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12/14/12

Summary:

  • Effective 11/01/12, CountyCare is a new medical benefits program authorized under a federal waiver from the Centers for Medicare and Medicaid Services;
  • Three month retroactive coverage (backdate) will be available to applicants; however retroactive coverage cannot begin prior to 11/01/12;
  • Eligibility is limited to Cook County residents between ages 19-64;
  • Persons who qualify for CountyCare are not otherwise eligible for full medical benefits (except for Veterans Care which is maintained in a central office);
  • Medical services are provided by a network that includes Cook County Health and Hospitals System (CCHHS) providers and a designated group of CountyCare network partners;
  • A new Family Community Resource Center (FCRC) is created to process applications and maintain the active cases for persons receiving medical services through CountyCare;
  • CountyCare cases will be authorized through the Automated Intake System (AIS) as category 94;
  • Some references to General Assistance (GA) are removed with this release.  General Assistance ended 07/01/12.  A manual release removing the remaining references to GA is forthcoming; and
  • Some references to FamilyCare Share, Premium and Rebate for parents and caretaker relatives are removed with this release.  FamilyCare for parents caretaker relatives with income greater than 133% of the federal poverty level (FPL) ended 07/01/12. These parents may still qualify for Family Health Spenddown.  A manual release removing the remaining references is forthcoming.

  1. Stroger FCRC: Office 197
  2. Responsibility of FCRCs
  3. Eligibility for CountyCare
    1. Who to Include in the Standard
    2. Nonfinancial Eligibility
      1. Screening Tool
    3. Choice Between Other Medical Programs and CountyCare
    4. Financial Eligibility
  4. Applications for CountyCare
    1. Role of CCHHS Application Assistors
    2. Processing Applications
      1. Approvals
      2. Denials
      3. Retroactive Coverage (Medical Backdate)
  5. Case Maintenance
    1. Changes
      1. Becomes Eligible for Regular Medical Under Family Health Plans
        1. Pregnancy
        2. Dependent Child Moves In
      2. Becomes Eligible for Regular Medical Under AABD
        1. Disability or Blindness
        2. Reaches Age 65
      3. Potentially Eligible for CountyCare when Regular Medical Ends
    2. Deletions
    3. Auto-Enrollment in Illinois Healthy Women
  6. Systems
    1. Automated Intake System
    2. Automated Case Management (ACM) System
    3. New Item 25 Coding
    4. New Item 28 Coding
    5. Item 53 County of Residence
    6. Item 80 Code 668 Office of Choice
    7. Form HFS 469 Medical Card
      1. Type Action Reasons
  7. Delivery of Services & Medical Benefit Package
    1. Delivery of Services
    2. Covered Services
    3. Non-emergency Transportation
    4. Noncovered Services
  8. Appeals
  9. Policy References to GA
  10. Policy References to FamilyCare Share/Premium and Rebate
  11. Manual Pages
  12. Forms referenced:

In response to P.A. 97-687, Illinois will offer medical benefits to Cook County residents who would not otherwise qualify.  This expansion is permitted through a federal waiver pursuant to section 1115 of the Social Security Act. Federal financial participation is available to Illinois for this new population.

Effective 11/01/12, persons may qualify for CountyCare if they do not qualify for one of the existing medical programs listed below: 

  • Family Health Plans
    • Family Assist;
    • All Kids;
    • FamilyCare;
    • Moms & Babies;
    • Medicaid Presumptive Eligibility (MPE);
  • Temporary Assistance for Needy Families (TANF);
  • Aid to the Aged, Blind or Disabled (AABD) at or below 100% of the FPL for those who are resource eligible (non-spenddown AABD cases);
    • Note: Persons with AABD resource spenddown and persons with AABD income spenddown at or below 133% of the FPL may choose CountyCare instead of spenddown;
  • Breast & Cervical Cancer (BCC);
  • Health Benefits for Workers with Disabilities (HBWD);
  • Medicare Savings Programs:  QMB, SLIB or QI-1; or
  • Refugee & Repatriate Assistance (RRA). 

Persons receiving Medicare are not eligible for CountyCare.

