Mc216 Medical Renewal Form – Fill Out and Use This PDF

The MC216 Medical Renewal form is a critical document issued by the California Department of Health Care Services. It facilitates the annual process of verifying beneficiary information for the continuation of Medi-Cal coverage. This form, revised as of April 2015, includes a crucial update in the "Income and Expenses" section to better capture the current calendar year's income estimations. To ensure uninterrupted Medi-Cal coverage, beneficiaries are encouraged to accurately complete and promptly submit their renewal forms.

Click the button below to begin filling out your MC216 Medical Renewal form.

Get Form Now Download PDF

Mc216 Medical Renewal Form PDF Details

The Mc216 Medical Renewal form, distributed by the State of California’s Health and Human Services Agency, Department of Health Care Services, plays a critical role in the annual process of renewing Medi-Cal coverage for beneficiaries. Designed to streamline the verification and renewal of beneficiary information, this form acts as a conduit between the California Healthcare Eligibility, Enrollment, and Retention System, the Statewide Automated Welfare Systems, and the beneficiaries themselves. As of a directive dated May 19, 2015, this revised form, inclusive of all threshold languages, has been shared with county welfare directors and related administrative officers to enhance procedural efficiency. Noteworthy in this revision is the modification in the "Income and Expenses" section, specifically addressing beneficiaries' fluctuating income and anticipating earnings for the current calendar year. The form facilitates the continuation of Medi-Cal coverage by requesting up-to-date household information, including income and tax deductions, while ensuring privacy and compliance with legal tax requirements. This document underscores the collaborative effort between state agencies and local entities to maintain essential health coverage for Californians, embodying a multifaceted approach to public health administration and beneficiary support. Additionally, the form provides avenues for reporting changes in household composition, such as deaths or incarcerations, and updates on other health insurance coverage, highlighting its comprehensive nature in capturing beneficiaries' current circumstances to assess eligibility accurately.

Question	Answer
Form Name	Mc216 Medical Renewal Form
Form Length	97 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	24 min 15 sec
Other names	mc 216 renewal form pdf, mc renewal mc 216, mc 216 english, mc 0216

Form Preview Example

State of California—Health and Human Services Agency

Department of Health Care Services

JENNIFER KENT	EDMUND G. BROWN JR.
Director	Governor

May 19, 2015

	Medi-Cal Eligibility Division Information Letter No.: I 15-14
TO:	ALL COUNTY WELFARE DIRECTORS
	ALL COUNTY WELFARE ADMINISTRATIVE OFFICERS
	ALL COUNTY MEDI-CAL PROGRAM SPECIALISTS/LIAISONS
SUBJECT:	Revised MC 216 Pre-Populated Renewal Form
	(Reference: All County Welfare Directors Letter 15-09 and
	14-38)

The purpose of this letter is to transmit the revised MC 216 Pre-Populated Renewal Form to counties, which is used to confirm and request verification of beneficiary information known to the California Healthcare Eligibility, Enrollment, and Retention System and the Statewide Automated Welfare Systems at annual renewal. Attached with this letter is a copy of the updated MC 216 form (Rev 04/15) in all threshold languages for counties to implement within 90 days from the receipt of this letter.

The single change to the form is specific to Section 3 titled “Income and Expenses” on Page 3, subsection “Fluctuating Income”, the question “What do you think your income will be for the next 12 months?” has been replaced with “Tell us what you think your income will be for the current calendar year?”.

If you have any questions regarding this letter, please contact Deborah Palmer at

(916)440-7855 or by email at deborah.palmer@dhcs.ca.gov or Michelle Marean-Williams at (916) 341-3968 or by email at michelle.marean-williams@dhcs.ca.gov. We appreciate the counties’ cooperation and assistance in this effort.

Original Signed By

Alice Mak, Acting Chief

Medi-Cal Eligibility Division

Attachments

Medi-Cal Eligibility Division

1501 Capitol Avenue, MS 4607, P.O. Box 997417, Sacramento, CA 95899-7417

(916)552-9430 phone, (916) 552-9477 fax Internet Address: www.dhcs.ca.gov

Medi-Cal Renewal Form	Respond By: [MM/DD/YY]	Case Number: [xxxxxxxxx]
[Insert Date]

You can get this notification in another language or in large print or another way that’s best for you. Call [1-800-XXX-XXXX]. The call is free. [(TTY: 1-888-XXX-XXXX)].

It is time to renew your Medi-Cal coverage. We need some information from you to help you keep your Medi-Cal for the next year.

