S
tate of California -
H
ealth and Human Services Agency
Department of Health Care Services
MC 05 (02/2016)
MILITARY VERIFICATION AND REFERRAL FORM INSTRUCTIONS
USE THE MILITARY VERIFICATION AND REFERRAL FORM:
1.
To verify monetary amounts of veterans’ benefits and VA health enrollment for new applicants, current Medi-Cal
recipients, and during Medi-Cal redeterminations.
To refer applicants or recipients to the County Veterans Service Office (CVSO).
To obtain or enhance veteran benefits when the information on the Statement of Facts indicate a military background.
* Do not complete this form if the service person is still on active duty.
INSTRUCTIONS FOR COMPLETION OF THE MEDI-CAL MILITARY REFERRAL FORM:
SECTION A: TO BE COMPLETED BY MEDI-CAL ELIGIBILITY WORKER
Enter name and address of Medi-Cal Eligibility worker’s office the form will be returned to.
Enter name and address of County Veterans Service Office (CVSO) the form will be sent to.
Enter case worker (person filling out the form) contact information on # 3 – 5.
Enter Medi-Cal case number of applicant/recipient (if applicable)
# 7
Enter valid Medi-Cal Aid Code. (Required)
* If necessary, county staff may enter the case’s anticipated aid code even though eligibility has not yet been established. When the aid code is
determined, county staff will update the aid code (if different from the anticipated aid code) and inform CVSO of the updated aid code.
Enter all known personal information of Veteran. Required: Date of Birth (DOB), and Social Security Number (SSN).
# 14
Enter the VA income reported by the applicant/recipient (if applicable). Verify and evaluate income when MC 05 is
returned.
Enter Veteran’s Military Background. This may include but not limited to Dates of Service/Branch of Service etc.
# 16-20
E
nter
a
ll
f
amily member
i
nformation if someone other than the veteran is applying
f
or benefits.
(
E.g. Spouse or dependent/child of veteran.)
N
ote: A
d
ependent
i
s defined as a veteran whose parent(s)/ or family member who
ar
e dependent upon
h
im/her for
f
inancial support may be paid additional benefits from the VA based on specific eligibility requirements.
# 21
En
t
er
any additional notes/remarks that the CVSO may need to know regarding the Medi
-C
al applicant/recipient’s
c
ase that may help determine VA and Medi
-C
al eligibility.
SECTION B: TO BE COMPLETED BY COUNTY VETERANS SERVICE OFFICE (CVSO)
# 1-2
Enter date you attempted to contact or verify the beneficiary and confirm whether they are the veteran, spouse, or
dependent/child.
*
Military dependents are the spouse(s), children, and possibly other familial relationship categories of a sponsoring military member (such as
dependent parent of a veteran) for purposes of pay as well as special benefits, privileges and rights.
# 3
S
elect
V
A benefit type the applicant is receiving
an
d/or eligible to receive. Mark all that apply.
# 4
Enter VA Health Information. Specify if applicable.
This may include the VA Health System, CHAMPVA, TRICARE, or any other military health coverage.
# 5
Select the type of monetary benefit the veteran is already receiving and/or entitled to receive (Mark all that apply if
applicable).
# 6
E
nter gross pay the veteran is reported to be receiving.
# 7
E
nter
am
ount of Aid and Attendance (A&A)/ Special Monthly Compensation (SMC)/ Special Monthly Pension (SMP)
if
app
licable.
(
A
&A/SMC/SMP is
r
equired
i
n order for the Medi
-C
al worker to properly treat income.
)
If the veteran is in Long Term Care (LTC), enter all known LTC information (if applicable)
# 10
If applicable, enter any additional information/comments/remarks that may be necessary for the Medi-Cal worker to
know for eligibility determination.
#11- 13
E
nter
a
ll
C
VSO contact information and date.
DISTRIBUTION AND FILING OF THE MEDI-CAL MILITARY VERIFICATION AND REFERRAL FORM:
1. The Medi-Cal eligibility worker will fill out Section A of the MC 05 form if a Medi-Cal applicant/beneficiary or anyone in the
household indicates they have a military background.
2.
The Medi-Cal eligibility worker will keep one copy of the MC 05 for their records and submit the original copy to the CVSO.
T
he copy for the case file is to be retained until the original is completed and returned by CVSO.
3. T
he CVSO will utilize any VA resources and/or contact the veteran and confirm VA benefits eligibility (if any) and complete
S
ection B of the MC 05 Form.
T
his may include VA compensation, Health, and enhancement of current benefits.
4. T
he CVSO will make a copy of the completed MC 05 form and keep it for case file records. The CVSO will then return the
or
iginal MC 05 form to the Medi
-C
al
e
ligibility
w
orker.
5.
The Medi-Cal eligibility worker will review the MC 05 form to complete/determine Medi-Cal eligibility. Any incomes reported
s
hould be evaluated and have the Share of Cost (SOC) adjusted, if applicable. If the applicant/recipient is in receipt
/
eligible
f
or
V
A Health, the applicant must accept any unconditionally available income for which they appear eligible
f
ollowed
b
y
§
5018
6 of Title 22 of the California Code of Regulations. For existing Medi
-C
al recipients, The Medi-
C
al eligibility
w
orker will
send the recipient an MC 215 for voluntary discontinuance.
1. To verify monetary amounts of veterans' benefits and VA health enrollment for new applicants, current Medi-Cal recipients, and during Medi-Cal redeterminations.
# 7 Enter valid Medi-Cal Aid Code. (Required) * If necessary, county staff may enter the case’s anticipated aid code even though eligibility has not yet been established. When the aid code is determined,
county staff will update the aid code (if different from the anticipated aid code) and inform CVSO of the updated aid code.
# 14 Enter the VA Income reported by the applicant/recipient (if applicable). Verify and evaluate income when MC 05 is returned.
# 16-20 Note: A dependent is defined as a veteran whose parent(s)/ or family member who are dependent upon
him/her for financial support may be paid additional benefits from the VA based on specific eligibility requirements.
# 21 Enter any additional notes/remarks that the CVSO may need to know regarding the Medi-Cal applicant/recipients case that may help determine VA and Medi-Cal eligibility.
# 1-2 Enter date you attempted to contact or verify the beneficiary and confirm whether they are the veteran, spouse, or dependent/child.
* Military dependents are the spouse(s), children, and possibly other familial relationship categories of a sponsoring military member
(such as dependent parent of a veteran) for purposes of pay as well as special benefits, privileges and rights.
# 4 Enter VA Health Information. Specify if applicable. This may include the VA Health System, CHAMPVA, TRICARE, or any other military health coverage.
# 5 Select the type of monetary benefit the veteran is already receiving and/or entitled to receive (mark all that apply if applicable).
# 7 Enter amount of aid and attendance (A&A)/ Special monthly compensation (SMC)/ Special monthly pension (SMP) if applicable. (A&A/SMC/SMP is required in order
for the Medi-Cal worker to properly treat income.)
# 10 If applicable, enter any additional information, comments/remarks that may be necessary for the Medi-Cal worker to know for eligibility determination.