Persons receiving Veterans Care or medical benefits with a spenddown may qualify for CountyCare, if they are Cook County residents.  They must meet the other eligibility criteria for CountyCare to qualify.

Persons receiving Illinois Healthy Women may continue to receive services concurrently with CountyCare.

Individuals who were eligible for GA in Chicago before the program ended 07/01/12, are likely to be eligible for CountyCare.

Stroger FCRC: Office 197 

The new Stroger FCRC office (197) is responsible for processing the CountyCare applications as well as regular medical applications from CCHHS. If eligible, Stroger FCRC will approve the regular medical application (for FHP or AABD) and transfer the case to the appropriate FCRC. Stroger FCRC will maintain the CountyCare cases.

Stroger Family Community Resource Center is located at:

600 S. Hoyne St.

Chicago, IL 60612

Phone:  312-433-3300

Nextalk: 866-214-8309

Fax: 312-433-3348

Note: Stroger FCRC will not take applications for Supplemental Nutrition Assistance Program (SNAP) or cash assistance.

Stroger FCRC will not be available to clients as an option through No Wrong Door PM 18-07-00. The application process for CountyCare is described later in this release.

Responsibility of FCRCs

When staff in the FCRCs speak to a Cook County resident by phone or in person regarding their ineligibility for regular medical benefits, tell them about CountyCare. Use the screening tool in the next section to determine if a referral to CountyCare is appropriate.

Eligibility for CountyCare

CountyCare is authorized on a category 94 case using system edits that apply to Family Health Plans cases. Up to two persons may be active on a CountyCare case: the applicant and their spouse.

If there are questions regarding eligibility, contact HFS Medical Policy at 217-557-7158.

Who to Include in the Standard

Include in the income standard the applicant and, if living together, the applicant's spouse. An adult son or daughter may not be included in their parent's CountyCare standard. Set up a separate case.

Nonfinancial Eligibility

Each eligible person must meet the nonfinancial factors of eligibility listed below:

  • Does not qualify for full medical benefits* including met spenddown;
  • Age 19-64;
  • Lives in Cook County;
  • Is not enrolled in Medicare;
  • Is a U.S. citizen or meets immigration requirements listed in PM 03-01-01; and
  • Has a valid Social Security Number (SSN) or provides proof of application for an SSN.

*Illinois Healthy Women and spenddown are not considered full medical benefits.

Verify nonfinancial factors of eligibility per PM 02-07-03.

Screening Tool

If the information is not already known, ask the person the following questions: 

Screening Tool for CountyCare Eligibility No Yes
1 Are you between age 19-64? Not eligible for CountyCare; potentially eligible for All Kids or AABD Go to question 2
2 Are you living with and raising children under age 19 who are related to you? Go to question 3 Go to question 2a
2a Are you the parent of the child? Go to question 2b Not eligible for CountyCare; potentially eligible for FamilyCare
2b Do the child's parent(s) live in the household also? Not eligible for CountyCare; potentially eligible for FamilyCare Go to question 3
3 Are you pregnant? Go to question 4 Not eligible for  CountyCare; potentially eligible for Moms & Babies
4 Are you blind or receiving SSI, SSDI or Medicare or have you been determined disabled? Go to question 5 Not eligible for  CountyCare; potentially eligible for AABD
5 Do you have an illness or disabling condition that might prevent you from working for more than 12 months? Refer to CountyCare Refer to CountyCare.  Person is potentially eligible for benefits from Social Security Administration.

If appropriate, encourage Cook County residents to apply for CountyCare and give them the phone number 1-312-864-8200 or toll free, 1-855-671-8883.

Choice Between Other Medical Programs and CountyCare

Cook County residents enrolled in the medical programs below may choose CountyCare if they qualify. These programs are:

  • Spenddown;
  • Illinois Healthy Women; and
  • Veterans Care.

Persons may choose between CountyCare or AABD spenddown if income is at or below 133% of the FPL. Persons who have a resource spenddown may also qualify for CountyCare. The person may have only one active case.

Dual coverage in MMIS may appear for women receiving Illinois Healthy Women and CountyCare.  Family planning claims will be paid under CountyCare.

