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GENERAL INSTRUCTIONS FOR COMPLETING FORM MC 224 A

If the potential overpayment for the entire period is less than $100, do not complete this form. The MC 224 A is completed in part by the county

and in part by DHCS Investigations Office.

Section I (Completed by the County)

County ID

Enter the MFBU/MBU case number.

IEVS/Non-IEVS

Check the IEVS box if potential overpayment is due to IEVS or the Non-IEVS box if due to other means.

Case Status

Active-effective date/closed effective date; indicate when the case was opened and/or closed.

Recipients Included in the

Enter name, date of birth, and Social Security number of each MFBU member in potential overpayment

Potential Overpayment MFBU

and the beginning and ending dates of their Medi-Cal eligibility.

Section II—Possession of Other Health Coverage

Complete this section if the potential overpayment is due to a change in other health coverage. Note: If there is NO income-related

potential overpayment, do not complete Section III. Complete Sections IV and V, and send these cases directly to Third Party

Liability Branch, Health Insurance Section (see address in Article 16 H–7).

Section III—Income Overpayment Computation (County Completes Columns 1–6)

Enter the dates of the potential overpayment period and brief reason why the SOC should have increased. Check whether the person:

A. Failed to report the information on the statement of facts at the time of application, or

B. If already on Medi-Cal, failed to report within 10 days a change that would impact the SOC, or

C. Failed to report the correct income on the status report.

If different reasons apply to different periods, link each reason to its respective period.

Column 1

List in chronological order the consecutive months in which there was a potential overpayment. Use MC 224 A

(Supplemental) if more space is needed.

Column 2

Enter the correct net income for each of the months listed in which there was a potential overpayment.

Column 3

Enter the correct maintenance need for each of the months listed in Column 1.

Column 4

Subtract the amount in Column 3 from the amount in Column 2. The remainder is the correct SOC to be entered in

this column.

Column 5

Enter the original SOC the beneficiary met (paid or obligated) in each of the months listed in Column 1. This is needed

to determine the difference between the original SOC and the newly calculated SOC.

Column 6

For each month in the overpayment period, subtract the amount in Column 5 from the amount in Column 4; this

amount is the potential overpayment for that month which must be entered in this column.

Columns 7 and 8

DHCS Investigations Office will complete.

Section IV—County Worker Comments

Include county worker comments pertaining to the Medi-Cal potential overpayment.

Section V—County Worker Completing the Form

Print your name, county name, EW number, telephone number, and date. Sign the form.

MC 224 A (06/07)

Form Mc 224 A - Medi-Cal Potential Overpayment Reporting Work Sheet Income Or Other Health Coverage Page 2

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