Mc 262 PDF Details

The process of ensuring continuity in Medi-Cal benefits for long-term care recipients hinges on a critical document recognized as the MC 262 form, issued by the State of California — Health and Human Services Agency, Department of Health Care Services. This comprehensive form serves a pivotal role in the redetermination process for those residing in their own Maintenance and Facility Beneficiary Units (MFBU). It's crafted to collect exhaustive information regarding a beneficiary's financial assets, property ownership, income sources, and other personal details pivotal for reassessing their eligibility for continued assistance under Medi-Cal. Each question must be meticulously answered to ensure an accurate evaluation of the beneficiary's circumstances. Moreover, it also addresses potential changes in personal circumstances that might affect eligibility, such as modifications in income, possessions, or living conditions, underscoring the necessity for beneficiaries or their representatives to promptly update their information to avoid disruptions in their benefits. This form encapsulates the essence of maintaining transparency and compliance with legal stipulations surrounding Medi-Cal benefits, emphasizing the importance of integrity in the information provided to safeguard both the beneficiaries and the integrity of the Medi-Cal program.

QuestionAnswer
Form NameForm Mc 262
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namescal redetermination form, medi cal 262 pdf, medi redetermination 262, form 262 medical

Form Preview Example

State of California—Health and Human Services Agency

Department of Health Care Services

REDETERMINATION FOR MEDI-CAL BENEFICIARIES

(LONG-TERM CARE IN OWN MFBU)

INSTRUCTIONS: Your continuing eligibility will be decided on the information you give on this form. If you are completing this form on someone else’s behalf, the term “you” applies to that person. ALL QUESTIONS MUST BE ANSWERED.

 

 

 

 

 

 

1.

Name (first, middle, last)

Date of birth (month, day, year)

Social security number

 

 

 

 

 

2.

Long-term care facility name

Marital status

 

Medicare claim number

 

 

 

 

 

 

 

Facility address (number, street)

City

 

ZIP code

 

 

 

 

 

 

 

3.

Name of spouse

Social security number

 

Telephone

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Address of spouse (number, street)

City

State

ZIP code

 

 

 

 

 

 

 

4.

Name of person helping complete form

Relationship

 

Telephone

 

 

 

 

 

(

)

5.

Address of person helping with form (if information regarding beneficiary should be sent to this person)

 

 

 

Number, street

City

State

ZIP code

 

6. Do you own any real property, have an interest in real property, or own a trailer or mobile home taxed

 

 

COUNTY USE ONLY

 

 

as real property?

 

 

 

 

 

 

ｕ Yes

ｕ No

PR ｕ Yes

ｕ No

 

If yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Is this property your former home?

 

 

 

 

ｕ Yes

ｕ No

 

 

 

 

 

 

If yes, do you intend to return to that property to live in the future?

....................................................

ｕ Yes

ｕ No

 

 

 

 

 

 

(If this intent changes, you must notify the county within 10 days.)

 

 

 

 

 

 

 

 

 

 

 

If you do not intend to return to that property, does anyone else live there now?

ｕ Yes

ｕ No

 

 

 

 

 

 

If yes, enter name:___________________________________Relation to you: ____________________________

 

 

 

 

 

 

Basis of dependency (financial, medical, etc.) ______________________________________________________

 

 

 

 

 

 

How long have they lived there? ________________________________________________________________

 

 

 

 

 

 

b. Is this property currently listed for sale?

 

 

 

 

ｕ Yes

ｕ No

 

 

 

 

 

 

Description of property: ________________________________________________________________________

ｕ DHCS 7014

 

 

 

 

Address of property: __________________________________________________________________________

 

 

 

 

 

 

Owner(s):___________________________________________________________________________________

 

 

 

 

 

 

Full value (from tax statement):

$___________________

Amount owed:

$ ___________________

 

 

 

 

 

 

Rent collected each month:

$___________________

Expenses on property:

$ ___________________

Utilized

ｕ Yes

ｕ No

 

Interest

$ ____________

ｕ Yearly

ｕ Monthly

Insurance $ ___________

ｕ Yearly

ｕ Monthly

 

 

 

 

 

 

 

Taxes and assessments

$ ____________

ｕ Yearly

ｕ Monthly

Upkeep and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Utilities

$ ____________

ｕ Yearly

ｕ Monthly

repairs $ ___________

ｕ Yearly

ｕ Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Do you have a life estate in any property?