To help clients make an informed choice, refer the Veterans Care or spenddown client to CCHHS at 1-855-671-8883. CCHHS will explain the benefit package to the client to help them decide if CountyCare is a better option for medical benefits.

Coordinate the closing of the Veterans Care or spenddown case with the opening of the CountyCare case to ensure there are no gaps in coverage. Staff at the Veteran's Care unit can be reached by calling the Health Benefits and All Kids Hotline at 1-800-226-0768.

Financial Eligibility

To qualify for CountyCare, the household income must be at or below 133% of the FPL. Note: There is no spenddown available for persons in CountyCare.

Resources (assets) are not considered for CountyCare.

Determine nonexempt monthly income and financial eligibility using Family Health Plans policy listed in PM 08-01-00 and PM 15-05-02Note:  Proof of a full 30 days' worth of earned and unearned income is required for CountyCare.

To determine countable monthly income for CountyCare, as with Family Health Plans, deduct the following items, in the order listed, from the unit's nonexempt monthly income:

  • allowable business expenses for self-employed persons (see PM 15-04-02-b);
  • $90 employment deduction for each employed person;
  • earned income exemption (see PM 15-04-02-c for the appropriate amount);
  • spousal or child support that was paid to someone not in the unit (see PM 15-04-02-f). 

A spouse is financially responsible for another spouse whether or not they are living together per PM 09-02-00.

Persons eligible for CountyCare are not eligible for medical extensions under Family Assist (FA). 

Applications for CountyCare

Persons interested in applying for CountyCare must call CCHHS at 1-312-864-8200 or toll free, 1-855-671-8883. Applications may be taken by phone or in person.

Role of CCHHS Application Assistors

CCHHS application assistors will screen applicants in person or over the phone to determine whether they are potentially eligible for CountyCare or regular medical benefits (FHP or AABD).

  • If the screening results in potential eligibility for CountyCare, the application assistor will submit a Web Benefits application to Stroger FCRC for processing.
  • If the screening results in potential eligibility for regular medical benefits, CCHHS will submit Form 2378H or 2378KC to Stroger FCRC for processing.
  • When a CountyCare applicant lives with a household member who requests regular medical benefits, CCHHS will submit an application form 2378H or 2378KC to Stroger FCRC for processing. 

Because the Stroger FCRC does not handle cash or SNAP assistance cases, CCHHS will refer applicants requesting cash and/or SNAP assistance to a full service FCRC.

CCHHS will send the application signature page and verifications electronically to the Stroger FCRC.

If the CountyCare applicant has an active unmet AABD spenddown case or a Veterans Care case, Stroger FCRC staff contacts the FCRC or Veterans Care office that has the active case to coordinate the closing of the case with the approval of the CountyCare case.

Example 1: Mr. D, age 43, requests CountyCare for himself and AABD for his wife who receives SSI.  CCHHS submits a CountyCare application for Mr. D using the Web Benefits application system and assists Mrs. D with an application for AABD using Form 2378H.  Stroger FCRC processes both applications. Upon approval, Stroger FCRC keeps the CountyCare case and transfers the AABD case to the appropriate FCRC.

Example 2:  Mrs. E, age 63, requests CountyCare for herself and her husband who is age 66.  CCHHS submits a CountyCare for Mrs. E and assists Mr. E with an application for AABD on Form 2378H.  Stroger FCRC processes both applications. Upon approval, Stroger FCRC keeps the CountyCare case and transfers the AABD case to the appropriate FCRC.

Example 3: Mr. F, age 38, requests CountyCare for himself.  CCHHS submits the electronic application for CountyCare. Stroger FCRC discovers Mr. F is not eligible for CountyCare because he was approved by the Social Security Administration last week for SSDI, and his income is at or below 100% of the FPL.  Deny the CountyCare application (no notice is sent). Re-register the application for AABD using the original application date and process as appropriate.

