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This letter:
Provides administrative information

This letter Supersedes:

This letter Suspends:

This letter Modifies:

This letter Clarifies: 

May 10, 2006

 

TO:  ALL COUNTY WELFARE DIRECTORS   Letter No.:  06-17
  ALL COUNTY ADMINISTRATIVE OFFICERS
  ALL COUNTY MEDI-CAL PROGRAM SPECIALIST/LIAISONS
  ALL COUNTY HEALTH EXECUTIVES
  ALL COUNTY MENTAL HEALTH DIRECTORS

SUBJECT: MEDI-CAL ANNUAL REDETERMINATION FORM

The purpose of this letter is to transmit the new Medi-Cal Annual Redetermination form (MC 210 RV, rev. 01/06) and the instructions on processing the information received on the form.  The new MC 210 RV was designed in collaboration with counties and consumer advocates.  The new form is more user-friendly, shorter and easier for the beneficiaries to complete.  See Enclosure A (English) and Enclosure B (Spanish).

The new MC 210 RV replaces the old MC 210 RV (08/99).  Counties are instructed to begin using the new MC 210 RV form 60 days from the release of this All County Welfare Directors Letter (ACWDL), and discard their existing stock of the old
MC 210 RV forms.  If counties have prepared Annual Redetermination packets containing the old MC 210 RV forms, the old form must be removed from the packets and replaced with the new form before they are mailed to the beneficiaries.     

Currently, the MC 210 RV is available in English and Spanish and it is being translated into the other threshold languages.  Counties will be notified with e-mails and Medi-Cal Eligibility Branch Information Letters as the form becomes available in other threshold languages at the California Department of Health Services’ (CDHS) warehouse.  In the meantime, follow the procedure used for the old version of the MC 210 RV when a beneficiary has a primary language other than English or Spanish.  The new
MC 210 RV will also be available for downloading from the CDHS Medi-Cal forms website at www.dhs.ca.gov/publications/forms/Medi-Cal/eligibilitybynumber.htm.

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In general, all Medi-Cal only beneficiaries are required to complete an MC 210 RV form at their Annual Redetermination, with the exception of the following groups:    

1. Beneficiaries receiving Medi-Cal benefits in the Long Term Care (LTC) aid codes. LTC beneficiaries are in their own Medi-Cal Family Budget Unit (MFBU) with income, property, and needs allocations that are computed differently from other Medi-Cal cases.  Counties shall continue to use the Annual Redetermination for Medi-Cal Beneficiaries, LTC in their own MFBU (MC 262) form that is specifically designed for LTC cases.  See Enclosure C. 

2. Beneficiaries receiving Medi-Cal benefits in the Former Foster Care Children (FFCC) Program, aid code 4M. 

FFCC beneficiaries do not have an income or property test and they do not have a share-of-cost (SOC).  The only requirement for FFCC beneficiaries at the Annual Redetermination is that they must indicate they still want Medi-Cal.  Counties can obtain the continued Medi-Cal request by contacting the beneficiary by telephone or mailing the Application and Statement of Facts for an individual who is over 18 and under 21 and who was in Foster Care placement on his/her eighteenth birthday (MC 250 A) (11/01).  See Enclosure D.

3. Beneficiaries receiving Medi-Cal benefits through the public cash assistance programs such as:     

  • Supplemental Security Income/State Supplementary Payment program;
  • California Work Opportunity and Responsibility to Kids program;
  • Foster Care Assistance program; or
  • Aid for Adoption of Children program. 

The Medi-Cal Annual Redetermination is a full eligibility review and nonexempt individuals must cooperate and meet all eligibility requirements for Medi-Cal to continue.  The new MC 210 RV has not changed the Medi-Cal Annual RV requirements and each case record must contain adequate information with supportive documentation to verify an individual’s eligibility.  

The ACWDL that provides counties with policy clarifications and instructions on the Annual Redetermination process will be released under separate cover.  The new

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MC 210 RV form reflects those implementation instructions, including that the beneficiaries are not required to provide information that is not subject to change, such as social security number (SSN) and date of birth at their Annual Redetermination. 