You Can Renew Your Medi-Cal in Any One of These Ways

■ By Mail: Complete this form and mail it to:	■ Online: renewing nline is quick and easy. Go to
[Medicaid agency]	www.coveredca.c m [saWs online portal]
[100 state street]	to upload your d cuments.
[any city, state]	Purposes
	Purposes

■In Person: Visit our office at

[Medicaid agency] [100 state street] [any city, state].

Office hours are [8:30 a.m. to 5 p.m. Monday to Friday].


How to Complete this Form
How to Complete this Form
	Informational	ge, you must let us know if there are any changes or not to
to make sure you or your family continue to have Medi-C l cover		ge, you must let us know if there are any changes or not to
the information on this form.
1.	Please review the information about you and members of	3.	return this form or provide this information online by
	your household and let us know about any cha ges.		[Insert Date].
2.	send us or upload copies of documen s hat sh w y ur most	4.	If you return this form by mail, please make sure to sign
	current information even if your inform ion h s not changed.		the form on page [Insert PaGe #].

Whose Information We Need

We need the most current inf		ation about every member of your household who is living with you or is listed on your tax
return, if you file taxes. We need information from:
■	People in your h useh ld who currently have Medi-Cal,		apply for Medi-Cal. their information will be kept private
■ People in your household who would like to apply.			and used only to help those in your household who want
■ People in your household who would like to apply.			to keep or apply for Medi-Cal.
	We may eed some information about people in your		to keep or apply for Medi-Cal.
■	We may eed some information about people in your
	household who live with you	are listed on your tax	You do not need to file a tax return to apply for or renew
	etu n, who do not have Medi-Cal and who do not want to		your Medi-Cal.

What Happens if My Information is Different?

If anyone in your household does not qualify for Medi-Cal because the information on this form has changed, we will use your new information to check to see if you or other people in your household qualify for other affordable health coverage, including Covered California. Your information

will be kept private and will be used only to see if you or your family qualifies for affordable health coverage. We may need more information from you to find you the most affordable health coverage. You do not need to file a tax return to apply for or renew your Medi-Cal.

Questions? Call [state agency name] at [1-800-XXX-XXXX]. The call is free. [(TTY: 1-888-XXX-XXXX)]. You can call [ days and hours of operation]. Or visit [web address]

MC 216 (Rev 04/15)

Page 1

For Informational Purposes Only

1Your Current Household

Please check the information below and tell us if there are any changes.

Is the address below correct?	Yes
If correct, go to Section 2.

[reCIPIent naMe] Home address: [aDDress 2] [Address 3]

Mailing address: [HOMe aDDress] [aDDress 2] [Address 3]

Phone:

Home: [nuMber1]

Other: [nuMber2]

no. If not, please write the correct information below.

name (first, middle, last & suffix)

Home address	apartment #

City (home)	state	ZIP code

Mailing address, only if different from above.		apartment #

City (mailing)	state	ZIP code

What number can we call to contact you? Home	Cell	Work

number:

What is the best time to reach you at this number?

(Optional) Is there another number we can use to call y	u?	Home Cell Work

number:

(Optional) What email address can we contact you?

2Who is in Your Household?

Please check the information below about people in your household who want to renew Medi-Cal. Please tell us if there are any changes to the information we have about people livi g with you or who are listed on your federal tax return.

Name (first, middle, last & suffix)

Tax Filing Status	How is this Person Related to the	Who Claims this Person Correct Information?
(e.g., primary tax filer, dependent)	Primary Tax Filer or Head of Household?	as a Dependant?

Yes	no

Yes	no

Yes	no

Yes	no

If the information above is ot correct, please write the correct information into the space provided below. If there are other members of your household, please write their information in below.

Name (first, middle, last & suffix)	Tax Filing Status	Related to Tax Filer	Who Claims this Person
			as a Dependant?

Page 2

For Informational Purposes Only

3Income and Expenses

We were not able to renew your Medi-Cal using the income below that we have for you or your household members from electronic data sources. Please let us know if the information below is correct or not. We need paper documentation showing us what your most current income is. Please attach any of the following that show income before taxes or deductions: recent pay stubs, benefits or award letters, checks received or signed statement from employer, or last year’s tax return. If income is from self-employment, send a copy of your most recent tax return or profit and loss statement.

the income information below is only for individuals within your household we could not otherwise verify. If you have members of your household not listed below it is because we were able to verify their income and no other income information is needed for the individual.

[Pre-Populated name:]

Our records show that this individual’s monthly income is:

this estimate includes the income sources and amounts below. Please let us know if this information is correct or has changed. If this information has changed, please tell us the correct information.

