Medi Cal Redetermination Template

The Medi-Cal Redetermination form is a crucial document required by the State of California for individuals to maintain their Medi-Cal benefits. This annual form collects essential information regarding income, expenses, and changes in living situations, ensuring that beneficiaries continue to meet eligibility criteria. Completing and submitting this form on time is vital to avoid any disruption in healthcare coverage.

To ensure your Medi-Cal benefits remain uninterrupted, please fill out the form by clicking the button below.

Table of Contents

The Medi-Cal Redetermination form is an essential document for individuals and families in California who rely on Medi-Cal for their healthcare needs. This form plays a crucial role in ensuring that you maintain your eligibility for Medi-Cal benefits. It requires you to provide detailed information about your current living situation, income sources, expenses, and any changes in your health insurance status. Throughout the form, you will need to answer questions regarding your household's financial situation, including income from employment, government benefits, and any support you receive. Additionally, it asks about expenses that can affect your eligibility, such as child care or medical costs. If there have been any changes in your household composition, such as new members moving in or out, or changes in immigration status, these must also be reported. Completing the form accurately is vital, as it helps the county assess your ongoing eligibility. Remember to sign and date the form before returning it, and if you have any questions while filling it out, assistance is readily available from your caseworker. Keeping your Medi-Cal benefits active is important for accessing necessary medical care, so understanding this form is the first step in ensuring you receive the support you need.

Medi Cal Redetermination Sample

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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▼ Medi Cal Redetermination PDF Form

Document Attributes

Fact Name	Detail
Purpose	The Medi-Cal Redetermination form is necessary for maintaining eligibility for Medi-Cal benefits.
Governing Law	This form is governed by California Welfare and Institutions Code, Section 14000 et seq.
Submission Requirement	Individuals must complete and return the form to their county office to avoid losing Medi-Cal coverage.
Income Reporting	Applicants must report all sources of income, including employment, benefits, and gifts, on the form.
Expenses Documentation	Proof of expenses, such as child care and health insurance, must be attached if applicable.
Living Situation Changes	The form requires disclosure of any changes in living situations, such as new family members or relocations.
Health Insurance Updates	Any changes in health insurance coverage within the last year must be reported on the form.
Immigration Status	Changes in immigration or citizenship status must be documented to ensure continued eligibility.
Signature Requirement	The form must be signed by the individual completing it, certifying the truthfulness of the information provided.
Contact for Assistance	If assistance is needed, applicants can contact their assigned worker using the number on the Annual Redetermination Notice.

Medi Cal Redetermination: Usage Instruction

Completing the Medi-Cal Redetermination form is an important step to ensure you maintain your Medi-Cal benefits. After filling out the form, it must be returned to your county office. Make sure all information is accurate and complete to avoid delays in processing.

Gather necessary documents such as pay stubs, benefit letters, and tax returns.
Fill in your case number and Social Security number if you have them.
Print your full name and birth date in the designated areas.
Provide your current street address, including apartment number if applicable. Check the box if your address has changed.
If your mailing address is different, provide that information as well.
In Section 1, indicate if you or any family member receives income from various sources. If yes, list each source of income along with the amount and frequency of payment.
Answer questions about receiving free rent, utilities, food, or clothing. If applicable, provide details.
In Section 2, indicate any expenses or deductions, such as child care or health insurance. List each expense with the amount and payment frequency.
In Section 3, answer questions regarding any changes in health insurance coverage within the last 12 months.
In Section 4, note any changes in living situation, including new family members or births. Provide details as needed.
In Section 5, report on cash, bank accounts, property, or any significant financial changes.
Section 6 asks about changes in immigration or citizenship status. Answer truthfully and provide proof if applicable.
In Section 7, indicate if you or any family member has a condition affecting daily activities.
Complete Section 8 by checking any boxes for additional health program information you want to receive.
Sign and date the form in Section 9. Include your daytime contact number and check if it’s a new number.
Use the postage-paid envelope to return the completed form to your county office.

Frequently Asked Questions

What is the Medi-Cal Redetermination Form?

The Medi-Cal Redetermination Form is an important document that individuals must complete to continue receiving Medi-Cal benefits. It is an annual requirement for those enrolled in the program. By filling out this form, you provide updated information about your income, living situation, and any changes in your health coverage. This ensures that you remain eligible for the necessary health services and support that Medi-Cal offers.
How do I fill out the Medi-Cal Redetermination Form?

