Send a Notice of Decision on Application for Medical Assistance (Form 458SP) for Community (AABD or Family Health Spenddown) cases approved with a spenddown. Form 458SP is computer generated for spenddown approvals processed through AIS. Enter code 80 or 92 in Item 39 on the correct AIS screen or on Form 552.
Send a Notice of Decision on Application for Medical Assistance - MANG Nursing Home/Supportive Living Facility (Form 458LTC) for approval of both regular and spenddown long term care cases. Enter code 80 in Item 39 on the correct AIS screen or on Form 552.
When the customer was a community case at application or for a backdated month(s), but before disposition became a long term care case, send Form 458LTC to notify the customer of the application disposition action and the change in case status.
Send a Nursing Home/Supportive Living Facility Calculation (Form 2500) with the approval notice, Form 458LTC.
For medical denials, complete and send Form 458LTC or a Notice of Decision on Application for Medical Assistance (Form 458) when central notification is not desired. Enter code 80 in Item 39.
For approved long term care cases, attach a copy of the completed Form 26 to the approval notice sent to the facility if a deposit was paid by the resident or someone on behalf of the resident. Add the following information to the approval notice.
Public Act 83-1530 requires long term care facilities to return deposits made by or on behalf of the resident within 30 days of the determination of eligibility. If the deposit is not returned within 30 days of the date of the approval notice, HFS will notify DPH.
Send a Notice of Decision on Application for Medicare Premiums, Deductibles and Coinsurance (Form 458M), to approve or deny QMB benefits when a Form 458 or Form 458SP is sent.
For children under age 18, send a copy of the notice of decision to the:
- FCRC serving the county of the child's current residence;
- parent or legal guardian;
- child; and
- required medical vendor(s).
When an application was made for a DCFS child who resides in a long term care facility:
- send the original of Form 458LTC to the customer's facility;
- file a copy in the case record.