How to Fill Out the Medi-Cal Health Care Options Choice Form

The Medi-Cal Choice Form is the one-page form California uses to record which managed care health plan you want after you qualify for Medi-Cal. When you first become eligible, the state mails you an enrollment packet listing the plans available in your county, and you have 30 days to return the form before the state assigns a plan for you.¹ The form is short. Getting it right ahead of the deadline is what keeps you with the doctor you already see.

What to Gather Before You Start

The form asks for less than you might expect. Pull these together first:

Head of household’s full legal name, home address, phone number, and email, written exactly as they appear in your Medi-Cal records.
The applicant’s first name, last name, sex, birth year, and Social Security Number. If the applicant is pregnant, you’ll also need the due date.
Your Client Identification Number (CIN), printed on your Medi-Cal Beneficiary Identification Card. The paper form doesn’t require it, but the online portal does (or your SSN).²
The name of the specific managed care plan you want. Your enrollment packet lists the plans that operate in your county.
A doctor or clinic code for your preferred primary care provider, found in that plan’s Provider Directory. This field is optional; leave it blank if you can’t find a code.³

Before you commit to a plan, call your doctor’s office and confirm two things: they accept that specific Medi-Cal managed care plan, and they’re taking new patients. Directories lag behind reality. A two-minute phone call now spares you weeks of untangling later.

Filling Out the Form, Section by Section

The form has five sections.⁴

Head of Household Information (Fields 1–7)

First name, last name, home address with apartment number, city, zip, phone with area code, and email. Match your Medi-Cal records exactly. A mismatch between what you write and what’s in the state system can slow processing.

Applicant Information (Fields 8–13)

This covers the person actually enrolling: first name, last name, sex, birth year, and SSN. If the applicant is pregnant, enter the due date. When more than one person in your household needs to enroll, each gets a separate row or a separate form. The form doesn’t collect everyone’s SSN in a single block.

Plan and Provider Selection (Fields 14–17)

Field 14 is the health plan you want to join or switch to. Field 15 is the doctor or clinic code from that plan’s Provider Directory.³ If you can’t locate a code, skip it and the plan will assign a provider after enrollment. Fields 16 and 17 are checkboxes for two specific options: Kaiser Permanente and the Program of All-Inclusive Care for the Elderly (PACE). Only mark them if that’s what you’re choosing.

Families don’t have to share one plan. If a child sees a specialist at one hospital and an adult’s doctor participates in a different network, you can pick different plans for each household member.

Reason for Change (Field 18)

If you’re switching plans rather than enrolling for the first time, fill in the oval next to the reason that fits best. The options include not being able to choose the doctor you wanted, the plan not meeting your needs, moving out of the county, distance to providers, and not having chosen the current plan yourself. There’s also an “Indian Health Program Exemption” oval and a general “Exempt from a plan” option for those who qualify to opt out of managed care.

Signature and Date (Section 5)

The head of household or an authorized representative has to sign and date the form. An unsigned form won’t be processed.

How to Submit It

You have three channels. Use whichever is easiest.

By Mail

Send the completed paper form to:⁵

CA Department of Health Care Services
Health Care Options
P.O. Box 989009
West Sacramento, CA 95798-9850

The county-specific form is downloadable from the Health Care Options website at healthcareoptions.dhcs.ca.gov.⁶

Online

The Health Care Options portal at healthcareoptions.dhcs.ca.gov/online handles enrollments and plan changes. Logging in requires at least three of the following: last name, date of birth, Social Security Number, and Client Identification Number. Last name plus date of birth plus CIN gets you in without an SSN.²

By Phone

Call Health Care Options at 1-800-430-4263 (TTY: 1-800-430-7077), Monday through Friday, 8 a.m. to 6 p.m. A representative will walk through your selections and enter them while you’re on the line.⁵

What Happens If You Don’t Return It in 30 Days

If the form doesn’t come back within 30 days of your enrollment packet arriving, the state assigns a plan for you automatically.¹ You don’t lose Medi-Cal coverage. You lose control over which plan and network you land in. The assigned plan may or may not include your current doctor. Most of the frustration people run into with Medi-Cal managed care starts here: the packet gets set aside, auto-assignment runs, and then the work of switching begins.

Changing Plans After Enrollment

An unwanted assignment or a wrong first choice isn’t permanent. Federal rules give you two no-questions-asked windows to switch:

Within the first 90 days after your initial enrollment, or 90 days after the state sends you notice of that enrollment, whichever is later, you can request a different plan for any reason.⁷
After that, you can switch at least once every 12 months.⁷

You can also change for cause at any time. Examples include the plan not providing adequate care, your provider leaving the network, or a move to an area the plan doesn’t serve. The channels are the same ones you’d use to enroll: mail a new Choice Form, use the online portal, or call Health Care Options at 1-800-430-4263. Field 18 on the form exists for exactly these requests.

Who Doesn’t Need to Submit the Form

Managed care enrollment is mandatory for most beneficiaries getting full-scope Medi-Cal without a share-of-cost, but some groups can opt out or are excluded.⁸ At the federal level, states cannot force mandatory managed care enrollment on certain children with special needs, Medicare beneficiaries who also have Medi-Cal, or American Indians.⁹

The form itself has an “Indian Health Program Exemption” checkbox and a general “Exempt from a plan” option in the Reason for Change section.⁴ If you think you qualify for an exemption, you can also request one by calling Health Care Options. Medical exemptions require a separate form that your doctor must complete and sign.

Mistakes That Cause the Most Delays

Writing your name differently than it appears on your Medi-Cal Beneficiary Identification Card. Even a missing middle initial can slow processing.
Using an outdated provider code. Codes change when doctors move between medical groups, so check against the plan’s current Provider Directory rather than an old printout.
Forgetting the signature. Without the head of household’s signature and date, the form is invalid.
Letting the 30-day deadline lapse. Once auto-assignment runs, fixing it means filing a change request and waiting.
Trusting a directory listing without calling. A doctor can appear in a plan’s directory and still not be accepting new Medi-Cal patients.

Medi-Cal managed care has no monthly premium, so a mistake on the Choice Form costs you time rather than money. For anyone with a specialist, an ongoing condition, or an established doctor they want to keep, that time is worth spending up front.

1
Department of Health Care Services. Medi-Cal Managed Care Health Plan Directory
2
Medi-Cal Managed Care Health Care Options. CA HCO Online Enrollment Portal
3
California Department of Health Care Services. How to Fill Out the Medi-Cal Choice Form
4
California Department of Health Care Services. Medi-Cal Choice Form
5
Health Care Options. Contact Us
6
Medi-Cal Managed Care Health Care Options. Enroll
7
eCFR. 42 CFR 438.56 – Disenrollment: Requirements and Limitations
8
Santa Clara County Social Services Agency. Overview of the Managed Care Two-Plan Model
9
Medicaid and CHIP Payment and Access Commission. Features of Federal Medicaid Managed Care Authorities