Medi Cal Redetermination Form PDF Details

The Medi-Cal Annual Redetermination Form serves as a critical tool for individuals and families in California aiming to maintain their Medi-Cal coverage. Issued by the State of California's Health and Human Services Agency, Department of Health Care Services, this comprehensive document requests updated information across various sections such as income, expenses, health insurance, living situation, real or personal property, changes in immigration or citizenship status, and any relevant changes in disability status. Participants are required to report income sources, including employment, child support, and benefits, along with expenditures on child or adult care, health insurance premiums, and educational expenses. The form also inquires about shifts in health coverage, living arrangements, property ownership, and any significant alteration in immigration or citizenship status that could impact eligibility. Additionally, it seeks information on physical or emotional conditions that might affect the applicant's ability to work. The process necessitates the signing and dating of the document to confirm the accuracy of the provided information, under penalty of perjury, ensuring all applicants understand their obligations and the necessity of reporting any changes that could affect their Medi-Cal eligibility. Failure to accurately complete and return this form could result in a loss of benefits, underscoring the importance of this annual redetermination process.

QuestionAnswer
Form NameMedi Cal Redetermination Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmedical redetermination form online, how to fill out medi cal annual redetermination form, medi cal redetermination form, annual redetermination recertification

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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)

Page 1 of 4

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

 

MC 210 RV (5/11)

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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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 210 RV (5/11)

Page 3 of 4

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)

Page 4 of 4

How to Edit Medi Cal Redetermination Form Online for Free

We found the most efficient programmers to develop our PDF editor. This software will assist you to create the medical redetermination form file easily and won't eat up a lot of your time. This straightforward instruction will allow you to begin.

Step 1: Hit the orange button "Get Form Here" on the following web page.

Step 2: At the moment you're on the file editing page. You can enhance and add content to the file, highlight specified content, cross or check selected words, include images, put a signature on it, get rid of unwanted fields, or remove them altogether.

The PDF document you desire to prepare will include the next areas:

where do i mail my medi cal redetermination form fields to complete

Provide the requested data in the Name of Person with income include, Source of income, income Amount before any deductions, How Often Paid weekly monthly, Hours Worked per week or month, b Do you or any family member in, Yes No, If yes who, What was free, c Was the free rent utilities food, Yes No, and MC RV Page of field.

Finishing where do i mail my medi cal redetermination form step 2

The application will request information to conveniently prepare the section Do you or any family member in the, Yes No, If yes complete below and list, Attach proof of expensesdeductions, Name of Person with, type of Expense or Deduction, Amount of Payment, Paid to Whom, How Often Paid weekly monthly, Section Other Health insurance, a Did you or any family member, coverage or insurance within the, If yes who has the, Which type of coverageinsurance, and b Is any family member living in.

stage 3 to entering details in where do i mail my medi cal redetermination form

When it comes to paragraph c Has any family member living in, If yes who, Section Living Situation, a Did anyone move into or out of, parent returns home, If yes complete below, Yes No, Yes No, Name include first and last name, Relationship to You, What Changed, Date Changed, b Does anyone in the home want, Yes No, and If yes who, state the rights and responsibilities.

Filling in where do i mail my medi cal redetermination form stage 4

Look at the sections Section Living Situation, continued, d Did anyone in the home get, If yes who, e Is anyone in the home pregnant, Yes No, Yes No, If yes who, Number of babies expected Due date, Section real or Personal Property, a Indicate the total amount of, b Does anyone have a checking or, wedding or oil or mineral rights, c Did you or any family member in, and past months or have any of the and thereafter complete them.

step 5 to filling out where do i mail my medi cal redetermination form

Step 3: Hit the Done button to confirm that your completed document may be transferred to every electronic device you use or forwarded to an email you specify.

Step 4: In avoiding potential future difficulties, make sure to obtain more than two copies of each separate form.

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