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Download Medi Cal Redetermination Form in PDF

The Medi-Cal Redetermination form is a crucial document that ensures individuals continue to receive their Medi-Cal benefits without interruption. By completing this form, applicants provide updated information about their income, living situation, and any changes in their health coverage. To maintain your Medi-Cal eligibility, it’s essential to fill out the form accurately and return it promptly—click the button below to get started.

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The Medi-Cal Redetermination form is a crucial document for individuals and families seeking to maintain their Medi-Cal benefits in California. This annual form requires applicants to provide detailed information about their current living situation, income, expenses, and any changes in health coverage. Key sections include inquiries about income sources, such as employment or government benefits, and any deductions that may apply. Applicants must also disclose any changes in their household composition, such as new family members or changes in marital status. Additionally, the form asks about real or personal property owned by the household, as well as any updates regarding immigration status. Completing the form accurately is essential, as it not only determines eligibility but also ensures that recipients continue to receive necessary healthcare services. To facilitate the process, applicants are encouraged to attach relevant documentation and utilize the provided postage-paid envelope for submission. Timely and accurate completion of the form is vital to avoid any disruption in benefits.

Preview - Medi Cal Redetermination Form

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?		❑ Yes ❑ No
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?)		❑ Yes ❑ No
(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 Specifics

Fact Name	Description
Purpose	The Medi-Cal Annual Redetermination Form is required to maintain eligibility for Medi-Cal benefits.
Submission Requirement	This form must be filled out and returned to the county office to avoid a lapse in coverage.
Information Needed	Applicants must provide details about income, expenses, living situation, and health coverage.
Governing Law	The form is governed by California Welfare and Institutions Code, Section 14000 et seq.
Signature Requirement	The form must be signed and dated by the person completing it, confirming the accuracy of the information.
Contact for Assistance	If help is needed, applicants can call their worker using the number on the Annual Redetermination Notice.
Attachments	Applicants should attach proof of income and expenses as specified in the form.

Medi Cal Redetermination: Usage Instruction

After you fill out the Medi-Cal Redetermination form, you will need to return it to your county office to ensure you maintain your Medi-Cal benefits. Make sure to review your answers carefully and provide any necessary documentation. Here’s how to fill out the form step by step:

Start by writing your Case Number and Social Security Number at the top of the form (both are optional).
Print your Full Name and Birth Date in the designated spaces.
Provide your Current Street Address, including the apartment number if applicable. If this address is new, check the box provided.
Fill in your City/State and Zip Code. If you have a different mailing address, include that information as well.
Use ink to answer all questions in Section 1 about your Income. If anyone in your household receives income, list each source and attach proof, such as pay stubs or tax returns.
In Section 2, answer questions about Expenses and Deductions. If applicable, provide details and attach proof of payments.
Proceed to Section 3 and indicate any changes in Other Health Insurance coverage within the last 12 months.
In Section 4, answer questions regarding your Living Situation. Note any changes in household members or living arrangements.
For Section 5, provide details about your Real or Personal Property and answer questions regarding cash, accounts, and assets.
In Section 6, indicate any changes in Immigration or Citizenship Status for anyone in your household.
Section 7 asks about Blindness/Disability/Incapacity. Answer these questions if they apply to you or anyone in your household.
In Section 8, check any boxes for Other Health Program Information that you want to receive.
Finally, sign and date the form in Section 9. Make sure to include your daytime or message telephone number.

Once completed, return the form using the provided postage-paid envelope. If you have any questions while filling out the form, don't hesitate to reach out to your caseworker for assistance.

Learn More on Medi Cal Redetermination

What is the Medi-Cal Redetermination form?

The Medi-Cal Redetermination form is an essential document that individuals must complete to maintain their Medi-Cal benefits. This form collects information about your current income, living situation, and any changes in your household. By filling out this form accurately, you help ensure that you continue to receive the health coverage you need.

Why is it important to submit the Redetermination form?

Submitting the Redetermination form is crucial because it allows the county to verify your eligibility for Medi-Cal. If you fail to submit the form or provide inaccurate information, you risk losing your benefits. This process ensures that the program can allocate resources appropriately and that you receive the correct level of assistance based on your current situation.

How do I fill out the Medi-Cal Redetermination form?

Filling out the Medi-Cal Redetermination form involves several steps:

Gather necessary documents, such as income statements and proof of expenses.
Complete each section of the form carefully, providing accurate information about your income, living situation, and any changes in your household.
Sign and date the form to certify that the information is true and correct.
Return the form using the postage-paid envelope provided or submit it to your county office directly.

If you need assistance, don't hesitate to reach out to your caseworker for guidance.

What happens if I miss the deadline for submitting the form?

Missing the deadline can have serious consequences. If you do not submit the Redetermination form on time, your Medi-Cal benefits may be suspended or terminated. It is essential to keep track of deadlines and submit the form as early as possible to avoid any disruption in your health coverage.

