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For individuals and families relying on Medi-Cal, the annual redetermination form is a crucial document that ensures continued access to essential healthcare services. This form requires you to provide updated information about your income, living situation, and any changes in health insurance coverage. Key sections of the form include inquiries about your income sources, such as employment or benefits, and any expenses that may affect your eligibility. Additionally, it seeks details about your household composition, including any recent changes like new family members or significant life events. You’ll also need to disclose any other health insurance coverage and provide information about your assets and property. Completing the form accurately is vital, as it not only helps maintain your Medi-Cal coverage but also ensures that you receive the appropriate benefits tailored to your current circumstances. Remember to sign and date the form before submission, and don’t hesitate to reach out to your caseworker for assistance if needed.
Medi Cal Redetermination Example
State of |
Department of Health Care Services |
You must fill out this form and return it to the county to keep your
Case Number (optional) |
Social Security Number (optional) |
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Print Your Full Name (if you have not moved, put address label here if one is provided) |
Birth Date (optional) (mm/dd/yyyy) |
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Current Street Address, Apartment Number ❑ (check here if address is new) |
City/State |
Zip Code |
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Mailing Address (if different from above) |
City/State |
Zip Code |
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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
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 |
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If yes, who? |
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What was free?⁜ |
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(c) Was the free rent, utilities, food, or clothing received in exchange for work done? |
❑ Yes ❑ No |
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MC 210 RV (5/11) |
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State of
Section 2. Expenses and Deductions |
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Do you or any family member in the home pay for child or adult care, health insurance or Medicare |
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premiums, |
❑ Yes ❑ No |
If yes, complete below and list each expense/deduction on a separate line. |
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Attach proof of expenses/deductions. |
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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 |
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(a) Did you or any family member have a change in, or get new health, dental, vision, or Medicare |
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coverage or insurance within the last 12 months? |
❑ Yes ❑ No |
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If yes, who has the coverage/insurance? |
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Which type of coverage/insurance? |
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(b) Is any family member living in the home receiving kidney |
❑ Yes ❑ No |
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If yes, who?⁜ |
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(c) Has any family member living in the home received an organ transplant within the last 2 years? |
❑ Yes ❑ No |
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If yes, who?⁜ |
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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 |
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❑ Yes ❑ No |
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If yes, who?⁜ ؠ |
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(c) If a new baby is in home, where was the baby’s place of birth? |
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Country |
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MC 210 RV (5/11) |
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State of
Section 4. Living Situation continued |
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(d) Did anyone in the home get inpatient care in a nursing facility or medical institution?⁜ |
❑ Yes ❑ No |
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If yes, who?⁜ |
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❑ Yes ❑ No |
(e) Is anyone in the home pregnant? |
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If yes, who? |
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Number of babies expected |
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Due date: ⁜ |
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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,
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 |
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supplement form, submit the form to the county and provide verification. |
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Section 6. Immigration or Citizenship Status Change |
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Has there been a change in immigration or citizenship status for anyone in the home that has |
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or wants |
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full scope |
❑ Yes ❑ No |
If yes, list the name(s) below and send proof of new status. |
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Name of Person
(include first and last name)
Status Change
(send proof of status)
Section 7. Blindness/Disability/Incapacity |
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(a) |
Do you or any family member in the home have a physical or emotional condition that makes it |
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difficult to work, take care of personal needs, or take care of your children? ⁜ |
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❑ Yes ❑ No |
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If yes, who? |
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(b) Was the physical, mental, or health condition a result of an injury or accident? |
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❑ Yes ❑ No |
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If yes, explain |