 

 

 

 

ｕ Yes

ｕ No

 

 

 

 

 

 

If yes, describe:_________________________________________________________________________________

$_________________

 

 

8. Do you own a note, mortgage, or deed of trust?

......................................................................................

 

 

 

ｕ Yes

ｕ No

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes: Appraised value $ _____________

Monthly payment: $ ______________

Interest rate: ___________%

 

 

 

 

 

 

9. Do you have any checks or money on hand in banks, savings and loans, or credit unions, etc.

 

 

 

 

 

 

 

 

(checking or savings accounts), or a patient trust account, or a trust or agreement where money or

 

 

 

Current month income included

 

 

 

 

ｕ Yes

ｕ No

 

 

 

property is being held for your benefit or being held for you by anyone, or being kept anywhere

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for you?

 

 

 

 

 

 

ｕ Yes

ｕ No

 

 

 

 

 

 

If yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. On hand?

 

_________________________________________________________

$_________________

 

 

 

 

Location

 

 

Amount

Account number

 

 

 

 

 

 

 

 

b. In bank or savings?

 

_________________________________________________________

$_________________

 

 

 

 

 

 

 

 

 

 

 

Location

 

 

Amount

Account number

 

 

 

 

 

 

 

 

 

 

_________________________________________________________

$_________________

 

 

 

 

 

 

 

 

 

 

 

 

Location

 

 

Amount

Account number

 

 

 

 

 

 

 

 

c. Held or kept for you by anyone?

_________________________________________________________

$_________________

 

 

 

 

Location

 

 

Amount

Account number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 262 (06/07)

Page 1 of 4

 

10. Have you sold, transferred, or given away any property (including money) at any time in the past year?

ｕ Yes

ｕ No

ｕ Verification

 

 

If yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Transfer,

 

Amount

 

 

 

 

 

Description

 

 

 

 

Sale, or Gift

Value

Received

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

11. Do you own any of the following items of property? Check yes or no. If yes, provide the other information requested.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Purchase Price

Current Value

Amount Owed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Stocks or bonds, certificates of deposit, money market,

 

 

 

 

 

 

 

 

 

 

 

 

or mutual fund account

 

 

 

$

 

$

$

 

$_________________

 

 

b. Jewelry valued over $100 (other than wedding or

 

 

 

 

 

 

 

 

 

 

 

 

engagement heirlooms)

 

 

 

$

 

$

$

 

ｕ Exempt

 

 

c.

Burial reserve or trust

 

 

 

$

 

$

$

 

$_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

Burial plot, vault, or crypt

 

 

 

$

 

$

$

 

$_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Business equipment, tools, inventory, or material

 

 

 

$

 

$

$

 

$_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f.

Other

 

 

 

$

 

$

$

 

$_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Do you own any annuities or life insurance policies or long-term care insurance policies for yourself or

 

 

Verification of CSV on file?

 

 

anyone else?

 

 

 

 

 

 

ｕ Yes

ｕ No

$_________________

 

 

If yes:

 

 

 

 

 

 

 

 

 

Copy of annuity on file?

 

 

 

 

 

 

 

 

 

 

 

ｕ Yes

ｕ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current

State certified LTC policy?

 

 

 

Company

 

Name of Insured or Annuitant

Face Value

Cash Value

 

 

 

 

ｕ Yes

ｕ No

 

 

a.

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

Amount paid out $___________

 

 

b.

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

DHCS 6155 completed

 

 

c.

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

ｕ Yes

ｕ No

 

13. Do you own a motor vehicle (car, truck, etc.); or a boat, camper, or motor home; or mobile home or

 

 

 

 

 

 

 

 

 

trailer not taxed as real property?

