For a customer determined permanently disabled by the Social Security Administration (SSA) or the Client Assessment Unit (CAU), include in the case record the information used to verify the disability (see WAG 03-08-01). No other verification of the medical barrier is needed. If it is an 06 case, change the category to 04. Enter code 2 (medical condition) in Item 73 on Form 552.
For a pregnant woman who is within 6 weeks of the verified expected delivery date, approve a medical barrier without further verification. Do not submit to CAU. Do not add Item 80 Code 156 DRD, as the EDD is sufficient. Enter code 2 (medical condition) in Item 73 on Form 552.
For all other customers who claim to have a temporary (illness, injury, or complications in early pregnancy prior to 6 weeks before EDD) or chronic medical barrier that prevents participation, take the following actions:
- (FCRC) Enter Item 80 Code 156 DRD on Form 552 with the month/year the customer claimed a barrier, and SUP. BY. 'P' to indicate a medical barrier request is pending.
- (FCRC) Complete Medical Evaluation - Social Information (Form 183B) based on the customer's statements, worker's observation, and other available information.
- (FCRC) Request medical information to support the customer's claim that they cannot work or participate in activities.
- Identify the medical providers the person has used in the past 12 months. Complete the top section on page 1 of Medical Evaluation - Physician's Report (Form 183A); use a separate Form 183A for each provider. If the customer has medical reports from the provider, attach the reports. If the customer does not have medical reports from a provider, ask the customer or person legally responsible for the customer to sign a Consent to Release Medical Records (Form 4701H) for the provider. Make a copy of the consent form for the case record. Send Form 183A and Form 4701H to the provider.
- If the customer was treated at a Veteran's Administration facility, also ask the customer to sign Request to Veteran's Administration (Form 1301). Check the box to specify that Medical Data is being requested. Attach Form 1301 to Form 4701H and send to the VA.
- If the customer was recently incarcerated in an Illinois Department of Corrections facility, also ask customer to sign Authorization for Release of Information (Form IL426-4517) to get information from IDOC. Specify the type of information being requested. Attach Form IL426-4517 to Form 4701H and send to IDOC.
- If the customer has not received treatment within the past 3 months, set up an appointment for a medical examination with the person's physician or physician of their choice who is an approved Medicaid provider. If the customer has mental health issues, set it up with an approved Medicaid psychiatrist. Go to step 5a.
Example: Ms. A applies for TANF and is interviewed on 06/01. She claims a medical barrier. Her last visit to a doctor was on 01/15. Since she has not received treatment within the last 3 months, set up an appointment for Ms. A with her physician.
- (FCRC) If the medical information has not been received after 30 days, contact the provider to determine the status of the request.
- (FCRC) If the information is not received within 45 days from the date the forms were sent to the provider, set up an appointment for a medical examination with the person's physician or physician of their choice who is an approved Medicaid provider. If the customer has mental health issues, set it up with an approved Medicaid psychiatrist.
Example: Ms. B applies for TANF and is interviewed on 06/15. She claims a temporary medical barrier due to injuries received in an auto accident. She was seen by her physician on 06/01. The caseworker completes the top section of Form 183A; Ms. B signs Form 4701H. The forms are sent to Ms. B's physician.
On 07/31, the forms have not been returned. Set up an appointment for Ms. B with her physician.
- Complete Referral for Medical Examination (Form 1864) in triplicate. Give or send the original and first copy to the customer to be given to the medical provider. Attach Form 183A, a copy of signed Form 4701H, and Letter to Medical Provider (Form 4216). File the 2nd copy of Form 1864 in the case record.
- Set a control to follow up after the appointment.
- If the customer misses the appointment without good cause, consider the person able to work. Deny the request for a medical barrier. Meet with the customer to revise the TANF Responsibility and Services Plan. No additional action is needed.
- If the customer misses the appointment and claims good cause, help them reschedule it.
- If the customer keeps the appointment, wait for the provider's report.
- (Provider) Completes a medical exam and enters the findings on Form 183A. If the customer was referred by Form 1864, keeps the first copy of Form 1864 for the provider's records.
- (Provider) Returns the completed Form 183A to the sending office. If ccustomer was referred by Form 1864, also returns the original Form 1864 and completed Health Insurance Claims Form (Form 2360).
- (FCRC) When the medical information is received, complete Invoice Voucher (Form C-13) to pay the provider (see step 15).
- (FCRC) When the medical information is received, check SOLQ.
- If SSA has determined the client disabled, a CAU decision is not needed. Take appropriate case action.
- (FCRC) If there has not been a favorable SSA decision, complete Client Assessment Unit (CAU) Memorandum (Form 183F) requesting the appropriate TANF determination.
- (FCRC) Prepare a packet with Form 183F, Form(s) 183A and related medical records, Form 183B, Form(s) 4701H, and all medical information from previous CAU determinations. Mail the original packet to:
Client Assessment Unit
PO Box 19492
Springfield, IL 62794-9492
If a decision is urgently needed, call CAU at (217) 524-8190 for permission to fax the packet.
- (CAU) Completes Form 183C showing:
- the decision regarding the applicant's medical barrier or a request for more information, and
- if approved, a medical review date, when needed.
- (CAU) Returns the entire packet with Form 183C to the FCRC.