Example 4: Ms. G's income is less than 133% of the FPL; however, she has an active AABD spenddown case in unmet status.  Ms. G requests CountyCare for herself.  CCHHS submits the electronic application for CountyCare.  Stroger FCRC finds the active unmet spenddown case is located in the Roseland FCRC in Cook County.  Stroger FCRC staff contact Roseland FCRC to coordinate the closing of the unmet spenddown case per client request, then approves the CountyCare case.

Example 5: Mr. H, age 46 received RRA medical coverage until 2 months ago when he reached his 8 month limit.  He lives alone and requests CountyCare.  CCHHS submits a CountyCare application for Mr. H.  Stroger FCRC processes the CountyCare application and keeps the case for on going maintenance.

Processing Applications

Medical coverage may not start prior to November 1, 2012.   

Approvals

Use type action reason (TAR) 81 to approve a CountyCare case.

Enter code 80 in Item 39 to suppress the central notice when approving a CountyCare case.  CCHHS will send the approval notice for each case approved.  CCHHS will also send a welcome packet and member ID card to each person approved for CountyCare.  A facsimile of the notice will be linked to this release at a later date.

No medical card (form HFS 469) is generated on a CountyCare case. 

The approval notice serves as evidence of the person's date of approval, Recipient Identification Number (RIN) and date of birth.  A note to CCHHS providers is included on the notice instructing them to contact MEDI to confirm eligibility when services are provided.

Denials

A Form 360C, Notice of Decision, is generated centrally for denials.  Refer to the list of new Type Action Reasons and the denial messages appearing later in this release.  For other denial reasons, refer to WAG 27-03-01-q.

Retroactive Coverage (Medical Backdate)

If requested, eligible persons may receive retroactive medical coverage beginning three months prior to the month of application per PM 17-02-05-a.  Because the start date of the CountyCare program is 11/01/12, retroactive coverage is not available prior to that date.

Case Maintenance

A person becomes ineligible for CountyCare in the following circumstances:

  • Reaches age 65;
  • Is enrolled in Medicare;
  • Has a dependent child move in with him or her;
  • Becomes pregnant;
  • Receives Social Security Disability Income (SSDI) or Supplemental Security Income (SSI) and qualifies for AABD without a spenddown;
  • Has income that exceeds 133% of the FPL;
  • Not living in Cook County; or
  • No longer meets eligibility criteria. 

Policy on annual redeterminations will be issued at a later date.  However, if all factors of eligibility are reviewed, report that a medical REDE was completed.

There is no spenddown available for persons in CountyCare.

Active cases in Office 197 will appear on program integrity reports including the Priority Action List and various crossmatch reports.  Follow up is required per PM 19-06-00.

Changes

When a person becomes ineligible for CountyCare, determine eligibility for all other medical programs before canceling the CountyCare case per PM 18-05-00.  If the person fails to cooperate in establishing eligibility for another program, cancel the CountyCare case using the TAR that describes the reason for noncooperation.

Becomes Eligible for Regular Medical Under Family Health Plans

When a person active in CountyCare becomes potentially eligible for Family Health Plans, re-verify income.  Do not require a new application.

Pregnancy

When a person active in CountyCare is pregnant, obtain proof of pregnancy.  Update the case by removing the new code W in Item 25.  See Systems for information regarding new codes. Update Item 28 and add the Estimated Date of Delivery to Item 60. 

Dependent Child Moves In

A person active in CountyCare may qualify for FamilyCare as a parent or caretaker relative based on raising a dependent child when the child moves in. Obtain a Form 243C Request for Medical Benefits for Another Family Member and the appropriate verification. Update the case by removing the new code W in Item 25. Update Item 28 and add the dependent child.

Becomes Eligible for Regular Medical Under AABD

When a person active in CountyCare becomes potentially eligible for AABD, re-verify income and verify resources per PM 07-02.  Do not require a new application.

Disability or Blindness

When a person active in CountyCare begins receiving SSDI or SSI, review financial eligibility for AABD. If eligible for non-spenddown AABD, cancel the CountyCare case using a new TAR G6.  TAR G6 does not generate a central notice.  Open an AABD category 93 case.