 

 

 

 

 

 

ｕ Yes

ｕ No

Exempt

ｕ Yes ｕ No

 

 

If yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Class Code

 

 

 

 

 

 

 

 

 

Description

 

(From Registration)

Year

Purchase Price

Amount Owed

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

14. Do you or your spouse receive any income?

 

 

 

 

 

 

ｕ Yes

ｕ No

$_________________

 

 

If yes, list the source and amount of income received each month. If income is received less often than monthly,

Use copy of award letter or

 

 

indicate how often received. Attach verification of this income.

 

 

 

 

check or other verification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When Paid/How Often

Applicant

Spouse

 

 

 

 

Social Security (green check)

 

 

 

 

 

 

$

$

 

$_________________

 

 

SSI/SSP

 

 

 

 

 

 

$

$

 

$_________________

 

 

Railroad retirement

 

 

 

 

 

 

$

$

 

$_________________

 

 

Veterans benefits (including Aid and Attendance payments)

 

 

 

$

$

 

$_________________

 

 

Retirement or pension

 

 

 

 

 

 

$

$

 

$_________________

 

 

Annuities

 

 

 

 

 

 

$

$

 

$_________________

 

 

Interest income or dividends

 

 

 

 

 

 

$

$

 

$_________________

 

 

Contributions (including those from relatives)

 

 

 

 

 

 

$

$

 

$_________________

 

 

Earnings (gross)

 

 

 

 

 

 

$

$

 

$_________________

 

 

Other (include lump sum payments, inheritance, etc.)

 

 

 

$

$

 

$_________________

 

15. a. Have you or any family member ever been in U.S. military service?

 

 

ｕ Yes

ｕ No

CA5 (if not already completed)

 

 

b. Are you or any family member the spouse, parent, or child of a person who has been in U.S.

 

 

 

 

 

 

 

military service?

 

 

 

 

 

 

ｕ Yes

ｕ No

 

 

 

16. Have you applied for or do you think you are eligible for any payments you are not now receiving?

ｕ Yes

ｕ No

 

 

 

 

If yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kind of Payment

 

 

 

 

 

 

Date Applied For

Date Expected

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 262 (06/07)

Page 2 of 4

17.

Do you have Medicare coverage?

 

 

 

ｕ Yes

ｕ No

 

If yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

Medicare claim number

Monthly premium

 

 

 

 

 

 

Deduction from check?

ｕ Yes

ｕ No

 

 

 

 

Paid by you?

ｕ Yes

ｕ No

 

 

 

 

 

 

 

18.

Do you have health or hospitalization insurance?

....................................................................................

 

 

ｕ Yes

ｕ No

 

If yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of insurance company

 

 

 

 

 

 

 

 

 

 

 

 

 

Premium you pay

 

How often?

 

 

 

 

$

 

ｕ Monthly

ｕ Quarterly

ｕ Yearly

 

 

 

 

 

 

 

 

19.

Would you like to speak to a social worker about services available to you?

 

ｕ Yes

ｕ No

 

If yes, explain the services you wish to discuss:

 

 

 

 

 

20. Additional information

Date verified

DHCS 6155 completed? ｕ Yes ｕ No

OHC Code ________________

Service Referral ｕ Yes ｕ No

BE SURE YOU HAVE READ EVERY ITEM AND ANSWERED ALL THE QUESTIONS.

READ THE FOLLOWING CAREFULLY BEFORE SIGNING.

I declare under penalty of perjury that the answers I have given are correct and true to the best of my knowledge.

I agree to tell the county welfare department within ten days if there are any changes in my (or the person’s on whose behalf I am acting) income, possessions, or expenses, or a change in my living situation. I agree to meet all the other responsibilities explained in the “Important Information for Persons Requesting Medi-Cal” (MC 219) I received at the time of my application for Medi-Cal. (A new “Important Information for Persons Requesting Medi-Cal” (MC 219) will be provided if there is a change in the person acting on behalf of the beneficiary.)

