Form Mc 224 A-S - Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet Income Or Other Health Coverage

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State of California—Health and Human Services Agency
Department of Health Care Services
SUPPLEMENTAL
MEDI-CAL POTENTIAL OVERPAYMENT REPORTING WORK SHEET
INCOME OR OTHER HEALTH COVERAGE
Section I
County ID
Use this space for additional MFBU members, if needed. Attach to the MC 224 A.
RECIPIENTS INCLUDED IN POTENTIAL OVERPAYMENT (MFBU)
Medi-Cal Eligibility Date
Name
Date of Birth
Social Security Number
From
To
Section III—Income Overpayment Computation
Use this space for additional months of overpayment computations, if needed.
1
2
3
4
5
6
7
8
Correct
Correct
Original
Potential
Amount Paid
Overpayment
Month/Year Correct Net Income
Maintenance Need
Share-of-Cost (2–3)
Share-of-Cost Met
Overpayment (4–5)
by Medi-Cal
(Lower of 6 or 7)
$
$
$
$
$
$
$
Section IV—County Worker Comments
(If additional space is needed, attach a separate sheet of paper.)
Section V—County Worker Completing Form
Name (print)
County
Signature
Date
EW number
Telephone number
(
)
White—DHCS Investigations
Yellow—DHCS Investigations
Pink—County
MC 224 A-S (05/07)

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