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GENERAL INSTRUCTIONS FOR COMPLETING FORM MC 224 B

If the potential overpayment for the entire period is less than $100, do not complete this form. If a Medi-Cal Family Budget Unit (MFBU) has

both a property-based overpayment and an income-based overpayment, use both the MC 224 B and the MC 224 A. Send the completed form

with the completed MC 609, Medi-Cal Complaint Form, to the DHCS Investigations Office.

Section I (Completed by the County for All Ineligibility)

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 (County Complete for all Potential Ineligibility)

Enter the month and year that the MFBU should have been ineligible (check the box(es) which apply).

Property was above the allowable property limit. Applies if the recipient held property over the Medi-Cal property limit during the

potential overpayment period.

Recipient should have been ineligible for nursing facility level of care from ____________ through ______________ due to a

disqualifying transfer of property. Applies only if the LTC recipient transfers or gives away property without adequate consideration

during or after the 30-month “look-back” period and the transfer was considered to be a disqualifying transfer that resulted in a period of

ineligibility, calculated on the MC 176 PI.

C. No eligibility existed due to: Provide reason for total ineligibility.

Section III (County Complete Only for Property Ineligibility)

Month/Year

Enter the consecutive month(s) and year(s) the recipient held the property.

Property

Columns can be used for any type of property, bank account, cash, etc. Provide account numbers when

available. Use the lowest balance per month.

Total Balance

Enter the sum of the lowest value of all nonexempt property (across) for each month of the overpayment

period.

Medi-Cal Property Limit

Enter the appropriate Medi-Cal property limit based on family size.

Excess Property Amount

Enter the amount of property held in excess of the Medi-Cal property limit.

Section IV—Summary (County Worker/DHCS Investigator Complete Where Applicable)

Potential Overpayment

Enter the highest amount of excess property in any one month of a consecutive period of overpayment (after

listing on a separate work sheet the lowest value of each item and computing the excess property in each

month).

Medi-Cal Usage for Period

DHCS Investigations Office computes this amount.

Actual Overpayment

DHCS Investigations Office computes this amount which will be the lesser of the:

Actual cost of services paid by DHCS during the potential overpayment period in which there was excess

property throughout each month, or

Highest amount of excess property in a single month during the potential overpayment period.

Section V—County Worker Comments

This section can be used to clarify the entries of any other section (e.g., were some family members ineligible, while other family members

had eligibility through Sneede, pregnancy, or a percent program or other means?).

Section VI—County Worker Completing the Form

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

MC 224 B (06/07)

Form Mc 224 B - Medi-Cal Potential Overpayment Reporting Work Sheet-Property Total Ineligibility Or Ineligibility For A Specific Level Of Services Page 2

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