Clarified By ACWDL 11-23, question 29 I.  The New MC 210 RV Form

The new MC 210 RV form eliminated the requirement that an individual provide a SSN and date of birth information for each household member.  The new form starts with the case identifying information:  case number, name, date of birth, SSN, residence and mailing address.  The SSN and the date of birth information are now optional and beneficiaries are not required to provide the information because they are already in the case record.  MC 210 RV forms that are otherwise complete but are missing the optional identifying information shall not be considered “incomplete” and counties must continue to process the Annual Redtermination using all other information provided by the beneficiary.        

Counties are encouraged to have procedures in place to match returned forms with case files to minimize errors and misplaced forms.  Counties, to the extent that it is feasible, shall explore the use of practices such as:   

  • Complete the case identifying information before the form is mailed to the beneficiary at Annual Redetermination.
  • Preprint the MC 210 RV form with case identifying information.
  • Place a label preprinted with case identifying information on the form.
  • Include a label preprinted with case identifying information in the Annual Redetermination packet for beneficiaries to put directly onto the space provided.
  • Use barcodes to track the MC 210 RV.
  • Log the receipt of forms when they are returned from the beneficiaries. 

Counties are to evaluate their own processes and use mechanisms tailored to their own specific needs that will minimize lost forms.  If the county has terminated benefits on a case due to non-receipt of paperwork and that paperwork is later found to have been returned timely by the beneficiary but it was lost at the county, counties must immediately restore benefits to the beneficiary before continuing to process the annual eligibility review.

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The new MC 210 RV is divided into eight sections, with each section asking the beneficiary to provide information on specific subject matters with simple instructions and examples.  The beneficiary is asked to attach supporting documentation of information reported on the MC 210 RV when it is returned to the county for review. 

The following highlights the purposes of each section:

Section 1.  Income

Section 1 applies to income received by all MFBU members living in the home or temporarily away from home.   

(a) Income.

If income is reported, the beneficiary is asked to provide documentation of all income received.  The county must review the source of income and treatment of that income for exemption and deductions.  If income is from employment, the county must allow work-related deductions.    

If income is reported, but documentation/verification is not provided and the MC 210 RV is returned to the county timely, the county must use the SB 87 three-steps process outlined in ACWDL No. 01-36 to obtain the documentation/verification, such as using any files that are open or were closed within 45 days for all known family members as well as other data exchange methods available to verify an individual’s earned and unearned income.  Counties must obtain income information from the following:   

  • Income Eligibility Verification Systems (IEVS),
  • Payment Verification System,
  • Social Security Administration (SSA), and
  • Employment Development Department.

Counties shall refer to the Medi-Cal Eligibility Procedures Manual (MEPM), Article 21-IEVS for detailed instructions on processing information received from IEVS.

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(b) In-kind Income (IKI).

If IKI is reported, the county must contact the beneficiary to determine whether the IKI is to be counted in budget computation.  If the IKI is received in exchange for work done, the county must allow the applicable work-related deduction.  If additional information or clarification is needed to determine the correct value of the countable IKI, the county may use the IKI and Housing Verification form (MC 210 SI) and ask the beneficiary to complete and return it within the SB 87 timeframe.  Counties shall note that the MC 210 SI is not a mandatory form and shall only be used if the beneficiary has IKI and does not agree with the chart value given by the worker.  Counties shall refer to the MEPM 10-F, IKI value and policies relating to their use.

For additional information on treatment of income, counties shall reference all applicable ACWDLs and MEPM Article 10, Income and Article 5-S, for determination under
Section 1931(b) program eligibility. 

Section 2.  Expenses and Deductions

Section 2 applies to expenses MFBU members have to pay from income received.  The beneficiary must provide supporting documentation before the allowable expense can be deducted from income.     

If the beneficiary reports expenses, but supporting documentation is not provided with the MC 210 RV, the county shall review the existing case file for the documentation if the expense was previously reported and the amount has not changed.  If no supporting document is on file for the expense claimed, the county shall contact the beneficiary and request documentation.  The county must continue to process the Annual Redetermination and not terminate benefits even if the beneficiary fails to provide supporting documentation on expenses claimed.  As long as other eligibility factors are met, the county shall certify the MFBU for another 12-month period and not allow the deduction(s) from income.