Reaches Age 65

When a person in CountyCare reaches age 65, review financial eligibility for AABD. If eligible for non-spenddown AABD, cancel the CountyCare case using a new TAR G6.  TAR G6 does not generate a central notice. Open an AABD category 91 case.

Potentially Eligible for CountyCare when Regular Medical Ends

When a Cook County resident who receives regular medical benefits under AABD, RRA or Family Health Plans becomes ineligible, they may qualify for CountyCare. If speaking to a client regarding their ineligibility for medical benefits, tell them about CountyCare.  Use the screening tool to determine if they are potentially eligible for CountyCare.

Deletions

When a spouse moves out of the home of an active CountyCare case, determine if the spouse is eligible for their own CountyCare case.  If the spouse is eligible for his/her own case, delete the spouse using TAR 43 and set up a separate CountyCare case.

If the spouse's whereabouts are unknown, delete using TAR 07 (no longer living in the household).

If the spouse is a woman who no longer lives in Illinois, contact HFS medical policy for guidance 217-557-7158.  A special procedure is required to prevent the auto enrollment of the woman in Illinois Healthy Women.

Auto-Enrollment in Illinois Healthy Women

Women who are canceled from CountyCare will be auto-enrolled in Illinois Healthy Women unless they move out of state.

Systems

Each case will contain no more than two household members: an adult and the adult's spouse.

Medical benefits will be authorized via IPACS using category 94 and a new central office number 197. 

SNAP or cash benefits are not valid for a 197 case.

Persons eligible for CountyCare are not eligible for medical extensions under Family Assist. 

Use AIS to dispose of pending applications and ACM or IPACS for case maintenance functions. 

Automated Intake System

For office 197 only, option 8 includes a new question on the Case Cooperation Screen:

Is this a Cook County waiver application? (Y/N):

Answer Y to authorize a CountyCare case.  Answer N to authorize a Family Health Plans case.  There are system edits in place for CountyCare cases that will permit one or two single adults to be approved when no children are in the household.

Automated Case Management (ACM) System

Eligibility may be calculated using ACM.  When income exceeds 133% of the FPL, ACM will display the following message:  CANCEL CASE.  INCOME EXCEEDS STANDARD.

Print the calculation screen for the case and return to the Additional Entry Screen and process the transaction as a cancelation.

New Item 25 Coding

Item 25 code W designates the 197 case as a CountyCare case.  To change a case from CountyCare to a Family Health Plans case, delete Item 25 code W.  Code W is only valid on category cases active in office 197. 

New Item 28 Coding

New Item 28 code W indicates a category 94 case containing persons eligible under the CountyCare. Code W is only valid on category cases active in office 197.

Item 53 County of Residence

Use code 200 for County of Residence.

Item 80 Code 668 Office of Choice

Use code 197 in Item 80 code 668 for CountyCare cases.

Form HFS 469 Medical Card

Medical cards (Form HFS 469) will not be issued to persons approved for CountyCare.  Persons approved may show their approval notice to CountyCare network providers.  CountyCare network providers will verify on going eligibility electronically.  CCHHS will issue their own medical identification card to persons approved for CountyCare.

Type Action Reasons 

Denial TARs Reason Message
G6 Person is categorically eligible for AABD or Family Health Plans No notice is sent.
G7 Income exceeds the standard.

"Your income is above the limit for medical benefits. PM 06-26"

"Sus ingresos sobrepasan el límite para beneficios médicos. PM 06-26"

G8 Person does not live in Cook County.

"You are not living in Cook County. Enrollment in CountyCare is limited to persons living in Cook County. PM 06-26"

"Usted no vive en el Condado de Cook. Inscribirse en CountyCare está limitado a las personas que viven en el Condado de Cook. PM 06-26"

Cancelation TARs Reason Message
G6 Person is categorically eligible to receive medical under a different program. No notice is sent.
G7 Income exceeds standard.

"Your income is above the limit for medical benefits. PM 06-26"

"Sus ingresos sobrepasan el límite para beneficios médicos. PM 06-26"

G8 Person does not live in Cook County.

