Medicare/Medi-Cal Coverage: Starting January 1, 2006, medications covered under Medicare Part D will not be a covered benefit under the Medi-Cal Program and are not eligible for reimbursement.

I know that the information in this renewal form will be used to decide if the people who are applying qualify for health insurance. The Medi-Cal program and Covered California will keep the information private, as required by federal and California law.

When retroactive Medi-Cal is needed, a “Supplement to the Statement Of Facts for Retroactive Coverage/Restoration” (MC 210A) must be completed by the FC EW for the retro month (s).

A person applying for retroactive MC must submit a MC 210 A. If the application is for retroactive MC coverage only, then an SSApp or any other acceptable MC application/SOF form must be submitted.

Income verification used to determine current month eligibility reported by an applicant on the MC 210 (Statement of Facts) may be used to determine income eligibility for each retroactive month provided that the applicant reports no change on the MC 210A (Supplemental Statement of Facts for Retroactive Coverage).

Individuals could previously request retroactive coverage before a year from the date of service by completing an MC 210A for each month in which retroactive coverage was requested.

Because of the cost of a production order, current supplies of the MC 213 will be exhausted before making the MC 210-A available. We anticipate that MC 210-A’s will be available for distribution after May 15, 1985. If there are any questions or comments, please contact Maxine Forster at (916) 324-4969 or ATSS 454-4969.

Documentation is needed to verify all sources of income and to support any difference in property, residence, etc. All Personal Property including motor vehicles, boats, bank accounts, etc. (Lowest bank account balances should be listed for each month unless they were exactly the same as the balance listed on the Statement of Facts.

See the next page for a copy of MC Form 210a.

May 15, 2014 · The MC 210A continues to be the required form to initiate a retroactive coverage eligibility determination. The Department acknowledges that some revisions are needed to the MC 210A to accommodate the new ACA rules and the process will …