If payment for health care coverage is reported on the MC 210 RV and it was not previously reported, the county shall review information in Section 3, Other Health Insurance, for follow-up.  If documentation is provided on health care insurance and premium payment, the county shall allow the deduction and continue to process the requirements for other health insurance.

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Section 3.  Other Health Insurance

(a) Other health care coverage information. 

If the beneficiary reports other health care coverage, the county shall compare the information with the case file.  If the health care coverage plan has not changed, the county shall not request the beneficiary to complete a new
DHS 6155.  If health care coverage is new or has changed, the county must send a new DHS 6155 to the beneficiary to complete and update the change in health care coverage on the Medi-Cal Eligibility Data System (MEDS). 

If the beneficiary reports no change in health insurance being provided to a child who has an absent parent, the beneficiary is not required to complete a new medical support questionnaire or other medical support information at Annual Redetermination.

Counties shall refer to MEPM Article 15 for Other Health Care Coverage and Medicare Buy-In Coverage, and Article 23 for Medi-Cal Support Enforcement Program.     

(b) Dialysis Special Treatment Programs.

If an individual is receiving Medi-Cal kidney dialysis-related services, that individual must provide the county with a copy of the SSA statement of Medicare status, or any evidence of eligibility if he/she has not provided such evidence previously.  If the individual is not already receiving Medicare coverage, the county shall refer the individual to apply for Medicare coverage and provide evidence of application status. 

Counties shall refer to MEPM Article 17C, Medicare Eligibility and the Medi-Cal Dialysis Special Treatment Programs. 

Section 4.  Living Situation

Section 4 provides information on household changes that may affect linkage, program eligibility and SOC.  The County shall refer to the MEPM, Article 5, Medi-Cal Programs; Article 8, Responsible Relatives and Unit Determination; and Article 11, Maintenance Needs.

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Clarified By ACWDL 11-23, questions 10 Clarified By ACWDL 11-23, questions 32 Clarified By ACWDL 11-23, questions 33(a) Household member changes.

If the beneficiary reports that someone has moved into or out of the home, the county shall review the case file to determine whether the person is or is not an MFBU member.  If the person is an MFBU member, the family’s eligibility and/or benefits level may be affected by this change.  If a new MFBU member is requesting Medi-Cal and being added to the case, the beneficiary must provide information on the new person, such as income, property, health insurance, and immigration status before he/she can be added to the existing case.     

(b) Newborn information.

If a newborn is reported and he/she is an MFBU member, the parent, by providing the newborn’s place of birth (city and country) on the MC 210 RV, has completed the requirement of declaring the newborn’s citizenship and satisfactory immigration status under penalty of perjury.  The parent is not required to complete an MC 13 for the newborn.  In addition, a birth certificate is not required to aid the infant child.    

(c) Person residing in a nursing facility or medical institution. 

If an MFBU member is reported to be residing in a nursing facility or medical institution such as a board and care facility, the county shall contact the beneficiary for additional information.  The county must review income and property allocation as well as put the individual in his/her own MFBU.

(d) Pregnant women in the home.

If a pregnant woman is reported living in the home, the county must determine if that individual is an MFBU member.  If the pregnant woman is an MFBU member, the county shall add the unborn to the MFBU and request that she provide pregnancy verification within 60 days so that an Redetermination for full-scope benefits may be determined.  If the pregnant woman is an MFBU member not currently on Medi-Cal and requests pregnancy related services only, she is allowed to self-declare that her pregnancy has been medically verified by a medical provider or a home pregnancy test if she is income eligible under the Federal Poverty Level (FPL) program.  The county shall not request a verification of pregnancy in this situation.  The County shall refer to MEPM, Article 4-M, Verification, for acceptable pregnancy verification.

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If the pregnant woman is not an MFBU member and requests Medi-Cal, the county shall contact the beneficiary and inform the beneficiary that a Medi-Cal application will be mailed to the pregnant woman.   

