DPSS ePolicy

The MC 210 A must be completed

1. The MC 210 A must be completed to request retroactive eligibility for any of the three months immediately prior to the initial month of Medi-Cal eligibility.
2. Staff must complete the MC 210 A form using information the beneficiary provides over the phone, if requested.
3. The request for retroactive eligibility must be made within 12 months of the date when medical services were provided.
4.  Separate income verification or information is not required if:
   •  “No change” is declared on the MC 210 A; or
   • The income reported on the MC 210 A is compatible with information already reported and verified; and
   • Both income reported on the application and on the MC 210 A are within the appropriate income range for MAGI eligibility.
5. The applicant/beneficiary is not required to complete questions on the MC 210 A regarding property, to request a MAGI eligibility determination.
6. A determination of retroactive eligibility will not be completed if the information requested on the MC 210 A is not provided.

Eligibility must be determined for requested retroactive benefits.

1. Only those months where eligibility is established will be approved for retroactive coverage.
2. Some household members may be eligible while others may be ineligible based on age and income limits.
3. A Notice of Action must be sent for the eligibility determination for each of the months for which retroactive eligibility was requested (see NOA samples attached).

A person must have unpaid medical expenses in the retroactive month.

1. Medi-Cal eligibility in the retroactive months will only cover unpaid medical expenses.
2. Retroactive eligibility will not terminate the APTC eligibility retroactively. If approved, the individual will have both APTC and MC coverage in the retroactive period. 

Note:  APTC premiums paid during the retroactive Medi-Cal eligibility period will not be refunded.