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Free Medi Cal Redetermination PDF Template

The Medi-Cal Annual Redetermination Form is a vital document for individuals and families in California receiving Medi-Cal benefits. This form is required to be completed and returned to the county annually to ensure continued healthcare coverage through Medi-Cal. It covers various sections including income, expenses, other health insurance, living situation, property, immigration status, and disability, requiring detailed information to verify eligibility for the upcoming year.

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Free Medi Cal Redetermination PDF Template

Outline

Keeping health care coverage active requires attention to detail and timely responses, especially for those enrolled in Medi-Cal, California's Medicaid program. For Medi-Cal beneficiaries, the Annual Redetermination Form is a critical piece of paperwork that cannot be overlooked. This form acts as a checkpoint to review and confirm eligibility for continued health care benefits. Recipients must provide updates on various aspects of their lives that could affect their eligibility, such as income changes, living situations, or any adjustments in family size. Detailed sections require information on income sources, property, expenses, and any other health insurance coverage. The form also inquires about specific life events over the past year, including marriages, births, or significant health changes. Completing and returning this form promptly ensures that beneficiaries do not experience any interruptions in their Medi-Cal coverage. Furthermore, the form is designed with the user's convenience in mind, allowing for additional space to attach detailed information and reminding recipients to use a provided postage-paid envelope for submission. This procedural step is not just about form-filling; it's an essential annual review to maintain the health care benefits that support many Californians in their wellness journeys.

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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

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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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Document Attributes

Fact Name	Detail
Form Purpose	The MEDI-CAL ANNUAL REDETERMINATION FORM is used by beneficiaries to maintain their Medi-Cal coverage by demonstrating continued eligibility.
Relevant Law	The form is governed by the regulations and policies set by the California Department of Health Care Services under the Health and Human Services Agency.
Form Components	The form includes sections on income, expenses and deductions, other health insurance, living situation, real or personal property, immigration or citizenship status change, and disability/incapacity information.
Submission Requirements	Beneficiaries must use ink to fill out the form, sign, and date it before returning it in a postage-paid envelope provided.
Documentation Needed	Applicants need to attach documentation such as recent pay stubs, proof of expenses/deductions, and proof of new immigration status, among others, for verification.
Assistance for Applicants	Individuals needing help with filling out the form can call their worker at the telephone number listed on the Annual Redetermination Notice.
Signature and Certification	The form must be signed under penalty of perjury, verifying that all provided information is true and correct to the best of the applicant's knowledge.

How to Fill Out Medi Cal Redetermination

After a year of using Medi-Cal, it's time to show that you still qualify for this health coverage through what's called the redetermination process. You need to report any changes in your income, household composition, or health insurance status. It might seem like a chore, but it's crucial to ensure your coverage continues without interruption. This step-by-step guide will help you fill out the Medi-Cal Annual Redetermination form correctly. Remember, if any of this feels confusing, don't hesitate to call the number provided on your Annual Redetermination Notice for guidance.

Start by writing your case number, social security number, full name, and birth date if these details are known and applicable.
Enter your current street address. If you’ve moved, check the box indicating your address is new.
For a different mailing address, provide that information in the designated area.
In Section 1 regarding income:
- Check “Yes” if you or anyone in your home has income and then list each income source—like jobs or social security—on separate lines. Attach proof such as pay stubs or tax returns.
- If there’s free rent, utilities, food, or clothing completely provided to anyone in your household, indicate who received these and in exchange for what, if applicable.
In Section 2 about expenses and deductions, check "Yes" if applicable, and provide details about each expense including the amount and to whom it is paid.
For Section 3 on other health insurance, report any recent changes in health, dental, vision, or Medicare coverage for any family member.
In Section 4 concerning your living situation, report any changes like someone moving in or out, marriage, or a new baby, and provide details as requested.
Section 5 asks about property. Report any cash, accounts, or valuable items held by family members and disclose any sold or given away property.
In Section 6, note any changes in immigration or citizenship status for anyone in your household seeking Medi-Cal, providing proof of new status.
Section 7 inquires about any disabilities, conditions, or incapacities, requiring specifics about the affected family member and their condition.
Check your preferences regarding the sharing of information and interest in various health programs in Section 8.
Lastly, sign and date the form in Section 9, providing your telephone number and any other required signatures or witness information.
Review your form to ensure all the information is accurate and complete. Then, use the provided postage-paid envelope to mail it to the address indicated.