Any non-MFBU member living in the home requesting Medi-Cal benefits is considered a new applicant and he/she must complete an application and meet all eligibility requirements.  The MC 210 RV cannot be used as an application for Medi-Cal benefits for non-MFBU members.  

Section 5.  Real and Personal Property

Section 5, in general, applies to all MFBU members who are receiving Medi-Cal.  However, if the case contains only infants, children and pregnant women receiving Medi-Cal under the FPL programs and property information or documentation is not provided when the MC 210 RV form is returned to the county, these infants, children and pregnant women, if eligible under the FPL programs, shall have their eligibility review completed without delay.  For families that provided the real and personal property information, counties shall first evaluate the family for Section 1931(b) eligibility before putting the children in the FPL programs.

If the MFBU contains adults and children from ages 19-21 who are also receiving
Medi-Cal benefits, the beneficiary must provide property information for those MFBU members not eligible for the FPL percent programs.  They must meet the property guidelines for Medi-Cal benefits to continue.  If property information is not provided after the SB 87 three-step process, their benefits may be terminated at the Annual Redetermination.    

Clarified By ACWDL 11-23, questions 34 Clarified By ACWDL 11-23, questions 36 Clarified By ACWDL 11-23, questions 37 If individuals answer “yes”, to questions 5(b) or 5(c) on the MC 210 RV, the county must send out the form, “Medi-Cal Property Supplement” (MC 210 PS), for the beneficiary to complete (see ACWDL, Number 03-11).  Note: Property verifications must be requested by the county only if verification has not been provided at the same time the RV form was submitted.  Property must be verified at RV only when there is a change or when the value of the property is variable (e.g., financial institution accounts).

(a) and (b).  Determining ownership of property

The beneficiary is required to report any real or personal property currently held by or for any family member in the home.  If he/she answers yes to questions 5(b) or 5(c), then he/she must be sent the MC 210 PS for completion.  Note: He/she must not be asked to resubmit any verification that was submitted with

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the MC 210 RV or verification of items with values that do not change.  During the eligibility review process, the county shall also review any IEVS matches in the case record to determine if there are any unreported income-producing financial accounts and request additional information and/or appropriate documentation at the bottom of the MC 210 PS.

If the value of the property the beneficiary reported will affect eligibility, the county shall contact the beneficiary and explain the spend down provisions and require verification of the spend down for eligibility to continue.  The county must document the disposition of any property sold or given away and the impact on the beneficiary’s eligibility.   

If business property is reported, the county shall refer to ACWDL No. 91-28 and 95-22 for treatment of business property.

Clarified By ACWDL 11-23, questions 35 (c) Disposition of property

If real or personal property was sold or transferred, the county shall ensure that the property was disposed of in a manner consistent with Medi-Cal policies and procedures.  If real or personal property has been previously reported and no information is reported to the county on the disposition of that property, then the county shall contact the beneficiary to clarify the change. 
Modified By ACWDL 07-12 Section 6.  Immigration or Citizenship Status Change

Section 6 only applies to family members in the home who have a change in citizenship or immigration status.  The beneficiary is not required to report the immigration or citizenship status of family members who are not in receipt of Medi-Cal.  Counties shall refer to MEPM, Article 7, Alienage, Citizenship, and Residence.

If an immigration or citizenship status change is reported, the county shall review the case file to determine if the person with the status change is an MFBU member receiving or not receiving Medi-Cal.  If the reported change is for an MFBU member who is receiving Medi-Cal, the county shall mail an MC 13 for completion by that individual or a person acting on his or her behalf.  If this MFBU member claims a satisfactory immigration status on the signed MC 13, the county shall grant full-scope Medi-Cal based on the Redetermination date if the person was otherwise eligible at that time, and he or she was receiving restricted scope Medi-Cal prior to the Redetermination.

