Form 552 Coding Charts for Family Health Plans

ITEM 78 CODES FOR PERSONS AGE 19 & OVER IN A 94 OR 96 CASE
Program Definition Item 78 Item 80
Family Assist Family income = or less than the Family Assist standard - (dash) 158

FamilyCare Assist

(Adults)

Income greater than FA standard but less than or = Family Health *Spenddown standard - (dash) 158

FamilyCare Assist

(Adults)

Income greater than Family Health *Spenddown standard but = or less than PA standard - State insurance not available. A 158

FamilyCare Assist

(Adults)

Income greater than Family Health *Spenddown standard but = or less than PA standard - State insurance available. F 158

*The Family Health Spenddown program ended for non-pregnant adults in Family Health Plans effective January 2014.

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ITEM 78 CODES FOR PERSONS UNDER AGE 19 IN A 94 OR 96 CASE
Program Definition Item 78 Item 80
Family Assist N/A (-), 3, C 158
All Kids Assist Income above FA standard, = or less than 147% of FPL; - child not previously coded C in Item 78 R 158
All Kids Assist Income above FA standard, = or less than 147% of FPL; - child was previously coded C in Item 78 T 158
Moms & Babies Newborn born to Medicaid eligible mother P 158
Moms & Babies Newborn born to Medicaid eligible mother who doesn't meet the immigration requirement N 158
Moms & Babies Pregnant P 158
Family Health Spenddown N/A - (dash) 158, 390
Extended medical N/A - (dash) 158

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ITEM 68 CODES FOR ALL 94 AND 96 CASES
Definition Code
Uninsured person - no state health insurance available - (dash)
Insured person - no state health insurance available 1
Uninsured person - state health insurance available 2
Insured person - state health insurance available 3

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ITEM 73 FOR All Kids SHARE AND PREMIUM
Program Item 73 Item 80
Share Y 177
Share (eligible for **Rebate - chose Share) J 177
Premium Levels 1-8 Z 177
Premium (eligible for **Rebate - chose Premium) L 177
Rebate (income = or less than 150% of FPL) V 177
Rebate (income greater than 150% of FPL) X 177

** The Rebate program ended effective January 2014.

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QMB Case Coding

Program Item 60
QMB/Medicaid 1
SLIB/Medicaid 2
QI-1 Spenddown 3
QI-1 Only 7
SLIB Only 8
QMB Only 9

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Program* District Office Eligibility Determination Case Maintenance
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IL Breast & Cervical Cancer 189 Dept. of Public Health All Kids Unit
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HFS Social Services 194 Central Action HFS
DHS Social Services 193 Central Action DHS
Incarcerated Persons 195 All Kids Unit All Kids Unit
Veterans Care 196 Veterans Care Unit Veterans Care Unit

*Except for Illinois Breast & Cervical Cancer and Veteran's Care, these programs provide limited benefits only and should not be considered active coverage when determining eligibility for other benefits, including other medical programs.

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