I understand that Section 1137 of the Social Security Act requires that I provide my Social Security number (SSN). My SSN will be verified and will be used in a computer match to check the income and resources I report with information from welfare, state employment, income tax, Social Security Administration, and other agencies.

I understand that Sections 215, 9202, and 9203 of the Probate Code and Section 14009.5 of the Welfare and Institutions Code provide for the recovery of all Medi-Cal benefits received after age 55 from the estate of a Medi-Cal beneficiary if there is no surviving spouse, minor children, or blind or totally disabled children, or it would create a hardship for my heirs. After the death of my surviving spouse, the State has the right to claim from the part of his/her estate received from me, all Medi-Cal benefits I received after age 55 up to the amount of property my spouse received from my estate.

I understand that I may be asked to prove my statements, but that the county is required by law to keep them confidential.

I understand that if I am dissatisfied with any action or inaction taken by the county welfare department, I have the right to a state hearing which I may request from the county welfare department within 90 days after the action or inaction with which I am dissatisfied.

I realize that if I deliberately make false statements or withhold information, I (or the person on whose behalf I am acting) may lose my (or his/her) Medi-Cal card and/or be prosecuted for fraud.

Signature of beneficiary

Signature of person acting for beneficiary

Signature of witness (if beneficiary signed with mark)

E.W. signature

Date

Date

Date

Date

MC 262 (06/07)

Page 3 of 4

PRIVACY STATEMENT

ｏMedi-Cal Confidentiality Notice: The information given in this application is private and confidential under Welfare and Institutions Code, Section 14100.2. This information will be disclosed only in accordance with those laws.

ｏMedi-Cal Privacy Notice: This information may be shared with federal, state, and local agencies for purposes of verifying eligibility and for other purposes related to the administration of the Medi-Cal program, including confirmation with the INS of the immigration status of only those persons seeking full scope Medi-Cal benefits. (Federal law says the INS cannot use the information for anything else except cases of fraud.)

ｏInformation required by this form is mandatory, with the exception of ethnicity information, and any other item marked voluntary or optional.

MC 262 (06/07)

Page 4 of 4

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1. For starters, while completing the form mc 262, begin with the section that features the following blank fields:

Completing part 1 in medical redetermination form

2. The subsequent part is to submit these particular blank fields: as real property ｕ Yes ｕ No If, Basis of dependency financial, How, long have they lived there, b Is this property currently, Address of property, Owners, Full value from tax statement, Rent collected each month, Expenses on property Insurance, ｕ Yearly ｕ Monthly, Interest Taxes and assessments ｕ, ｕ Yearly ｕ Monthly, repairs, and ｕ Yearly ｕ Monthly.

medical redetermination form completion process explained (step 2)

3. This next portion is mostly about In bank or savings, c Held or kept for you by anyone, Location, Account number, Amount, Location, Account number, Amount, Location, Account number, Amount, and MC Page of - type in each of these blank fields.

Completing segment 3 in medical redetermination form

4. This next section requires some additional information. Ensure you complete all the necessary fields - Have you sold transferred or, ｕ Verification, If yes, Description, Date of Transfer, Sale or Gift, Value, Amount Received, Do you own any of the following, Check yes or no, If yes provide the other, Yes No Purchase Price Current Value, Amount Owed, a Stocks or bonds certificates of, and or mutual fund account - to proceed further in your process!

The best way to complete medical redetermination form stage 4

5. While you get close to the finalization of this form, you'll notice just a few more requirements that must be fulfilled. Particularly, Do you own a motor vehicle car, trailer not taxed as real property, Description, From Registration, Year, Purchase Price Amount Owed, Class Code, ｕ Yes ｕ No, Amount paid out, DHCS completed, ｕ Yes ｕ No, Exempt ｕ Yes ｕ No, Do you or your spouse receive any, If yes list the source and amount, and indicate how often received must all be filled out.

Part no. 5 for filling in medical redetermination form

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