What if my income or living situation changes after I submit the form?

If your income or living situation changes after you have submitted the Redetermination form, it is your responsibility to report these changes to your county office within ten days. This ensures that your eligibility is reassessed based on your new circumstances, allowing you to receive the appropriate level of benefits.

Can I attach additional information to the form?

Yes, if you need more space to provide information, you can attach a separate sheet to the form. Be sure to clearly label any additional information so that it can be easily associated with your application. Providing thorough and complete information will help expedite the review process.

What if I have questions while filling out the form?

If you have questions or need help while completing the Medi-Cal Redetermination form, you should contact your caseworker. The contact information for your worker is typically included in the Annual Redetermination Notice. They can provide guidance and clarify any confusing sections of the form.

What should I do if I have not received my Redetermination form?

If you have not received your Medi-Cal Redetermination form, it is important to take action. You can contact your county's Medi-Cal office to request a form or inquire about your eligibility status. Do not wait until the deadline approaches, as this could jeopardize your benefits. It’s better to be proactive in ensuring you have all necessary documentation.

Common mistakes

Filling out the Medi-Cal Redetermination form is crucial for maintaining eligibility for health care services. However, many individuals make common mistakes that can jeopardize their coverage. One frequent error is not providing complete information. Omitting details, such as income sources or household changes, can lead to delays or denials. Ensure all sections are filled out thoroughly, as incomplete forms may require resubmission.

Another mistake is failing to attach necessary documentation. The form requires proof of income and expenses, such as pay stubs or tax returns. Without this documentation, the application may be considered insufficient. Always double-check that all required attachments are included before submission.

Many applicants also overlook the importance of updating their address. If you have moved recently, check the box indicating a new address and provide the correct information. Failing to do so can result in important correspondence being sent to the wrong location, complicating your case further.

People often misunderstand the requirements for reporting changes in household composition. If someone has moved in or out, or if there has been a marriage or new baby, this must be reported. Not doing so can affect eligibility and benefits, leading to potential issues down the line.

Another common oversight involves the signature and date. It is essential to sign and date the form before submitting it. An unsigned form may be returned, causing delays in processing your application. Ensure that you have completed this step to avoid unnecessary complications.

Lastly, applicants sometimes fail to read the instructions carefully. The form includes specific guidelines about what to report and how to fill it out. Taking the time to read through the instructions can help prevent errors and ensure that your application is processed smoothly. Attention to detail is key when completing the Medi-Cal Redetermination form.

Documents used along the form

The Medi-Cal Redetermination form is a crucial document for maintaining eligibility for California's Medicaid program. However, it often goes hand-in-hand with other forms and documents that can help streamline the process. Understanding these additional documents can make the redetermination process smoother and more efficient. Below is a list of some commonly used forms alongside the Medi-Cal Redetermination form.

Property Supplement Form: This document is necessary if there have been any changes in property ownership or if any family member has sold or given away property in the past year. It helps the county assess eligibility based on assets.
Important Information for Persons Requesting Medi-Cal (MC 219): This form provides essential details about the responsibilities of Medi-Cal applicants. It outlines what information must be reported and the consequences of failing to do so.
Verification Documents: Applicants may need to submit various verification documents, such as pay stubs, tax returns, or benefit letters. These documents substantiate claims made on the Medi-Cal Redetermination form regarding income and expenses.
Other Health Program Information Forms: Depending on individual circumstances, additional forms related to other health programs may be required. These can include applications for programs like the Child Health and Disability Prevention Program (CHDP) or the Women, Infants, and Children (WIC) program.

By familiarizing yourself with these associated forms and documents, you can better prepare for the Medi-Cal Redetermination process. This preparation not only helps ensure that you maintain your Medi-Cal benefits but also alleviates some of the stress associated with paperwork and eligibility requirements. Remember, being organized is key to navigating this important aspect of healthcare access.

Similar forms

The Medi-Cal Redetermination form shares similarities with the Supplemental Nutrition Assistance Program (SNAP) application. Both documents require applicants to provide detailed information about their household income and expenses. This ensures that the eligibility for benefits is assessed accurately. Each form asks for specifics on income sources, such as employment or government assistance, and may require documentation to verify the information provided. Additionally, both forms emphasize the importance of reporting any changes in household circumstances that could affect eligibility.

Another document comparable to the Medi-Cal Redetermination form is the Temporary Assistance for Needy Families (TANF) application. Like the Medi-Cal form, the TANF application collects information about family composition, income, and expenses. Both forms aim to determine financial need and eligibility for assistance programs. They also require applicants to disclose any changes in their living situation or financial status, ensuring that benefits are adjusted accordingly to reflect current circumstances.

The Low-Income Home Energy Assistance Program (LIHEAP) application is also similar to the Medi-Cal Redetermination form. Both documents require applicants to report income and household size. The purpose of this information is to assess eligibility for energy assistance. Additionally, both forms ask for proof of expenses related to utilities, reinforcing the need for comprehensive documentation to support claims for assistance.