After submitting the form, the county will review your information. They may contact you if additional details are necessary or to inform you of your continued eligibility. Keeping this coverage active means reporting honestly and responding to any further requests from Medi-Cal. Doing so ensures that you and your family remain covered and can access necessary healthcare services.

More About Medi Cal Redetermination

What is the purpose of the Medi-Cal Annual Redetermination Form?

The form is used to evaluate if individuals or families continue to qualify for Medi-Cal benefits. You must complete and return it to the county office to maintain your Medi-Cal coverage. It collects information on income, living situation, health insurance, property, and other factors that could affect eligibility.
How often do I need to fill out the Medi-Cal Annual Redetermination Form?

This form must be filled out and submitted once every year. The exact timing is typically on the anniversary of when you first received Medi-Cal benefits or the last time you were redetermined. The county will send you a notice when it's time to complete your redetermination.
What should I do if my address or phone number has changed?

Mark the checkbox indicating a new address on the form and update your contact details accordingly. Keeping your address and phone number current is crucial to ensure you receive all communications about your Medi-Cal coverage without delays.
What documents do I need to attach to the Medi-Cal Redetermination Form?

You may need to attach proof of income, such as recent pay stubs, benefit letters, or tax returns. Furthermore, provide evidence of any deductible expenses mentioned in the form, and any changes in health insurance coverage. If you report owning property or changes in assets, additional forms or documentation could be required.
What happens if I do not return the form?

Failing to return the form by the specified deadline can result in a loss of Medi-Cal benefits. It's important to complete and send back the form promptly to avoid any interruption in your healthcare coverage.
Can I get help filling out the form?

Yes, if you need assistance, you can call the number listed on your Annual Redetermination Notice. County workers can help answer your questions and guide you through the process of completing the form correctly.
What should I do if my income or family situation changes after I submit the form?

You are required to report any significant changes to your income, family situation, or assets within ten days of the change. This ensures that your eligibility and benefits are accurately assessed based on your current situation.

Common mistakes

Filling out the Medi-Cal Annual Redetermination form is a crucial step in maintaining your Medi-Cal benefits. However, there are common mistakes people make that can delay the process or affect their eligibility. By being aware of these mistakes, you can ensure a smoother process in keeping your Medi-Cal coverage.

Not using ink to fill out the form: The instructions specify to use ink, which makes your responses easier to read and prevents alterations.
Failing to sign and date the form: This is a key step in confirming the accuracy and truthfulness of the information provided.
Overlooking the need for additional sheets: If you run out of space, attaching a separate sheet is necessary to provide complete information.
Not attaching proof of income and expenses: Documentation like pay stubs, benefit letters, or receipts for expenses is critical for verification purposes.
Incorrectly reporting household changes: Any changes in income, family composition, or living situation must be accurately reported to assess eligibility accurately.
Omitting information on other health insurance: Reporting existing coverage is vital for coordinating benefits and ensuring proper coverage.
Leaving sections incomplete: Skipping sections or not answering all questions can lead to delays or questions about your eligibility.
Not updating personal contact information: Keeping your address and phone numbers up to date ensures you receive all communication regarding your Medi-Cal.
Ignoring property and asset changes: Failing to report changes in assets or property can affect your eligibility and must be disclosed on the form.

By avoiding these common mistakes, you can help ensure a timely review of your Medi-Cal eligibility and maintain your benefits without interruption. The details you provide are crucial for the Department of Health Care Services to make accurate determinations about your coverage.

Documents used along the form

When applying for or renewing Medi-Cal benefits, several other forms and documents might be needed along with the Medi-Cal Annual Redetermination Form. These documents are essential to ensure that all necessary information is provided, facilitating a smoother process.

