Application

In addition to basic application requirements, this chapter includes information about the various forms and procedures that are used to determine MC eligibility if certain criteria are met.

The “Single Streamlined Application” (SSApp) is an application for MC, Advanced Premium Tax Credit (APTC) and Qualified Health Plan (QHP). Refer to How to File an Application.

MC Application

For MC applications, the following forms are given to an applicant in the initial contact packet:

Form #	Form Name	EW Must Explain	Available Languages
Form #	Form Name	EW Must Explain	Eng.	Sp.	Viet.	Other
SCD 41	Identification and Intake Record	No	X	X	X
CCFRM 604	Application for Health Insurance (Also known as the SSApp)	Yes	X	X	X
SCD 115	Consent to Exchange/Release Information - Children’s Health Initiative	Yes	X	X	X	X
NVRA	Voter Preference Form	No	X	X	X	X
GEN 1365	Notice of Language Services	Yes	X	X	X
GEN 100	Examples of Verifications	No	X	X	X
SCD 2304	Additional Information Notices	No	X	X
SCD 2263	Consent to Release Public Assistance Information for Health Services Reimbursement	Yes	X	X	X	X

Note: A county postage-paid return envelope must be included with all mail-in applications.

MC Intake Informational Packet

The following forms are to be used in the MC Intake Informational packet:

Form #	Form Name	Hard Copy	DEBS Forms Library	EW Must Explain	Available Languages
Form #	Form Name	Hard Copy	DEBS Forms Library	EW Must Explain	Eng.	Sp.	Viet.	Other
DHCS 7077	Notice Regarding Standards for Medi-Cal Eligibility	Yes	Yes	No	X	X
MC 004	Important Information for Nursing Home Patients	No	Yes	No	X	X
MC 019	Medi-Cal Information for Applicants	No	Yes	No	X	X	X	Arm., Chin., Farsi, Hmong, Khmer, Korean, Lao., Russ.
MC 18	Important Notice About Your Medi-Cal Benefits	No	Yes	No	X	X
MC 219	Important Information for Persons Requesting Medi-Cal (Rights and Responsibilities)	Yes	Yes	No	X	X	x	Arm., Chin., Farsi, Hmong, Khmer, Korean, Lao., Russ.,
MC 325	Transitional Medi-Cal	Yes	Yes	No	X
MC 372	Breast and Cervical Cancer Treatment Program	Yes	Yes	No	X	X
PUB 13	Your rights Under CA Welfare Programs	Yes	Yes	No	X	X	X
PUB 68	My Medi-Cal pamphlet- How to Get the Care You Need	Yes	No	No	X	X
SCD 391	Keep Your Medi-Cal on Target	No	Yes	No	X	X	X
SCD 827	Citizenship Fact Sheet	No	Yes	No	X	X	X
SCD 830	Important Notice about Domestic Abuse	No	Yes	No	X	X	X
SCD 2610	BenefitsCal Flyer for Intake Packet	Yes	Yes	No	X	X
WIC 2	Families Grow Healthy with WIC	Yes	Yes	No	X	X	X	Chinese
MC 020	Informing Notice of IRS Form 1095-B	Yes	Yes	No	X	X

Note: A county postage-paid return envelope must be included with all mail-in applications.

MC Intake Packet

A county postage-paid return envelope, the appropriate application forms and informing notices must be given or sent to the client.

The “Important Information for Persons Requesting Medi-Cal” (MC 219) must be sent to the applicant but does NOT have to be signed or returned by the client. It must be documented in the case that it was sent.

If the client calls, the MC 219 must be read to the client completely.

Note: The SAWS 1 is NOT required. MC applicants are not required to sign the SAWS 1.

Minor Consent

A mail-in application may NOT be used when applying for Minor Consent services. Refer to Application Requirements.

Applications from the Single Point of Entry

Refer to Single Point of Entry Applications.

CalWORKs

When an applicant applies for MC, explore eligibility for CalWORKs (CW) and inform the applicant if he/she is potentially eligible.

The EW will either process the CW application or complete an “Informal Application Refusal” (SCD 166) if they refuse. If the SCD 166 is completed, then scan it into IDM to document that the applicant was informed of potential CW eligibility.

CalFresh

Explore CalFresh (CF) eligibility and inform the applicant if he/she is potentially eligible. Refer to CalFresh Application for MC.

Paper Applications

Following the implementation of the Affordable Care Act (ACA), clients can complete applications on the phone, in person, online, mail, or fax.

Paper forms are not required; however, when processing an application without the forms (i.e. by phone) the Eligibility Worker (EW) is required to read the MC 219 to the client and document clearly that the client understood and provided approval to submit the application.

Additional Information/Verifications Needed

Review the application for completeness. If additional information is needed to determine eligibility, and the client/family has an open case or a case that has been closed within the last 90 days, the EW must use information/verifications in the case file when available.

Follow Ex Parte requirements when requesting information if necessary information is not in the case file.

Outdated but Acceptable Forms

The Department of Health Care Services (DHCS) allows counties to continue receiving outdated MC applications. The following forms are no longer available and should not be printed, ordered or distributed (but can be used to determine MC eligibility if received from an individual):

“Medi-Cal Mail-In Application and Instructions” (MC 210)
“Additional Family Members Requesting Medi-Cal” (MC 321 HFP)

The client must not be required to complete a second application if they have submitted an outdated application form.

Eligibility Workers must contact the client for additional information or supplemental forms, as needed.

Statement of Facts for Cash Aid, CalFresh and Medi-Cal/State CMSP (SAWS 2 PLUS)

A current SAWS 2 PLUS can be used for MC when:

A CW/CF application is denied and the client wishes to apply for MC, or
A SAWS 2 PLUS was completed within the past 12 months and circumstances have not changed that would require a new application for MC.

Applicants must not be required to complete an additional application or Statement of Facts (SOF) form if the information on file is sufficient. A SAWS 1 is used to preserve the date of application for MC. EWs must obtain all other required forms and verifications according to the family's circumstances and provide all mandatory informing notices to the applicant.

Note: Clients are NOT initially required to provide supporting verification of information until after an attempt has been made to electronically verify through the Federal Data Services Hub (Federal Hub). If an applicant’s information cannot be electronically verified, then paper verifications (i.e. paystubs, SSN card, etc.) will be required. For Non-MAGI MC applicants/clients, paper verification is required.