Filling out the form is straightforward. Start by providing your personal details, including your name, address, and case number if available. You will need to answer questions regarding your income sources, expenses, and any changes in your living situation. Be sure to attach any required documentation, such as pay stubs or proof of expenses. It's essential to use ink, print your answers clearly, and sign the form before submitting it. If you need additional space, feel free to attach extra sheets as necessary.
What happens if I do not submit the form?

If you fail to submit the Medi-Cal Redetermination Form by the deadline, you risk losing your Medi-Cal benefits. The county will not have the updated information needed to determine your eligibility, which could lead to a suspension of services. It is crucial to return the completed form on time to avoid any interruptions in your healthcare coverage.
Where do I send the completed Medi-Cal Redetermination Form?

You should return the completed form to your county's Medi-Cal office. Typically, a postage-paid envelope is included with the form for your convenience. If you have questions about where to send it or need assistance, you can contact your case worker using the phone number provided on the Annual Redetermination Notice. They can guide you through the process and ensure your form is submitted correctly.

Common mistakes

Filling out the Medi-Cal Redetermination form can be a straightforward process, but mistakes can lead to delays or loss of benefits. One common error is failing to provide accurate income information. Applicants often overlook reporting all sources of income, including part-time jobs, freelance work, or rental income. This omission can result in complications during the review process. It is essential to list every source of income clearly and attach the required documentation, such as pay stubs or tax returns.

Another frequent mistake involves neglecting to update personal information. When there are changes in living situations, such as moving to a new address or changes in household members, applicants may forget to reflect these updates on the form. Not checking the box for a new address or failing to list new family members can lead to significant issues with eligibility. Keeping the information current is crucial for maintaining Medi-Cal benefits.

Many individuals also fail to sign and date the form before submission. A signature is necessary to validate the information provided and confirm that the applicant understands their responsibilities. Without a signature, the form may be considered incomplete, resulting in delays or denial of benefits. It is important to double-check that all required signatures are included.

Lastly, applicants often neglect to read the instructions thoroughly. Skipping over the guidelines can lead to incomplete sections or missing documentation. For example, if proof of expenses or income is not attached, the application may be rejected. Taking the time to review all instructions ensures that the form is filled out correctly and completely, minimizing the risk of errors.

Documents used along the form

The Medi-Cal Redetermination form is essential for individuals seeking to maintain their Medi-Cal benefits. Along with this form, several other documents may be required to ensure a complete and accurate application process. Here are some commonly used forms and documents that accompany the Medi-Cal Redetermination form:

Income Verification Documents: These documents provide proof of income for the household. They may include recent pay stubs, benefit letters, or tax returns. Accurate income information is crucial for determining eligibility.
Property Supplement Form: If there have been any changes in property ownership or significant financial transactions, this form must be completed. It helps the county assess the value of assets held by the household.
Immigration Status Documentation: If there has been a change in immigration or citizenship status, proof of the new status is necessary. This documentation can affect eligibility for Medi-Cal benefits.
Health Insurance Information: Any changes in health insurance coverage must be reported. This includes new policies or changes to existing coverage, which can impact Medi-Cal eligibility and benefits.

Submitting the Medi-Cal Redetermination form along with these supporting documents ensures a smoother review process. It helps to maintain eligibility and access to vital health services without unnecessary delays. Always check with your county office if you have questions about required documents or the process itself.

Similar forms

Medicaid Application Form: Similar to the Medi-Cal Redetermination form, this document collects personal information, income details, and living situations to determine eligibility for Medicaid benefits.
Food Stamp Application: This form requests information about household income, expenses, and family composition to assess eligibility for food assistance programs.
Temporary Assistance for Needy Families (TANF) Application: Like the Medi-Cal form, this application gathers information about income, family structure, and living conditions to evaluate eligibility for cash assistance.
Supplemental Security Income (SSI) Application: This document requires personal and financial information to determine eligibility for disability benefits, similar to the income and expense sections of the Medi-Cal form.
CalFresh Renewal Form: This form is used to renew food assistance benefits and requires updated income and household information, much like the Medi-Cal Redetermination.
Housing Assistance Application: This document collects information about income, family size, and living arrangements to assess eligibility for housing support, paralleling the living situation inquiries in the Medi-Cal form.
Child Care Assistance Application: Similar to the Medi-Cal form, this application requests details about income and family needs to determine eligibility for subsidized child care services.
Health Insurance Marketplace Application: This form gathers information about household income and family size to evaluate eligibility for health coverage options, akin to the Medi-Cal Redetermination process.
Veterans Affairs Benefits Application: This document collects personal and financial information to assess eligibility for various veterans' benefits, similar to the income and asset inquiries in the Medi-Cal form.
Low-Income Home Energy Assistance Program (LIHEAP) Application: This application requires information about household income and expenses to determine eligibility for energy assistance, paralleling the expense sections of the Medi-Cal form.