Proof of Income Documentation: These include the most recent pay stubs, tax returns, or benefit letters. They are used to verify the income information provided on the Medi-Cal Redetermination form.
Proof of Expenses: Receipts, bills, or official statements that show costs such as health insurance premiums, educational expenses, child care, or adult care. This helps to determine eligibility for certain deductions or additional benefits.
Property Supplemental Form: If you answered "yes" to owning various types of property or assets, this form provides detailed information about such assets, which is required for Medi-Cal eligibility assessment.
Proof of Immigration or Citizenship Status: Documents such as a green card, naturalization papers, or a U.S. passport are needed if there's been a change in the immigration or citizenship status of anyone in the household seeking Medi-Cal benefits.
Disability Verification: Medical records or letters from healthcare providers that confirm any disabilities or incapacities. This is important for individuals claiming benefits based on disability status.
Other Health Insurance Documentation: If an applicant or any family member has health, dental, or vision insurance, relevant documents such as insurance cards or policy statements must be submitted to determine how Medi-Cal can work with other insurance plans.

Each of these documents supports the information provided in the Medi-Cal Annual Redetermination Form. The aim is to paint a full picture of an individual's or family's financial, medical, and living situation to accurately determine eligibility and ensure that those in need receive appropriate benefits.

Similar forms

The Medi-Cal Annual Redetermination form is a critical document for continuity in receiving medical benefits through California's Medi-Cal program. It ensures that individuals and families provide up-to-date information about their financial, living, and health situations to maintain their eligibility. This form has similarities with other documents related to eligibility and benefits in various programs. Here's how:

Federal Tax Return: Similar to the Medi-Cal Redetermination form, a Federal Tax Return requires detailed financial information, including income from various sources and deductions. Both forms are used to assess eligibility for benefits or tax responsibilities based on financial status.
Social Security Benefit Verification Letter: This document, like the Medi-Cal form, confirms the receipt of income, in this case from Social Security. It's crucial for determining eligibility for Medi-Cal based on income and other resources, paralleling the need to report such income on the Medi-Cal Redetermination form.
Food Stamps Application (SNAP): Filling out an application for the Supplemental Nutrition Assistance Program (SNAP) involves reporting household income, expenses, and the number of people living in the household, much like the Medi-Cal Redetermination process. Both determine benefits based on need and income levels.
CHIP Application (Children’s Health Insurance Program): The CHIP application, like the Medi-Cal form, is designed to collect detailed information about children's health insurance needs, including household income and other insurance coverage, to ensure children have access to health care services.
Section 8 Housing Choice Voucher Program Application: Applicants for Section 8 housing must provide financial information, disclose household composition, and provide proof of income, similar to the Medi-Cal Redetermination form, to determine the level of assistance for which they are eligible.
Disability Benefits Application: Applying for disability benefits requires detailed information about the applicant's health condition, work history, and financial resources, comparable to the Medi-Cal form's inquiries about health, income, and living situations to establish eligibility for benefits.

These documents collectively aim to ensure that individuals and families receive the assistance they qualify for, based on their current circumstances. The Medi-Cal Redetermination form plays an essential role in this process by updating the state on changes that may affect one's eligibility for health coverage.

Dos and Don'ts

When it's time to complete your Medi-Cal Annual Redetermination Form, ensuring that your benefits continue without interruption is crucial. Here are essential dos and don'ts to keep in mind:

Dos:

Fill out the form using ink and ensure your handwriting is clear and legible. This prevents any misunderstandings or processing delays due to illegible information.
Provide current and accurate information for every section. Whether it's about your income, expenses, living situation, or any other required detail, ensuring accuracy is crucial for a fair assessment.
Attach copies of requested documents, such as recent pay stubs, tax returns, or proof of expenses. These documents support the information you provide and are essential for verifying your eligibility.
If you need more space to provide complete answers, attach additional sheets with all the necessary information clearly marked and referenced to the question it pertains to.
Finally, sign and date the form before sending it back. An unsigned form can delay processing and might affect your coverage.