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State of |
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 |
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Families Program if your child gets |
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(b) Do you want information on the |
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❑ Yes ❑ No |
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and Disability Prevention Program, also known as CHDP?) |
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(c) Do you want information on the |
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feeding women and children under 5 (Women, Infants, and Children Program, also known |
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as WIC)? |
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❑ Yes ❑ No |
(d) Do you want information on the Personal Care Services Program, an |
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for aged, blind, or disabled persons (also known as |
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❑ 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
➤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
➤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) |
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Signature of Witness (if signed by a mark), Interpreter or Person Assisting |
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— County Use Only —
Referrals |
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❑⁜HF |
❑⁜WIC |
❑⁜MC 13 |
❑⁜MC 210 PS |
❑⁜Other: |
❑⁜CHDP |
❑⁜PCSP |
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❑⁜DDSD Packet |
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MC 210 RV (5/11) |
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File Breakdown
| Fact Name | Description |
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| Purpose | The Medi-Cal Redetermination form is used to determine ongoing eligibility for Medi-Cal benefits. |
| Submission Requirement | It must be filled out and returned to the county to maintain Medi-Cal coverage. |
| Optional Information | Providing the case number and Social Security number is optional but can help with processing. |
| Income Reporting | Applicants must report all sources of income, including employment, benefits, and gifts. |
| Expense Documentation | Proof of expenses, such as child care or health insurance, must be attached if applicable. |
| Living Situation Changes | Any changes in living situation, such as new family members or moves, must be reported. |
| Property Disclosure | Applicants must disclose any significant property or assets held by family members. |
| Immigration Status | Changes in immigration or citizenship status must be reported, which may affect eligibility. |
| Signature Requirement | The form must be signed, certifying that all information provided is true and correct. |
| Governing Law | This form is governed by California Welfare and Institutions Code, Section 14000 et seq. |
Guide to Using Medi Cal Redetermination
After you fill out the Medi-Cal Redetermination form, return it to your county office to ensure you maintain your Medi-Cal benefits. If you have questions or need assistance, don’t hesitate to contact your worker using the number provided on your notice.
- Start by writing your Case Number and Social Security Number at the top of the form, if you have them.
- Print your full name clearly. If your address hasn’t changed, you can use the address label provided.
- Fill in your birth date in the format (mm/dd/yyyy).
- Provide your current street address, including apartment number if applicable. If you have a new address, check the box indicating this.
- Complete the city, state, and zip code fields for your current address.
- If your mailing address is different, fill it out in the designated section.
- Use ink and print your answers clearly throughout the form.
- Sign and date the form at the bottom. Make sure to include your daytime or message telephone number and home telephone number.
- For each section, answer the questions accurately. If you need more space, attach a separate sheet.
- In Section 1, list any income sources for you or family members. Attach proof of income, such as pay stubs or tax returns.
- In Section 2, provide details about any expenses or deductions. Attach proof of these expenses.
- In Section 3, indicate any changes to health insurance coverage. List any family members receiving kidney dialysis or who have had organ transplants.
- In Section 4, note any changes in living situations, such as new family members or births.
- In Section 5, report on any real or personal property owned by family members. Indicate if any money or property was sold or given away in the past year.
- In Section 6, mention any changes in immigration or citizenship status for family members.
- In Section 7, indicate if anyone has a condition that makes it difficult to work or care for themselves.
- In Section 8, check any applicable boxes for additional health programs or information you may want.
- Once everything is complete, use the postage-paid envelope to return the form to your county office.
Get Answers on Medi Cal Redetermination
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What is the Medi-Cal Redetermination form?
The Medi-Cal Redetermination form is a document that individuals enrolled in Medi-Cal must complete annually to verify their eligibility for the program. This form collects information about income, expenses, living situations, and any changes in health insurance or citizenship status. Completing this form is essential to ensure continued access to Medi-Cal benefits.
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Who needs to fill out the Medi-Cal Redetermination form?
Anyone who is currently enrolled in Medi-Cal must fill out the Redetermination form. This includes individuals and families who receive Medi-Cal benefits. It is crucial for all household members to be accurately represented on the form to maintain eligibility.
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What information do I need to provide on the form?
The form requires various types of information, including:
- Personal details such as name, address, and date of birth.
- Income sources for all household members, including wages, benefits, and support payments.
- Expenses related to child care, health insurance, and educational costs.
- Details about any changes in living situations, such as new family members or moves.
- Information about any other health insurance coverage.