- (FCRC) When CAU requests more information, attempt to obtain it. Set up additional appointments or request test results, as needed. Resubmit the entire packet to CAU with the additional information. (See steps 2 - 8.)
- If the customer does not provide the required additional information, do not resubmit the packet to CAU. Consider the person able to work; deny the request for a medical barrier. Meet with the customer to revise the TANF Responsibility and Services Plan. No additional action is needed.
- (FCRC) Take action based on CAU's decision(s).
- If CAU determined that the customer should apply for SSI and has not already done so, refer the customer to SSA to apply for SSI as a condition of continued cash eligibility (see PM 01-02-03). Refer customers who need assistance with an SSI application or appeal to legal assistance for advocacy.
- (FCRC) Send the customer Form 2827 to notify them of the decision on the medical barrier.
- If CAU determined a temporary or chronic medical barrier exists, code Form 552 as follows: Item 1- For 06 cases, change the category number to 04. Item 60 - If the medical condition is due to pregnancy, enter the EDD (expected delivery date). Item 73 - Enter code 2 for the person. Item 80 - Enter code 156 DRD, with the review month and year under PERSONS and code 1 (chronic condition) or 2 (temporary condition, complications in early pregnancy) under SUP. BY.
- If CAU denied the temporary or chronic medical barrier, determine if the customer has another barrier to participation. If no other barrier exists, delete Item 80 Code 156 and engage the customer in appropriate work and training activities. Unless the customer appeals CAU's determination, or there is additional medical information included, do not resubmit the same packet to CAU.
- (FCRC) When Form 1864 and/or Form 2360 are received with Form 183A or copies of medical records, complete Invoice-Voucher (Form C-13). Enter the customer's name, case number, and a statement saying why the exam or records were needed, e.g., TANF medical barrier, etc. Leave the payment amount and signature areas blank.
- (FCRC) Attach Form 1864 and/or Form 2360 to the Form C-13 and send to:
Illinois Department of Healthcare and Family Services
Bureau of Claims Processing - Pricing Unit
PO Box 19106
Springfield, IL 62794-9106
- (HFS) Handles pricing and payment to the provider.
- (FCRC) File the entire CAU packet and a copy of Form 2827 in the case record to verify the decision.
- (FCRC) SWAP assistance to Medical if the customer fails to apply for SSI after CAU recommends it.
- (FCRC) If the customer applies for SSI after CAU recommends it, update the customer's RSP to include cooperation with the SSI disability determination.
- (FCRC) Monitors the customer's cooperation with SSI.
- (FCRC) Impose a sanction if the customer fails without good cause to cooperate with the SSI disability determination.
Review of Medical Barrier
Review the customer's medical condition when indicated by Item 80 code 156 DRD. Follow the same instructions as for establishing a medical barrier. When submitting the current medical evaluation forms, attach all previous CAU packets (including Forms 183A, 183B, 183C, and related medical information) that relate to the medical condition.
If CAU decides the customer continues to have a medical barrier to participation, update the review month and year under PERSONS in Item 80 code 156 DRD as indicated on Form 183C.
If CAU decides the customer no longer has a medical barrier, take the following action.
- Determine if the customer has another barrier to participation.
- Send the customer Form 2827 to advise them that they no longer have a medical barrier and that they are now required to participate, or are not required to participate for another reason.
- Update Form 552 by entering the correct Item 73 code for the customer and deleting Item 60 EDD or Item 80 code 156 DRD. If the customer is placed in a work and training activity, enter the activity coding in Item 60.
Appeal of CAU Determination
When CAU denies the barrier request, and the customer files a timely appeal, enter Item 80 Code 156 with SUP. BY code A on the 552. Enter the month and year the customer filed the appeal. The appeal is considered timely if filed within 60 days after the date of Form 2827.
See PM 01-07-00 for policy on Appeal Rights and Fair Hearings.
Conduct a pre-hearing meeting following the procedure for appealing a "Not Disabled" determination. See PM 01-07-07-b.
The case will select for Code X on the PAL four months after the date entered with message "REVIEW MEDICAL BARRIER STATUS. APPEAL", and will continue to appear each subsequent month until Code 156 is deleted, or updated with a new SUP. BY code. See WAG 19-06-01-l.
If the appeal affirms CAU's determination, engage the customer in work or training activities unless another barrier exists. Unless there is additional medical information included, do not resubmit the same packet to CAU.
Example 1: Mr. B's medical barrier was denied by CAU on 5/22/11. He files an appeal on 6/3/11. The worker enters Item 80 Code 156 with SUP. BY Code A and date 06/11. The case selects for Code X on the PAL every month beginning with the report for 10/11. The appeal is heard on 01/18/12 and the hearing officer finds in favor of Mr. B, with a review to take place in 3 months. The worker updates Item 80 Code 156 with SUP. BY Code 2 and enters 04/12 in the date to show the barrier was approved.
Example 2: CAU found Mrs. D not eligible for a medical barrier based on a Form 183A dated 3/1/11 from her physician. Mrs. D appealed the determination. The hearing officer upheld CAU's determination. When meeting with Mrs. D to engage her in a work activity, she continues to claim she cannot work due to the same condition. As the hearing officer's ruling is final, she is subject to sanction if she does not cooperate with the work activity. Do not resubmit the Form 183A dated 3/1/11 to CAU without additional information.