Don'ts:

Avoid guessing or estimating figures. Provide exact numbers for income and expenses to avoid issues or incorrect eligibility determination.
Do not leave sections blank. If a section doesn't apply to you, mark it as "N/A" (Not Applicable) instead of leaving it empty. This shows you didn't overlook the question.
Don't ignore the instructions about attaching additional documentation. Failing to provide required documents can result in processing delays or denial of benefits.
Avoid waiting until the last minute. Submit the form and all documentation promptly to ensure there's sufficient time for processing and to avoid any lapse in coverage.
Lastly, don't hesitate to ask for help if you're uncertain about any part of the form. Contacting the number provided on your redetermination notice can clarify any confusion and help you complete the form accurately.

Misconceptions

There are several misconceptions surrounding the Medi-Cal Redetermination form process. Understanding the truths behind these can aid individuals in navigating the renewal process more effectively.

Completing the Medi-Cal Redetermination Form Is Optional - A common misconception is that completing the redetermination form is optional or not strictly necessary. However, to maintain Medi-Cal benefits without interruption, beneficiaries must complete and return this form to the county office each year. Failing to do so could result in a loss of coverage.
Income Information Does Not Need to Be Up-to-Date - It is often believed that if one's income has not changed significantly, updating this information on the redetermination form is not required. In reality, current and accurate reporting of all sources of income is critical. A beneficiary must attach proof of income, such as the most recent pay stubs or tax returns, to ensure continued eligibility.
Reporting New Household Members Is Not Necessary - Another misunderstanding is that adding new household members to the form is unnecessary if they do not need Medi-Cal coverage. This is incorrect as the number of people in your household can affect your eligibility and the amount of benefits you receive. Any changes in household size, such as the birth of a baby or a relative moving in, must be reported.
No Need to Inform about Other Health Insurance Coverage - Lastly, there is a belief that beneficiaries do not need to mention if they have any other form of health insurance. On the contrary, the redetermination form asks specifically about any changes in health, dental, vision, or Medicare coverage. Providing details about any other insurance coverage is important for determining how Medi-Cal works together with other insurances to cover health care costs.

Clearing up these misconceptions can help ensure that individuals who rely on Medi-Cal for their healthcare needs are able to continue receiving these vital services without unnecessary interruptions or complications in their coverage.

Key takeaways

Filling out the Medi-Cal Annual Redetermination Form accurately and promptly is essential to maintaining your Medi-Cal benefits. This form helps the Department of Health Care Services assess your eligibility for continued benefits each year. Here are some key takeaways to ensure the process goes smoothly:

Complete the form using ink and print clearly to avoid any misunderstandings or processing delays.
Report all sources of income for every family member in the home, including wages, child support, alimony, social security, and any other form of income, and attach the required evidence, such as pay stubs, tax returns, or benefit award letters.
Detail any non-monetary support such as free rent, utilities, food, or clothing, specifying what was received for free and whether it was in exchange for work.
Include information on all expenses and deductions related to child or adult care, health insurance premiums, and any court-ordered payments, providing evidence for each.
Update any changes in health insurance coverage, including new policies or changes in existing health, dental, vision, or Medicare coverage for any household member.
Notify changes in your living situation over the past 12 months, such as someone moving in or out of your home, marriage, a baby's birth, or if someone in the home started receiving inpatient care at a medical institution.
Disclose all real or personal property owned by family members living in the home. This includes checking and savings accounts, life insurance, vehicles, and real estate, among others. Remember to report any significant changes in assets or property transactions over the past year.
Report any changes in immigration or citizenship status for anyone in the household with Medi-Cal or seeking Medi-Cal benefits, as changes may affect eligibility.

It is also crucial to highlight any conditions of blindness, disability, or incapacity affecting the ability to work or take care of personal needs, and to indicate if this was due to an injury or accident.

Lastly, make sure the form is signed and dated. The signature certifies that all information provided is true and correct under penalty of perjury according to the laws of California. If assistance was required or used in filling out the form, the assisting individual should also sign.

Remember, maintaining accurate and up-to-date information with Medi-Cal through the Annual Redetermination Form is key to ensuring uninterrupted access to health care benefits for you and your family.

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