MC RD Forms

In general, all MC only clients are required to complete an annual MC RD, with the exception of the following groups:

  • FFY in aid code 4M
  • Clients receiving MC through public cash assistance programs:
    • CalWORKs
    • Supplemental Security Income/State Supplementary Payment (SSI/SSP)
    • Foster Care, or
    • Adoption Assistance Program (AAP).

MC RD Packets

There are four different sets of forms based on the case type for MC RDs:

  • The MAGI MC RD packet for cases with information that was not e-verified through the Federal HUB.
  • The Mixed Medi-Cal (both MAGI and Non-MAGI) MC RD packet.
  • The Non-MAGI MC RD packet.
  • The LTC MC RD packet.

Clients should NOT be discontinued for not returning the paper MC RD packet if the information has been provided verbally and a telephonic signature has been obtained. Clients can provide the information requested in the packet by mail, by fax, by email, in person, over the phone, or through BenefitsCal.

A signature is required to complete the annual renewal process and may be obtained by:

  • Obtaining a wet Signature from the client on the renewal forms or
  • Obtaining an electronic signature via Covered CA or BenfitsCal (when the client completes the MC RD online)
  • Obtaining a Telephonic Signature 

Refer to Job Aid (JA): Electronic Signature (e-Sign) in CalSAWS for detailed system entries.

MAGI MC RD Packet

For MAGI MC only cases, when information is not e-verified the following form will be mailed to the clients:

Form Number

Form Name

Description of Form

MC 216

Medi-Cal Renewal Form

The pre-populated MC 216 will be auto-generated and sent by CalSAWS. The system will pre-populate case information on the form.

NOTE: The additional informational forms listed in Informational MC RD Forms are also sent to the client.

Non-MAGI MC RD Packet

The Non-MAGI MC only MC RD packet (non-LTC) consists of the following form:

Form Number

Form Name

Description of Form
MC 210 RV Medi-Cal Annual Redetermination form The MC 210 RV is the main MC RD form for Non-MAGI MC individuals.

NOTE: The additional informational forms listed in Informational MC RD Forms are also sent to the client.

Mixed MC RD Packet

A Mixed MC case consists of both individuals who are MAGI MC eligible and Non-MAGI MC eligible (i.e. a 68-year-old spouse on an ABD program and his/her 60-year-old spouse on MAGI MC).

The following form will be mailed to the client:

Form Number

Form Name

Description of Form
MC 217  Medi-Cal Renewal Form The prepopulated Mixed Household MC 217 Annual Renewal Form combines the required sections from both the MAGI (MC 216) and Non-MAGI (MC 210 RV) renewal forms for those mixed household members who must complete a prepopulated renewal form if they have not been automatically renewed during ex parte review.

NOTE: The additional informational forms listed in Informational MC RD Forms are also sent to the client.

Long Term Care MC RD Packet

The LTC MC RD Packet consists of the following forms:

Form Number

Form Name

Description of Form
MC 210 RV Notice Medi-Cal Annual Redetermination Notice

This cover letter explains to a MC client the change to the annual MC annual RD process due to ACA. The informing notice also contains the following information:

  • Purpose of the annual MC RD.
  • Requirements of the annual MC RD, and
  • The due date when required forms must be completed/returned for MC benefits to continue.
  • Completing the annual MC RD in a timely manner will ensure continuous coverage if all eligibility factors are met, and
  • Non-cooperation may cause interruption/termination of MC benefits.
MC 210 RV  Medi-cal Annual Redetermination Form Includes questions currently listed on several different forms, including the MC 262, and the MC 604 IPS. It also includes a section for resources and property information and questions to ensure resources and property are correctly counted.

NOTE: The additional informational forms listed in Informational MC RD Forms are also sent to the client.

