Form Mc 224 B - Medi-Cal Potential Overpayment Reporting Work Sheet-Property Total Ineligibility Or Ineligibility For A Specific Level Of Services

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State of California—Health and Human Services Agency
Department of Health Care Services
MEDI-CAL POTENTIAL OVERPAYMENT REPORTING WORK SHEET—PROPERTY
TOTAL INELIGIBILITY OR INELIGIBILITY FOR A SPECIFIC LEVEL OF SERVICES
Section I (County complete for all ineligibility.)
County ID
Case status effective date(s)
IEVS
_____/_____/_____
_____/_____/_____
Active
Closed
Non-IEVS
RECIPIENTS INCLUDED IN POTENTIAL OVERPAYMENT (MFBU)
Medi-Cal Eligibility Date
Name
Date of Birth
Social Security Number
From
To
If additional space is needed, use the MC 224 B-S (Supplemental).
Section II (County complete for all potential ineligibility.)
Recipient was potentially ineligible for Medi-Cal from _______________________ to _____________________ because:
(month/year)
(month/year)
Ì A. Property was above the allowable property limit.
Ì B. Recipient should have been ineligible for nursing facility level of care from _______________________ to _____________________
due to a disqualifying transfer of property.
(month/year)
(month/year)
Ì C. No eligibility existed due to _____________________________________________________________________________________
Section III (County worker complete only for property ineligibility.)
Overpayment is computed according to Title 22, California Code of Regulations, Sections 50786–50787. Use for any type of property, bank
account, stocks, cash, etc. Provide bank or institution account number when available. Deduct regular income from the account to which it
is regularly deposited. Use the lowest balance per month. For additional months of overpayment computations, use the MC 224 B-S
(Supplemental).
Use the Lowest Balance Per Month.
1
2
3
4
5
6
7
8
Month/Year
Property
Property
Property
Property
Total Balance
Medi-Cal Property
Excess Property
(One line per month)
(Describe)
(Describe)
(Describe)
(Describe)
(Sum of 1–5)
Limit
Amount (6 minus 7)
$
$
$
$
$
$
$
Section IV—Summary (County worker/DHCS investigator complete where applicable.)
Potential overpayment:
$ ________________
(Highest amount of excess property in any one month of the overpayment period)
Medi-Cal usage for period:
$ ________________
(Computed by DHCS)
Actual overpayment:
$ ________________
(Lesser of Medi-Cal usage or excess property, computed by DHCS)
Section V — County Worker Comments
(This space can be used to specify the circumstances of ineligibility.) (If additional space is
needed, attach a separate sheet of paper.)
Section VI—County Worker Completing Form
Name (print)
County
Signature
Date
EW number
Telephone number
(
)
White—DHCS Investigations
Yellow—DHCS Investigations
Pink—County
MC 224 B (06/07)

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