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If the beneficiary completing the Redetermination form is the person whose status has changed, it is not necessary to wait for receipt of the MC 13 to grant full Medi-Cal benefits, if otherwise eligible, but a new MC 13 must be provided for the case file.  A beneficiary who claims a change from a restricted scope status to a full-scope immigration status must provide evidence of their new status within 30 days of the claim or the time it takes to complete the Redetermination process, whichever is longer.  The county must verify a claim of satisfactory immigration status through the Systematic Alien Verification for Entitlements (SAVE) system.  Otherwise eligible individuals are eligible for full-scope Medi-Cal while their status is being verified.

If an excluded MFBU member is not receiving Medi-Cal but now wants Medi-Cal, he/she may be added to the MFBU when the county receives all appropriate information and verification on that individual.  The county shall not delay the Annual Redetermination process for the MFBU pending additional verification or information on this individual.  The individual shall remain an excluded MFBU member until the county has the necessary documentation to determine his/her Medi-Cal benefits.    

If a non-MFBU member is reported to have a change to his/her immigration status and he/she is not receiving any type of Medi-Cal benefits, the county shall contact the beneficiary to determine if that person wants Medi-Cal.  If that individual is not an MFBU member and wants Medi-Cal, the county shall mail a Medi-Cal application to the household and inform them that he/she must complete the application and eligibility determination process. 

Section 7.  Blindness/Disability/Incapacity

Section 7 allows the beneficiary to report any disabling condition not previously known or reported to the county.  Counties shall refer to Article 22, Title 22 and MEPM Article 22, Disability Determination Referrals. 

(a) Person with blindness, disability or incapacity.

If the person claiming to have a disability is not currently receiving disability-linked Medi-Cal, the county shall contact the beneficiary to clarify the condition of the person reported as having the disability.  If the person considers himself/herself to be blind or disabled, the county shall send out forms necessary to initiate a referral to the State Programs Disability Adult Program Division for evaluation.  The county shall not make an independent determination that the condition is not severe enough to qualify the person as blind or disabled.

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If, at the time of the Annual Redetermination, the beneficiary no longer has linkage to a Medi-Cal program, such as the last child has left home, and he/she claims to be disabled, the county must continue the individual’s Medi-Cal benefits during the disability evaluation process at the same benefit level that he/she was previously receiving.   

If, at the time of the Annual Redetermination, a non-Medi-Cal parent in the home reports that he/she is incapacitated, the county shall contact the parent to determine if he/she wants Medi-Cal and document the results of that contact.

(b) Disabling conditions related to an injury or accident.

If the beneficiary reports a person in the home has physical, mental, or health problems as a result of an injury or accident, the county shall contact the beneficiary and follow the procedures contained in MEPM, Article 15-B, Medi-Cal Casualty Claims.

Section 8.  Other Health Program Information and Referrals

Section 8 serves as a request for additional information on, or referral to, other program and services available to low-income families.  With the exception of the Healthy Families (HF) program, CDHS has not issued formal or specific referral processes for the Child Health and Disability Prevention (CHDP) program; Women, Infant and Children program; or In-Home Supportive Services/Personal Care Services (IHSS/PCS) because counties have specific referral processes in place for these programs within their local offices.  If the beneficiary requests information, explanation and/or referral to any of these programs and services, the county must ensure the request is met and any action taken is documented on the MC 210 RV form, county use section and in the case record. 

(a) Referral to HF. 

If the box is not checked indicating that the family does not want their child’s information to be shared with HF and their child is determined to have a SOC at the Annual Redetermination, the county will share the child’s information with the HF program.  In addition, the county shall review the Medi-Cal to HF Bridging program for the SOC child as outlined in ACWDL No. 03-01.  The HF program requires the following documentation:

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  • Medi-Cal to HF Transmittal form
  • Copy of birth certificates and Bureau of Citizenship and Immigration Services Documentation (if available).
  • Notice of action (NOA) showing the SOC computation
  • Appropriate case information and budget if not shown on the NOA.

(b) Referral to CHDP program.

CHDP informing is required at Annual Redetermination.  Each Annual Redetermination packet must contain a CHDP brochure in the language understandable to the beneficiary.  If the beneficiary requests CHDP services or additional CHDP information, the county must complete a CHDP referral.  Each county has developed its own CHDP referral procedures with their local CHDP program.  If a CHDP referral is requested, the county shall complete the referral process and document the information in the case file. 

