Medi-Cal Mail In Application, MC210

1 HEALTH CARE COVERAGEFOR PEOPLE WITH LIMITED INCOME OR RESOURCESMAIL-IN APPLICATION AND INSTRUCTIONSForFREE help to apply for Medi-Cal ,contact your local social services CareDental CareEmergencyMedicalTransportationPharma cyServicesPhysicalTherapyNursingHome CarePregnantWomenWorkingParentsInfants/C hildrenVision CareDisabledFamiliesMC21004/09 INSTRUCTIONSWhat is Medi-Cal ? Healthcarecoverageforqualifyingpersonswh oliveinCalifornia,whohaveincomeandresour cesbelowestablishedlimitsWho can get Medi-Cal ? Persons65orolder Personswhoareunder21yearsofage Certainadultsbetween21and65yearsofage,if theyhaveminorchildrenlivingwiththem Personswhoareblindordisabled Pregnantwomen Personsreceivingnursinghomecare CertainRefugees,Asylees,Cuban/HaitianEnt rantsDo I have to be a citizen to get Medi-Cal ?

2 No, ;othersareeligibleforfullMedi-Calbenefit sdependingontheiralienstatusWhen Medi-Cal says a minor child, what does it mean? Achildmarriedorunmarriedunder21yearsofag elivinginyourhomeorawayatschoolWhat do I do to get Medi-Cal coverage? Completeandsendintheenclosedapplication Sendcopiesofanyrequireddocumentation(See instructions)How can my family and I qualify for Medi-Cal coverage?Ifyouareinoneofthegroupslistedi n WhocangetMedi-Cal? above: Welookatyourincomeandsubtractsomeexpense syoupaytodecideyourfamily scountableincomeforMedi-Cal Welookatthingsyouandyourfamilyown(bankac counts,vehicles,etc.) Note:Notallthethingsyouoryourfamilyownar ecounted;yourlocalsocialservicesofficeca ngiveyoumoreinformationIf I do not fall into one of the covered groups,how can I get coverage?

3 Contactyourlocalsocialservicesofficefori nformationaboutmedicalservicesinyourcoun tyMC21004/09 INSTRUCTIONSINSTRUCTIONS When Applying For medi -CalHealth m a minor/teenager and wantconfidential Minor Consent Services, forfamily planning, pregnancyrelated care, mental health, drugand alcohol abuse treatment/counseling, sexually transmitteddiseases (STD) or sexual assault. To maintain confidentiality, you must takethis application to the local social servicesoffice or eligibility worker NOT mail , whether you take your application to the local social services office oryou mail it, you should not payanyone to help you with this FREE help to apply for Medi-Cal ,contact your local social services office.

4 I want to ask for medi -Calin person. I do not wantto mail the application. Contact your local social services office andask for an interview to apply in have an immediate need for healthcare services, such as severe illnessor pregnancy. Take this application directly to the nearest socialservices office to start the application filled out the applicationand want to mail it. mail the completed application and documentation to your local social services have the Application, but need help. Read Instructions carefully. Contact your local social services office for help. Ask a friend or relative to help m homeless or do nothave a mailing NOT mail THIS APPLICATION.

5 Go to the nearest local social services officeto turn in this spouse or I are enteringa nursing home and applyingfor Medi-Cal . Immediately contact your local social services office for a copy of the notice regard-ing standards for Medi-Cal eligibility form(DHCS 7077). This form will explain certain exempt resources, certain protectionsagainst spousal impoverishment, and certaincircumstances under which an interest in ahome may be transferred without affectingMedi-Cal : Medi-Cal will only pay for the covered services you get from an enrolled Medi-Cal provider after you apply. If you want Medi-Cal to pay, make sure your provider is an enrolled Medi-Cal provider.

6 MC 210 04/09 INSTRUCTIONSW hose information should you put on this application? If you are an adult not living with a spouse, and you have no children,enter your own information. If you are legally married and living together, enter your and yourspouse s information. If you are legally married but one or both of you are living in a nursinghome or board and care facility, enter your and your spouse s information. If your children are under 21 years of age and living with you and theirother parent, enter your own information, your children s and the other parent s. If you are under 21 years of age and not living with your parents, enter yourown information.

7 If you are an unmarried minor under 21 years of age living with your parent(s) andasking for Minor Consent confidential services, enter your own will happen after I send in my application? The local social services office will notify you within 10 working days that they receivedyour application. They will give you the name of someone you can contact for moreinformation about your application. You will receive a packet from the county with additional program information. You may receive a request for additional information that the county will need in orderto determine your eligibility. In most instances the local social services office will determine your eligibility within 45 days and notify you in writing of that decision.

8 An eligibility determination based on disability may take up to 90 days. If you are determined eligible, depending on what county you live in, you maybe able to choose a health plan. Even before you know if you qualify for Medi-Cal , you cancall 1-800-430-4263 (the call is free), to find out about health plans that are available in yourarea and to ask for an informing packet with enrollment forms. If you do not qualify for no-cost Medi-Cal and you wish to apply for the Healthy Familiesprogram, the local social services office will forward this application to that program. Tear out the application Read the instructions completely Fill out as much of the applicationas you can Include requested documentation(See instructions) If help is needed contactthe local social servicesoffice Do not delay in sendingin your applicationHow to fill out the applicationTEAR HERETEAR HEREMC 210 04/09 INSTRUCTIONSQ uestions 1-8:Enter the name, home addressand telephone numbers of theperson who wants medi -Calor the parent/caretaker ofthe children whowant 9-13:Enter the phone number andmailing address (if different thanhome address provided in #2) of theperson who wants Medi-Cal .

9 This is the addresswhere all information regarding the applicationand health benefits will be 14A-B:Enter the language you speak and/or read us about the person who wantsMedi-Cal for themselves, theirfamily or children in their 1 Tell us about the person listed inSection 1, his or her family and thechildren they care for, even if theydon t want 2 Who counts as an adult? Persons 21 years of age or older Persons under 21 years of age who are notliving in the home of their parent or caretakerrelative and are not claimed as tax dependentsWho counts as children? All natural and adoptive children under 21living in the home All natural and adoptive children between18 and 21 years of age, away from home andclaimed as tax dependents All stepchildren under age 21 living in the homeQuestion 15.

10 Write the last, first and middle name of each personin the TO PAGE 2 INSTRUCTIONSP lease read before beginning you are applying formore than 5 people,use a separate piece ofpaper or a photocopyof pages A1, A2, A3 andA4 of theapplication,to give us informationabout the proof is not needed for Persons in an institution Children in a family, if identity of one parenthas been established Children requesting Medi-Cal for MinorConsent services The spouse of a person whose identity hasbeen verifiedSend proof of one person(a parent or caretaker) in a family needs to providean identity document. Send a photocopyof oneofthe following identity items: California driver license Identification card issued by the Departmentof Motor Vehicles citizenship or alien status documents(passport) School identification card Birth certificate Marriage record Social Security card or document containinga Social Security number Divorce decree Work badge, building pass Adoption record Court order for name change Church membership or baptismalconfirmation certificateQuestion 23:Check Yes, if person is blind or has a physical ormental illness that is expected to last at least 30days.