State of California—Health and Human Services Agency Department of Health Care Services
Medi-Cal Program
CALIFORNIA DEPARTMENT OF AGING (CDA)
WAIVER REFERRAL
Multipurpose Senior Services Program (MSSP) site: Please complete this portion and forward to the
appropriate County Waiver contact person.
COUNTY USE ONLY
Case name Case number
Worker name Worker number
Name of applicant
Address (number, street) City State ZIP code
Social security number Date of birth Telephone
( )
Guardian (if applicable)
Address of guardian (if different) , street) City State ZIP code (number
Status
U New Medi-Cal applicant.
U Currently receives Medi-Cal with a share-of-cost.
Living Arrangement
U The applicant is currently in an institution. Please determine Medi-Cal eligibility based on his/her
anticipated return to the community. Anticipated date of discharge:
U The applicant is currently living in the home.
U Other:
Eligibility Determination
If applicant/beneficiary is living or will live at home with his/her spouse and is property eligible and
entitled to zero share-of-cost Medi-Cal under regular eligibility rules, spousal impoverishment rules
are not utilized. If the applicant/beneficiary is property ineligible or has a share-of-cost, apply spousal
impoverishment income and resource rules (i.e., institutional deeming rules) even if the
applicant/beneficiary lives in the home. See Article 19D of the Medi-Cal Eligibility Procedures
Manual.
This is to certify that the individual named above has met the admission criteria for a nursing facility
as defined in the California Code of Regulations, Title 2, Division 3, Subdivision 1, Chapter 3,
Article 4, Sections 51334 and 51335.
Signature of MSSP site contact person
➤
Printed name of MSSP site contact person Title Telephone
(
MSSP site address (number, street) City State ZIP code
)
NOTE TO COUNTY: Please send a copy of the Notice of Action to the MSSP site when the determination is completed.
White: County Copy Yellow: MSSP Site Copy
MC 364 (05/07)
