WAG 19-02-03-b: Proving Eligibility

PM 19-02-03-b

Forms used for AABD Cash cases:

• AABD Redetermination Report Form (Form 643G), which applies to community cases but not to sheltered care cases, is centrally sent to cases which do not receive SNAP. These cases are listed on PAL with message "REDE FORM 643GC CENTRALLY MAILED. DUE BY MM/DD/YY"; or

  Redetermination - Group Care/Sheltered Care (Form 1229). Complete for long term care and sheltered care cases. 

• Budget Computation Worksheet (Form 553A). Attach to Form 643G.
• Form 157C. Centrally sent if there is a decrease in the amount of benefits or if benefits are being canceled.

Forms used for AABD Medical cases:

• AABD Medical Eligibility Review (Form 643C), for Community Medical cases (except sheltered care cases) and DoA Home and Community Based Services (HCBS) waiver cases, is centrally sent to cases which do not receive SNAP. These cases are listed on PAL with message "REDE FORM 643C CENTRALLY MAILED. DUE BY MM/DD/YY"; or

  Redetermination - Group Care/Sheltered Care (Form 1229) for NH, SLF and sheltered care cases. 

• Nursing Home/Supportive Living Facility Redetermination Report Form (Form 1229A) is sent by Maximus, an external vendor and part of the Illinois Medicaid Redetermination Project (IMRP), to the customer, the community spouse, and/or the customer's representative for NH and SLF cases. This includes customers in Medical Field Operations (office 200). These cases are listed on PAL with message "REDE FORM 1229A CENTRALLY MAILED. DUE BY MM/DD/YY". 
• AABD MANG Computation Sheet - Community Case (Form 2382A) for Community Medical cases; or

  Nursing Home/Supportive Living Facility Resource Calculation (Form 2500) for NH and SLF cases. 

• Qualified Medicare Beneficiary (QMB) - Computation Sheet (Form 2382M) for QMB Only or SLIB Only.
• Form 157 if benefits are being canceled. Form 157 must identify the reason for the action being taken and refer to the correct policy.
• Notice of Changes During the Enrollment Period or Eligibility Period - MANG Community Case (Form 2434A) if the case status changes from Regular to Spenddown.
• Notice of Change - MANG Long Term Care Case (Form 2434C) for changes in the spenddown amount and case status for NH and SLF cases.

REDE Completed by FCRC

For a person who receives SSA or SSI, use SOLQ instead of requiring verification from the customer. Accept the customer's statement for Illinois residency unless it is questionable.

1. Review the case record and/or Summary of Case Information (Form 1376/Form 1376C) to determine what information needs verification. Consider Form 1376/Form 1376C part of the case record.
2. Review the current Form 552 and the current computation sheets [AABD MANG Computation Sheet-Community Case (Form 2382A); Nursing Home/Supportive Living Facility Resource Calculation (Form 2500); or Qualified Medical Beneficiaries/Specified Low-Income Medical Beneficiaries (Form 2382M) for QMB Only and SLIB Only cases].

a. Community Cases (Excluding Sheltered Care Cases)

1. REDE forms are centrally sent to community cases which do not have SNAP authorized. Redetermination Form (Form 643GC) is sent to Cash cases and AABD Medical Eligibility Review (Form 643C) is sent to Medical Only cases. If Form 643 (GC or C) is sent centrally, the message "REDE FORM 643 (GC or C) CENTRALLY MAILED. DUE BY MM/DD/YY" appears on the PAL. The REDE form is sent the 20th day of the calendar month in which it is printed or the first working day thereafter. The form is due back in the local office within 21 days of the day it is sent.
2. If a REDE is not sent centrally and a customer has a phone, first try to do the REDE over the phone. If you are unable to contact the customer by phone or more information is needed, mail the correct Redetermination Form (Form 643G) for Cash cases and AABD Medical Eligibility Review (Form 643C) for Medical Only cases. Attach Instructions to Client (Form 1721) to Form 643G. Request only the required proofs, as listed above. Never check all boxes on Form 1721.
3. If you were unable to contact the person by phone, for Cash cases on Form 1721 put either a time for the person to call to complete the REDE or a request that the person mail the form back within 21 days with the appropriate proofs attached. For Medical Only cases, request the person return Form 643C within 21 days with the appropriate proofs attached.
4. For REDEs completed by phone, the person does not need to return or sign Form 643C or Form 643G. The worker completes Form 643C or Form 643G based on information provided over the phone. The person must still return any required proofs.
5. For REDEs completed other than the yearly REDE, Form 643C or Form 643G is not required. Document in the record how the REDE was completed.
6. Always review TPL information at each REDE and complete Health Insurance Report (Form 1442), if necessary.
7. Complete an AWVS clearance for each known multiple SSN not listed on Form 552.
8. For noncitizens, verify immigration status through SAVE if it has not been done previously or the status is subject to change.
9. If the customer wants help in scheduling appointments for Healthy Kids Services or in obtaining transportation to and from Healthy Kids Services, complete a Healthy Kids Request Card (Form 2280). Enter the date the customer asked for the help in the box in the lower right-hand corner of Form 2280.