The Women, Infants, and Children (WIC) program application parallels the Medi-Cal Redetermination form in that it targets specific populations, namely pregnant women and young children. Both applications require detailed information about household income and composition. They also emphasize the importance of reporting any changes in circumstances that may affect eligibility, ensuring that benefits are provided to those who need them most.

The Social Security Administration (SSA) disability benefits application is another document that shares similarities with the Medi-Cal Redetermination form. Both require applicants to provide personal information, including income and medical history. Each form seeks to determine eligibility based on financial need and medical conditions. Furthermore, both applications may require supporting documentation to validate claims, such as medical records or income statements.

The Housing Choice Voucher Program (Section 8) application is similar in that it also assesses eligibility based on income and family composition. Like the Medi-Cal Redetermination form, it requires detailed information about household income and expenses. Both documents aim to ensure that assistance is directed to families who meet specific income thresholds and have demonstrated financial need.

The Medicare Savings Program (MSP) application mirrors the Medi-Cal Redetermination form in its focus on income and assets. Both forms require applicants to disclose financial information to determine eligibility for benefits. The MSP application, like the Medi-Cal form, emphasizes the need for supporting documentation to verify income and expenses, ensuring that only those who qualify receive assistance.

The Child Care Subsidy application is another document that resembles the Medi-Cal Redetermination form. Both applications require information about household income and the number of dependents. They aim to assess eligibility for financial assistance based on specific criteria. Additionally, both forms require applicants to report any changes in their financial situation or family structure that may impact their eligibility for benefits.

The Unemployment Insurance benefits application shares similarities with the Medi-Cal Redetermination form in that both require applicants to report income and employment status. Each form aims to determine eligibility based on financial need and current circumstances. Furthermore, both applications may require documentation to support claims, such as pay stubs or termination notices, ensuring that benefits are accurately distributed to those in need.

Lastly, the Medicaid application form is very similar to the Medi-Cal Redetermination form, as Medi-Cal is California's version of Medicaid. Both require detailed information about income, assets, and household composition. They are designed to assess eligibility for health care benefits based on financial need. Additionally, both forms emphasize the importance of reporting any changes in circumstances that could affect eligibility for benefits, ensuring that applicants receive the appropriate level of assistance.

Dos and Don'ts

When filling out the Medi-Cal Redetermination form, it is essential to follow specific guidelines to ensure a smooth process. Here are five things you should and shouldn't do:

Do use ink and print your answers clearly.
Do attach proof of income and expenses when required.
Do sign and date the form before submission.
Do return the form using the postage-paid envelope provided.
Do call your worker if you have questions or need assistance.

Don't leave any required fields blank.
Don't forget to report any changes in your living situation.
Don't ignore instructions for additional documentation.
Don't submit the form without reviewing it for accuracy.
Don't wait until the last minute to submit your form.

Misconceptions

Understanding the Medi-Cal Redetermination form can be challenging, and several misconceptions often arise. Let's clarify some of these misunderstandings to ensure that individuals can navigate the process more effectively.

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

This is not true. Completing and returning this form is essential to maintain Medi-Cal benefits. Failure to submit it may result in loss of coverage.

Misconception 2: Only the primary applicant needs to fill out the form.

In reality, all family members living in the household may need to be included, especially if they have income or expenses that affect eligibility. It's important to provide comprehensive information.

Misconception 3: You can submit the form without any supporting documents.

Supporting documents are often necessary to verify the information provided. This includes proof of income, expenses, and any changes in living situation. Failing to include these can delay the process.

Misconception 4: The form can be submitted at any time.

There are specific deadlines for submitting the Medi-Cal Redetermination form. It's crucial to pay attention to these deadlines to avoid any lapse in coverage.

Misconception 5: If your income changes, you don't need to report it until the next redetermination.

This is misleading. Any changes in income or household circumstances should be reported immediately. Timely reporting helps ensure that benefits are adjusted appropriately.

Misconception 6: The Medi-Cal Redetermination form is the same every year.

While there are common elements, the form may change from year to year. It's important to review the current form and instructions carefully to ensure compliance with any new requirements.

Misconception 7: You cannot get help filling out the form.

On the contrary, assistance is available. Individuals can contact their caseworker for help or seek support from community organizations that specialize in Medi-Cal services.

Key takeaways

Key Takeaways for Filling Out the Medi-Cal Redetermination Form

Ensure all information is accurate and complete. Double-check your case number, social security number, and personal details to avoid delays.
Attach necessary documentation. Include recent pay stubs, proof of expenses, or any other relevant documents to support your claims.
Use the provided postage-paid envelope for submission. This ensures your form reaches the county without additional cost to you.
Contact your worker for assistance. If you have questions or need help, don’t hesitate to reach out to the contact number listed on your Annual Redetermination Notice.