Income 1			How often received?
Is this correct?	Yes	no	If no, enter correct information
Income 2			How often received?
Is this correct?	Yes	no	If no, enter correct inf rmati n
Income 3			How often eceived?
Is this correct?	Yes	no	If no, enter co ect information

Please enter below any additional income you expect that is not shown above:

source of Income	amount	How Often received?
Informational
Fluctuating Income

You told us that your income changes from mon h m nth and gave us an estimate of what you thought your income would be for the


past 12 months. Last year, you told us your income would be		.
tell us what you think your income will be	the current calendar year?

Expenses/Tax Deductions

Our records show that this individual had the following tax expenses (deductions) last year. Please let us know if this will be the same for next year or not:

Tax Deduction 1			How often paid?
Tax Deduction 1			How often paid?
Is this correct?	Yes	no	If no, enter correct information
Is this correct?	Yes	no	If no, enter correct information
Tax Deduction 2			How often paid?
Tax Deduction 2			How often paid?
Is this co ect?	Yes	no	If no, enter correct information
Tax Deduction 3			How often paid?
Is this c rrect?	Yes	no	If no, enter correct information

Page 3

For Informational Purposes Only

Is this Individual Deceased?

4Other Health Insurance

Please let us know if the information below is still correct. If someone in your family now has other health insurance nOt listed below, please write it in below.

name

type of Insurance

Do You still Have this Coverage?

Yes no

5Incarceration

Our information shows that one or more people in your household is incarcerated. Is this information correct?

	name	Is this Individual Incarcerated?

Yes no

6 Deceased

Our information shows that one more in your househo d has died. Is this information correct?

name

Yes no

Informational

Yes no

Page 4

For Informational Purposes Only

How to Edit Mc216 Medical Renewal Form Online for Free

It is simple to fill out forms taking advantage of our PDF editor. Updating the medical renewal form mc 216 form is a breeze as soon as you use these actions:

Step 1: Select the "Get Form Now" button to begin.

Step 2: You'll find all of the functions that you can take on your template once you've accessed the medical renewal form mc 216 editing page.

Fill out the next areas to fill in the template:

mc 216 renewal form pdf gaps to complete

Within the area You Can Renew Your MediCal in Any, By Mail Complete this form and, Medicaid agency state street any, In Person Visit our office at, Online renewing online is quick, How to Complete this Form to make, Please review the information, return this form or provide this, Insert Date, send us or upload copies of, If you return this form by mail, the form on page Insert PaGe, and Whose Information We Need We need write down the data that the program demands you to do.

Entering details in mc 216 renewal form pdf step 2

Write down the crucial details in Whose Information We Need We need, People in your household who, People in your household who would, We may need some information, apply for MediCal their, You do not need to file a tax, What Happens if My Information is, will be kept private and will be, Questions Call state agency name, MC Rev, Page, For Informational For Informational, and Purposes Only Purposes Only section.

Filling in mc 216 renewal form pdf stage 3

The Is the address below correct If, Yes, no If not please write the correct, reCIPIent naMe, Home address, aDDress, Address, Mailing address, HOMe aDDress, aDDress, Address, Phone, Home nuMber, Other nuMber, and name first middle last suffix field has to be applied to list the rights or obligations of both sides.

Entering details in mc 216 renewal form pdf stage 4

Finish the document by taking a look at the next fields: Name first middle last suffix, Tax Filing Status, How is this Person Related to the, Who Claims this Person Correct, eg primary tax filer dependent, as a Dependant, Yes, Yes, Yes, Yes, If the information above is not, Name first middle last suffix, Tax Filing Status, Related to Tax Filer, and Who Claims this Person as a.

Filling in mc 216 renewal form pdf part 5

Step 3: Choose the Done button to confirm that your finalized document can be transferred to any type of gadget you use or forwarded to an email you indicate.

Step 4: You may create duplicates of your document tostay away from different future concerns. Don't be concerned, we do not reveal or record your details.

Mc216 Medical Renewal Form – Fill Out and Use This PDF

Mc216 Medical Renewal Form PDF Details

Form Preview Example

How to Edit Mc216 Medical Renewal Form Online for Free

Watch Mc216 Medical Renewal Form Video Instruction

Mc216 Medical Renewal Form isn’t the one you’re looking for?

Please rate Mc216 Medical Renewal Form

Mc216 Medical Renewal Form – Fill Out and Use This PDF

Mc216 Medical Renewal Form PDF Details

Form Preview Example

How to Edit Mc216 Medical Renewal Form Online for Free

Watch Mc216 Medical Renewal Form Video Instruction

Mc216 Medical Renewal Form isn’t the one you’re looking for?

Related Documents

Please rate Mc216 Medical Renewal Form

Related Resources