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How do I submit the Medi-Cal Redetermination form?
After completing the form, individuals should return it to their county's Medi-Cal office. A postage-paid envelope is typically provided for this purpose. It is important to ensure that the form is signed and dated before submission. If additional space is needed, individuals can attach separate sheets of paper.
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What happens if I do not submit the form on time?
Failing to submit the Medi-Cal Redetermination form by the deadline may result in a loss of benefits. It is essential to adhere to the submission timeline to avoid any interruptions in coverage. If a person misses the deadline, they should contact their county office immediately to discuss options.
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Can I get help filling out the form?
Yes, assistance is available for individuals who need help completing the Medi-Cal Redetermination form. Those needing support can call their assigned worker using the contact information provided on the Annual Redetermination Notice. Additionally, family members or community organizations may offer guidance.
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What if my information changes after I submit the form?
If any changes occur after submitting the form—such as changes in income, family size, or health insurance—it is important to report these changes to the county within ten days. Timely reporting helps ensure that the individual’s eligibility for Medi-Cal remains accurate and up to date.
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What should I do if I have questions about the form?
If there are any questions or uncertainties regarding the Medi-Cal Redetermination form, individuals should reach out to their caseworker or the county Medi-Cal office. They can provide clarification on specific sections of the form and offer guidance on what information is necessary.
Common mistakes
Completing the Medi-Cal Redetermination form can be straightforward, but there are common mistakes that can delay your application or lead to complications. One frequent error is not providing accurate personal information. Ensure that your full name, address, and contact details are correct. Any discrepancies can lead to confusion and may affect your eligibility.
Another common mistake is failing to report all sources of income. It's essential to include income from jobs, benefits, or any other financial support. If you check "yes" for income, be sure to list each source accurately and attach the required documentation. Incomplete or incorrect income information can result in a denial of benefits.
Some individuals overlook the importance of providing proof for expenses and deductions. If you indicate that you pay for child care, health insurance, or other expenses, attach the necessary documentation. Missing this step can lead to delays or a request for additional information, which can be frustrating.
Many applicants forget to update their living situation. If someone has moved in or out of your home, or if there have been changes like marriage or a new baby, it's crucial to report these changes. This information impacts your eligibility and the benefits you may receive.
Another mistake is neglecting to sign and date the form. A missing signature can cause your application to be considered incomplete. Always double-check that you have signed the form before submitting it.
Some people fail to use the postage-paid envelope provided for returning the form. Using the correct envelope ensures that your application reaches the right department without unnecessary delays. Always verify that you have the right address and postage before mailing.
Additionally, applicants sometimes forget to follow up after submitting the form. If you don’t receive confirmation or any communication within a reasonable time, it’s advisable to contact your worker. Staying proactive can help resolve any issues quickly.
Lastly, be cautious about the information you share. If your immigration or citizenship status has changed, this must be reported accurately. Providing the correct details can affect your eligibility for Medi-Cal benefits, so ensure all information is up to date.
Documents used along the form
When you are completing the Medi-Cal Redetermination form, there are several other documents that may be required to support your application. These documents help ensure that your eligibility is accurately assessed. Here’s a list of commonly used forms and documents that you might need to submit alongside your redetermination form.
- Proof of Income Documentation: This includes recent pay stubs, benefit letters, or tax returns that verify your income. You may need to provide this for all family members living in the household.
- Property Supplement Form: If you have answered "yes" to questions regarding property ownership or transfers, this form is necessary to provide additional details about your assets.
- Health Insurance Verification: If you or any family member has changed health insurance, you may need to submit documentation of the new coverage, such as an insurance card or policy statement.
- Child Support Documentation: If you pay or receive child support, you may need to provide proof of these payments, which can include court orders or payment records.
- Immigration Status Documentation: If there has been a change in immigration status, you will need to submit proof of the new status, which may include immigration documents or citizenship certificates.
- Medical Records: If you or a family member has a disability or chronic health condition, providing relevant medical documentation can help support your case for Medi-Cal eligibility.