Additional forms that were previously sent with the LTC MC RD packet will continue to be sent. The following are the LTC MC RD supplemental forms:

Form Number Form Name
DHCS 7068

Responsibilities of Guardian/ Conservator or Applicant/ Beneficiary Representative

Note: This supplemental form is required for clients with an Authorized Representative (AR).
MC 004  Nursing Home Patient Information
MC 019 Medi-Cal Information for Beneficiaries
MC 18 Important Notice About Your Medi-Cal Benefits
MC 210 PS Property Supplement
MC 219 

Important Information for Persons Requesting Medi-Cal

Note: A returned, signed copy of the MC 219 is not required; however case comments that the form was sent (or read over the phone) must still be entered in CalSAWS.
PUB 13 Your Rights Under California Welfare Programs
NVRA Voter Preference Form
GEN 1365 Notice of Language Services
SCD 2610 BenefitsCal Flyer

Informational MC RD Forms

The informational MC forms are sent to all MC clients at least 60 days prior to their MC RD due date. The following are the MC RD informational forms:

Form Number

Form Name

GEN 1365

Notice of Language Services

MC 019

Medi-Cal Information for Beneficiaries

MC 219

Important Information for Persons Requesting Medi-Cal

Note: A returned, signed copy of the MC 219 is not required; however case comments that the form was sent (or read over the phone) must still be entered in CalSAWS.

MC 372

Breast and Cervical Cancer Treatment Program (BCCTP) information
PUB 13 Your Rights Under California Welfare Programs

SCD 115

Consent to Exchange/ Release Information - Children’s Health Initiative (CHI)
NVRA Voter Preference Form

SCD 2610

BenefitsCal Flyer 

SCD 2365

Second Harvest Food Bank and CalFresh Outreach Flyer

WIC 2

WIC Outreach Flyer

Foster Care MC RD Forms

Form Number

Form Name

Description of Form
MC 250  Application and Statement of Facts for Child Not Living with A Parent or Relative and for Whom a Public Agency is Assuming Some Financial Responsibility   The MC 250 is used for the annual RD for Foster Care (FC) children.
MC 250A Application and Statement of Facts for an Individual who is over 18 and under 26 and who was in FC Placement on his or her 18th Birthday

The MC 250 A may be used for clients in the FFY program, aid code 4M.

Note: The MC 250 A is NOT a mandatory form.

Additional MC RD Forms

The following additional forms must be completed at the annual RD, if applicable:

  • “Student Educational Expenses” (MC 210 S-E)
  • “Income In-Kind/Housing Verification” (MC 210 S-I)
  • “SSA Referral Notice” (MC 194), if there is no SSN on file.
  • Medical Support Forms: (if an absent parent exists and the form was not previously completed or the custodial parent has new information to report.):
    • “Notice and Agreement for Child, Spousal and Medical Support” (CW 2.1)
    • “Support Questionnaire” (CW 2.1Q)
  • “90-Day Status Letter” (MC 179) (if reexamination date is due).
  • “Referral To/From Social Security” (SCD 169) [Medicare eligibility referral if client is 64 years and 9 months of age.]
  • “Veteran's Benefits Referral” (MC 05) if not previously completed.
  • “Insurance Affordability Program - Request for Tax Household Information” (RFTHI/SCD 2350)
  • “Request for Tax Household Information Supplemental Form” (SCD 2350 Supplemental)
  • “Request For Additional Income Information For Medi-Cal” Form (DHCS 7103)

SAWS 2 PLUS

EWs may use the “Application for Cash Aid, CalFresh, and/or Medi-Cal”
(SAWS 2 PLUS) for both the CW and MC only RD when all the following conditions are met:

  • The case contains CW and MC only family members,
  • CW and MC eligibility information/verifications are kept in the same case number and assigned to the same caseload number, and
  • Both the CW and MC RDs are scheduled and completed in the same month.

Example Example A family consists of both CW and MC only family members. The EW schedules the CW/MC annual RD for January 2017 and both are completed with the client on January 10, 2017. The SAWS 2 PLUS is sufficient for both the CW and MC RD. 

Notices Of Action at Annual Renewal or Change In Circumstance

A Medi-Cal Notice of Action (NOA) is to be issued to all MC recipients when an eligibility determination is made during annual renewal or a change in circumstance redetermination that results in the resetting of the annual renewal date. The NOA’s will auto-generate in CalSAWS and include the applicable information used in determining eligibility (e.g., Household Size, Marital Status, Monthly Countable Household Income, Countable Property, Blind or Disabled, Citizenship/Immigration Status). The NOA’s will inform the recipient to contact the county within 90 days if any of the information used in the eligibility determination is incorrect.

Related Topics

Redeterminations