DPSS ePolicy

• To convert existing policy to the new webpage - No content changes
• To revise existing policy and/or form(s)

What changed?

The Medi-Cal Application (Intake) Packet has been updated with:

• Revision of the required informational notices at intake for all Medi-Cal (MC) applicants; and
• Removing the Non-Modified Adjusted Gross Income (MAGI) informational notices.

Counties are required to provide mandatory informational notices to all households when an initial application is submitted to the county in person, by phone, by mail, or the online portal Your Benefits Now (YBN).  For applicants who apply through Covered California, counties must provide the informational notices when the county becomes aware that the application has been forwarded by Covered California to the counties for a MC determination.

Federal and State requirements (42 Code of Federal Regulations 435.905, Title 22, California Code of Regulations § 50157 & 50185, Federal National Voter Registration Act of 1993, and the MC Eligibility Procedures Manual Section 4S) mandate County Social Services offices to provide mandatory publications/forms for each household at application.

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The list below indicates required forms to be included in the application intake packet, which consists of the Single Streamline Application and Informational Notices for all MC applications:

• CCFRM604 - Single Streamline Application (SSA) - Revised 11/13
• MC 219 - What You Need to Know When You Apply for and Enroll in Medi-Cal - Revised 11/15
• PUB 183 - Child Health and Disability Prevention Program - Revised 9/15
• PUB 68 - My Medi-Cal – How to Get the Health Care You Need -Revised 2/19
• MC 003 - Early and Periodic Screening, Diagnostic and Treatment Mental Health Services (EPSDT) Brochure - Revised 11/12
• WIC Brochure - Women, Infants & Children Program - Revised 3/16
• California Voter Registration Card (VRC) - California Voter Registration Application - Revised 5/16
• PA 106 - “Would You Like to Register to Vote?” (Voter Preference Form) - Revised 1/13
• MC 372 - Breast and Cervical Cancer Treatment Program (BCCTP) Information Notice - Revised 9/09
• GEN 1365 - Notice of Language Services - Revised 6/17
• PUB 13 - Your Rights Under California Welfare Programs - Revised 8/16
• MC 018 - Medi-Cal Information for Applicants - Revised 2/15
• 1095-B Beneficiary Notice - Medi-Cal Beneficiaries Will Receive IRS Form 1095-B - Revised 10/15
• MC 13 - Statement of Citizenship, Alienage and Immigration Status - Revised 12/09
• PA 2457 - Civil Rights Information Notice - Revised 3/10
• Health Care Options Brochure - My Medi-Cal Choice for Health Care - Revised 9/07
• PA 6076 - Medi-Cal and IHSS Informational Flyer - Revised 5/19
• DE Notice - Important Information Notice - Deemed Eligible Children - Revised 11/17
  

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