Dos and Don'ts

When filling out the Medi-Cal Redetermination form, it's important to approach the process with care. Here are some guidelines to follow:

Use clear ink and print your answers. This ensures that your information is legible.
Attach any necessary documents, such as pay stubs or proof of expenses, to support your claims.
Sign and date the form before submitting it. An unsigned form may delay processing.
Return the form using the postage-paid envelope provided. This helps ensure it reaches the county office promptly.
Double-check that you have answered all questions completely. Incomplete forms can lead to delays.
If you have questions, don't hesitate to reach out to your caseworker for assistance.
Make sure to report any changes in income or living situation within ten days to avoid complications.

Conversely, here are some things you should avoid when filling out the form:

Do not leave any required fields blank. This can cause your application to be rejected.
Avoid using pencil or any other writing instrument that may smudge or fade.
Do not submit the form without reviewing it for accuracy. Mistakes can lead to delays.
Do not forget to keep a copy of the completed form for your records.
Do not ignore the deadline for submission. Late submissions may affect your benefits.
Avoid providing false information, as this can have serious legal consequences.
Do not hesitate to ask for help if you find any section confusing. Support is available.

Misconceptions

Understanding the Medi-Cal Redetermination form is crucial for maintaining eligibility. However, several misconceptions exist that can lead to confusion. Here are eight common misconceptions:

It’s optional to submit the form. Many believe they can skip the redetermination process. In reality, submitting this form is mandatory to continue receiving Medi-Cal benefits.
Only income needs to be reported. Some think they only need to disclose income. However, the form also requires details about expenses, living situations, and any changes in health insurance.
All information is confidential. While personal information is protected, the form may be subject to verification and investigation by the county.
It’s okay to leave questions blank. Many assume they can skip questions that don’t apply. It’s important to answer every question, even if the answer is “no” or “not applicable.”
Proof of income is not necessary. Some individuals think they can simply state their income. In fact, attaching proof, such as pay stubs or tax returns, is required.
Changes in living situation don’t matter. People often overlook the importance of reporting changes like moving or new family members. These changes can significantly affect eligibility.
Submitting the form late is acceptable. Many believe they can submit the form at their convenience. However, it’s essential to return the form by the deadline to avoid a lapse in coverage.
Help is not available for completing the form. Some think they must fill it out alone. Assistance is available through county workers or community organizations.

Being aware of these misconceptions can help ensure a smoother redetermination process and continued access to essential health services.

Key takeaways

Filling out the Medi-Cal Redetermination form can seem daunting, but understanding the process can help ensure you maintain your coverage. Here are some key takeaways to keep in mind:

Complete the Form Accurately: Use ink and print your answers clearly. Double-check all information before submitting.
Sign and Date: Don’t forget to sign and date the form. An unsigned form may lead to delays in processing.
Use the Provided Envelope: Return the form using the postage-paid envelope included with your notice to ensure it reaches the county office.
Attach Supporting Documents: If you report income or expenses, include the necessary documentation, like pay stubs or benefit letters.
Report Changes Promptly: If your income, living situation, or health coverage changes, report these changes within ten days.
Ask for Help: If you have questions while filling out the form, contact your worker using the phone number provided on your notice.
Keep Copies: Make a copy of the completed form and any attachments for your records before sending it in.
Check for New Family Members: If someone has moved in or out of your home, or if there’s a new baby, include this information as it may affect eligibility.

By following these steps, you can navigate the Medi-Cal Redetermination process more smoothly. Staying organized and informed is key to maintaining your health coverage.