(c) Referral to Women, Infants, and Children (WIC) program.       

If information on a referral to WIC is requested, the county shall contact the beneficiary to follow-up and document the referral process in the case file.    

(d) IHSS/PCS

If the beneficiary requests IHSS/PCS information, the county shall contact the beneficiary and provide the local IHSS/PCS program telephone number. 

Modified By ACWDL 07-12, page 22, Specific Requirements for Assisting Beneficiaries at Redetermination  II.  Obtaining Verification on information reported

When a beneficiary reports information on the MC 210 RV or MC 210 PS that requires verification, but fails to provide the documentation when the MC 210 RV is returned timely to the county, counties must follow the SB 87 three-step process to obtain them.  Counties shall avoid unnecessary and repetitive requests of the beneficiary to provide verification when the county can obtain the verification through available sources such as other case records or is available through MEDS, IEVS, SAVE, etc.  Exchange of important eligibility information in case records among county staff is crucial in meeting the Medi-Cal Annual Redetermination processing timeline.  When a beneficiary reports information on the MC 210 RV form that requires the county to send additional form(s)

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to the beneficiary to complete, the county shall document the reason in the case record.  Counties shall refer to the MEPM 4M verification section and other related ACWDLs if there are questions on verification of income, alien status, pregnancy and blindness/disability.  

III. Other Acceptable Forms for the Medi-Cal Annual Redetermination

Clarified By ACWDL 11-23, questions 49There will be circumstances that counties shall accept other Statement of Facts forms such as the Statewide Automated Welfare System 2, MC 210 or the old MC 210 RV instead of the new MC 210 RV from the beneficiaries or their representatives at the Annual Redetermination.  If the beneficiary or their representative mailed in any one of these Statement of Facts forms and it is complete and signed, counties shall document in the case file that the form is being accepted as the Annual Redetermination form and use the information provided on these forms to continue to process the Annual Redetermination.  The beneficiaries, or their representatives, shall not be required to complete a MC 210 RV to provide the same information. 
Clarified By ACWDL 11-23, questions 17In Interim Statewide Automated Welfare System (ISAWS) counties, if a beneficiary requests a face-to-face appointment with the county to complete the MC 210 RV form, the ISAWS counties may, if the beneficiary agrees, use the “interactive” interviewing method to complete the Statement of Facts form in place of the MC 210 RV.  Counties must inform the beneficiary that he/she always has the option of completing the MC 210 RV at home and mailing it back to the county.

Counties shall always allow the beneficiary the option of completing the Annual Redetermination in person.  If the beneficiary requests a face-to-face appointment with his/her caseworker to complete the Annual Redetermination, the caseworker must document the request and reason in the case record.

If you have questions regarding the Annual Redetermination process or the MC 210 RV, please contact Ms. Debora Wong-Kochi at (916) 552-9490 or by email: dwongkoc@dhs.ca.gov

Original signed by

Tameron Mitchell, R.D., M.P.H., Chief
Medi-Cal Eligibility Branch

Enclosures

Medi-Cal Annual Redetermination Form - Enclosure 1

Redetermination For Medi-Cal Beneficiaries (Long-Term Care in Own MFBU) - Enclosure 3

Application and Statement of Facts for An Individual Who is Over 18 and Who was in Foster Care Placement on His or Her 18th Birthday - Enclosure 4

 

 

List of ACWDL 06-17 Annotations (see the specific pages to identify the text that has changed and to link to the changes)

 

Page 3

  • Clarified by ACWDL 11-23, question 29

Page 7

  • Clarified by ACWDL 11-23, question 10
  • Clarified by ACWDL 11-23, question 32
  • Clarified by ACWDL 11-23, question 33 

Page 8

  • Clarified by ACWDL 11-23, question 34
  • Clarified by ACWDL 11-23, question 36
  • Clarified by ACWDL 11-23, question 37

Page 9

  • Modified by ACWDL 07-12

Page 12

  • Modified by ACWDL 07-12, Page 22, Specific Requirements for Assisting Beneficiaries at Redetermination