- Living Situation Documentation: If there have been changes in your household, such as new members moving in or out, you may need to provide documentation to reflect these changes.
- Expense Documentation: For any deductions you claim, such as child care or health insurance premiums, you should include receipts or statements that verify these expenses.
- Witness Signature Form: If you require assistance completing the form and someone else helps you, a witness signature may be necessary to validate the information provided.
Gathering these documents can streamline the redetermination process and help ensure that your Medi-Cal benefits continue without interruption. Always check with your local county office if you have specific questions about the documents needed for your situation.
Similar forms
The Medi-Cal Redetermination form shares similarities with several other important documents. Here are five examples:
- Food Stamp Application: Like the Medi-Cal form, this application requires personal information about household members, income sources, and expenses. Both documents aim to assess eligibility for assistance programs.
- Medicaid Application: This form is similar in that it collects detailed information about income, assets, and family composition to determine eligibility for healthcare coverage under Medicaid.
- Welfare Benefits Application: This document also gathers information regarding household income, expenses, and changes in living situations, paralleling the Medi-Cal form's focus on financial circumstances.
- Health Insurance Marketplace Application: Both forms require applicants to provide personal and financial information to evaluate eligibility for health insurance coverage, ensuring that applicants receive the appropriate benefits.
- Child Care Assistance Application: Similar to the Medi-Cal Redetermination form, this application requires details about family income and expenses, focusing on determining eligibility for child care support.
Dos and Don'ts
When filling out the Medi-Cal Redetermination form, it is crucial to ensure accuracy and completeness. Here’s a list of essential dos and don’ts to guide you through the process:
- Do use blue or black ink to fill out the form.
- Do provide accurate information about your income, expenses, and living situation.
- Do attach any necessary documentation, such as pay stubs or proof of expenses.
- Do sign and date the form before submission.
- Don't leave any sections blank; if something does not apply, indicate that clearly.
- Don't forget to check if your address has changed and update it accordingly.
- Don't submit the form without reviewing it for errors or omissions.
Completing the form correctly is vital to maintaining your Medi-Cal benefits. Make sure to follow these guidelines closely to avoid any delays or issues with your application.
Misconceptions
Understanding the Medi-Cal Redetermination form is crucial for maintaining your benefits. However, several misconceptions can create confusion. Here are four common misunderstandings:
- Misconception 1: The form is optional.
- Misconception 2: You must provide all information requested, even if it doesn’t apply to you.
- Misconception 3: You can submit the form without any supporting documents.
- Misconception 4: You can wait until the last minute to submit the form.
Some people believe that completing the Medi-Cal Redetermination form is optional. In reality, it is a requirement. If you do not submit this form, you risk losing your Medi-Cal coverage.
While it is important to provide accurate information, you only need to answer questions that are relevant to your situation. If a question does not apply, simply mark it as “No” or leave it blank.
Many assume that submitting the form alone is sufficient. However, you are required to attach supporting documents, such as proof of income or expenses, as specified in the form. Failing to do so may delay your application.
Some individuals think they can wait until the deadline to submit their forms. It’s best to submit your redetermination form as early as possible. This allows time for any potential issues to be resolved before your coverage is affected.
Key takeaways
Completing the Medi-Cal Redetermination form is essential for maintaining your Medi-Cal benefits. Here are some key takeaways to keep in mind:
- Timely Submission: Ensure you fill out and return the form promptly to avoid any interruptions in your Medi-Cal coverage.
- Accurate Information: Provide accurate details about your income, expenses, and living situation. Any discrepancies may delay the processing of your application.
- Documentation Required: Attach necessary documents, such as pay stubs or proof of expenses, to support the information you provide on the form.
- Contact Information: If you have questions while filling out the form, reach out to your assigned worker for assistance. Their contact number is on the Annual Redetermination Notice.
- Signature Matters: Don’t forget to sign and date the form. An unsigned form may be considered incomplete and could lead to a denial of benefits.
By following these guidelines, you can help ensure a smooth redetermination process for your Medi-Cal benefits.