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State of California Health and Human Services Agency Department of Health Care Services ADDITIONAL INCOME AND PROPERTY INFORMATION NEEDED FOR MEDICAL We are still evaluating your Medical eligibility.

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How to fill out the CA DHCS MC 604 IPS online

The CA DHCS MC 604 IPS form is essential for providing additional income and property information needed for Medi-Cal eligibility. This guide will help you navigate the online completion of this important document, ensuring that you accurately provide the necessary details.

Follow the steps to effectively complete the form online.

  1. Click ‘Get Form’ button to obtain the form and open it in the editor.
  2. Begin by filling out your case name, case number, worker's name, worker's phone number, date sent, and return date for this form. It is important to ensure all names and numbers are accurate to avoid processing delays.
  3. Provide additional household information as required. If you or a member of your household is living apart due to legal marriage, indicate this and list the name of the spouse. Also, provide details if there is a step-parent living in your household or if a child is being cared for by a relative.
  4. Answer the income and expenses section. Check 'Yes' or 'No' for each income type and expense type relevant to your household. Ensure that you gather and attach proof for any 'Yes' responses, ensuring to meet documentation requirements as specified.
  5. In the property and possessions section, check the boxes for the types of property your household owns. Be thorough and provide any necessary documentation if you answer 'Yes' to ownership of specific property, such as vehicles, real estate, or valuable possessions.
  6. If applicable, answer questions about long-term care or nursing facility residence. Provide any details related to the sale or transfer of property or financial assets within the specified time frames.
  7. Read through the declaration section carefully, understanding that by signing, you confirm the truth of your information. Ensure the signature is completed accurately along with the date.

Complete your CA DHCS MC 604 IPS form online today to ensure your Medi-Cal eligibility is assessed promptly.

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MC 604 IPS (5/14) Page 2. Tell Us About Your Income And Expenses. Tell us about your income and expenses for you, your spouse and any of your children under 21 years of age who are living in the home, or are temporarily absent from the home for reasons such as attending school or work or is hospitalized.

If a Medi-Cal applicant's property/assets are over the Medi-Cal property limit, the applicant will not be eligible for Medi-Cal unless they lower their property/assets ing to the program rules. The Medi-Cal eligibility worker looks at how much an applicant and their family has each month.

Medi-Cal Income & Assets Limits for Eligibility April 2023 – March 2024 California Medicaid / Medi-Cal Long-Term Care Eligibility for SeniorsType of MedicaidSingleMarried (one spouse applying)Regular Medicaid / Aged Blind and Disabled$1,677 / month$195,0003 more rows • Mar 15, 2023

Household sizeAsset limits1 person$130,0002 people$195,0003 people$260,0004 people$325,0006 more rows • Feb 15, 2023

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