   Send the completed Form 2280 to:

   Healthy Kids
   PO Box 19103
   Springfield, IL 62794-9103

10. Document in the record when Form 643C or Form 643G is returned.
11. If Form 643C or Form 643G is not returned or the customer fails to provide necessary information by the due date, cancel the case for failure to cooperate.

b. NH, SLF, and Sheltered Care Cases

(1) NH and SLF Cases

Maximus will send Nursing Home/Supportive Living Facility Redetermination Report Form (Form 1229A) to NH and SLF customers. The mail date and requested return date are listed on the PAL for the month the REDE is due. Form 1229A is sent on the 20th day of the calendar month in which it is printed, or the first working day thereafter. The form is due back to the Illinois Medicaid Redetermination Project by the 21st day following the mail date, or the first work day following the 21st day. For all cases, a copy of Form 1229A will be sent to the community spouse and/or the customer's representative. Twenty-one (21) days will be allowed to return the completed form and provide the verification needed. If the due date of a centrally mailed REDE form differs from the due date of a REDE manually sent to a spouse and/or representative, use the later due date. Form 1229A must be signed by the person providing the information.

• If Form 1229A is not returned by the requested date and the customer is capable of providing information, obtain answers to the questions during the visit to the NH or SLF. If verifications are needed, give or send a request for the needed verifications. Send a copy to the community spouse and/or the customer's representative. Allow 10 days for the return of the needed information. Maximus assists the customer as necessary.
• If Form 1229A is not returned by the requested date and the customer is incapable of providing information, Maximus assists the customer in obtaining any needed verifications. If the customer has a representative, Maximus sends a request for additional information.

  NOTE: Accept a representative's statement of the competence or ability of the customer to provide information. However, if the person's statement is questionable or if the customer does not have someone acting on his or her behalf, the FCRC is to make the determination of the customer's ability to provide information. Document in the case record whether the customer is capable or incapable of providing information. 

• If the customer's community spouse and/or representative fails to provide needed information requested , initiate action to cancel the case.

  To REDE cases in NH and SLF, use Redetermination - Group Care/Sheltered Care (Form 1229) to record case information. 

(2) Sheltered Care Cases

Use Form 1229 to record case information for REDE of all sheltered care cases.

c. Completion of the REDE

After all necessary information and verifications are obtained, review and document eligibility and complete the authorization and reporting of the REDE.

Central Redetermination

Each month the Department receives SSI information from the Social Security Administration (SSA) through the SSI/SDX system. It is compared to customer information for AABD Community, NH, and SLF (non-spenddown) cases.

When the case is due for a REDE and information on the SSI/SDX system matches the Department's record for the Medical case, a central REDE is considered completed.

A Form 552 is produced by the system for each Community or LTC case which is centrally REDEd.  The form shows the actual month and year in which the central REDE was completed in Item 30. TA 30 is entered in Item 3. Item 32 is updated to show a date 12 months from the previous date in Item 32. The message CENTRAL REDETERMINATION COMPLETE is printed in Item 93. For certain cases where data does not match, an exclusion code is centrally entered in REMARKS on Form 552 (see WAG 22-14-03-b). Central REDEs are not completed for these cases.