"You are not living in Cook County. Enrollment in CountyCare is limited to persons living in Cook County. PM 06-26"

"Usted no vive en el Condado de Cook. Inscribirse en CountyCare está limitado a las personas que viven en el Condado de Cook. PM 06-26"

Deletion TARs Reason Message
G6 Person is categorically eligible to receive medical under a different program. No notice is sent.
G8 Person does not live in Cook County.

"X_________X is not living in Cook County. Enrollment in CountyCare is limited to persons living in Cook County. PM 06-25"

"X_________X no vive en el Condado de Cook. Inscribirse en CountyCare está limitado a las personas que viven en el Condado de Cook. PM 06-25"

Delivery of Services & Medical Benefit Package

Delivery of Services 

Eligible persons must receive their medical care through the CountyCare network. Services provided out of network must have prior approval from CCHHS or be for emergency services.  CountyCare clients and providers can call the CountyCare phone number 1-312-864-8200 or toll free, 1-855-671-8883 for assistance regarding prior approval and emergency services.

Covered Services 

Persons who qualify for CountyCare will receive a comprehensive medical benefit package that includes the services listed below.  Some of these services are subject to limits or will require prior authorization from CCHHS.

  • Inpatient hospital services;
  • Outpatient hospital services;
  • Emergency room;
  • Prescription drugs;
  • Physician;
  • Clinic services;
  • Lab and X-ray;
  • Family planning;
  • Hospice;
  • Transportation;
  • Medical supplies, equipment, prostheses;
  • Nurse or other practitioner;
  • Mental health services;
  • Subacute alcohol and substance abuse treatment;
  • Dental (limited to Early Periodic Screening Diagnosis and Treatment-EPSDT for persons age 19-20)
  • Therapy and rehabilitation;
  • Advanced Practice Nurse;
  • Nursing facility (limited); and
  • Case management.

Non-emergency Transportation

Non-emergency transportation is only available through the CCHHS network.  Do not refer clients to First Transit. CountyCare clients and providers can call the CountyCare phone number 1-312-864-8200 or toll free 1-855-671-8883 for assistance with transportation services.

Noncovered Services

Noncovered services include the following.

  • Renal dialysis;
  • Midwife;
  • Personal care;
  • Private duty nurse;
  • Dental (unless EPSDT);
  • Optometry; and
  • Out of network services in a non-emergency without CountyCare prior approval

Funeral and burial services are not available to persons in CountyCare.

Appeals

Clients applying for or receiving CountyCare have the same appeal rights as described in PM 01-07-00.

Policy References to GA

This release removes some of the references to GA that appear in the Policy Manual and Worker's Action Guide (WAG) pages. GA ended 07/01/12 with the enactment of the Saving Medicaid Access and Resources Together (SMART) Act. A manual release to remove the remaining references to GA is forthcoming.

Policy References to FamilyCare Share/Premium and Rebate

This release removes some of the references to FamilyCare Share, Premium and Rebate for parents and caretaker relatives that appear in the PM and WAG pages. FamilyCare for parents and caretaker relatives with income above 133% of the FPL ended 07/01/12 with the enactment of the SMART Act. These parents may still qualify for Family Health Spenddown. A manual release to remove the remaining references to FamilyCare is forthcoming.

Manual Pages

PM I-01-02

PM I-03-00

PM 03-02-01

PM 04-04-00 

PM 04-04-01 (deleted)

PM 04-04-02 (deleted)

PM 04-04-02-a (deleted)

PM 04-04-03 (deleted)

PM 06-25-00

PM 06-25-01

PM 06-25-02

PM 06-25-03

PM 06-25-03-a

PM 06-25-04

PM 08-01-00

PM 15-05-02

PM 22-06-01

WAG 03-02-01

WAG 04-04-00 (deleted)

WAG 04-04-01 (deleted)

WAG 04-04-02 (deleted)

WAG 04-04-02-a (deleted)

WAG 04-04-03 (deleted)

WAG 06-25-00

WAG 06-25-01

WAG 06-25-02

WAG 06-25-03

WAG 06-25-03-a

WAG 06-25-04

WAG 08-01-00

WAG 25-02-04

WAG 25-05-03 

[signed copy on file]

Michelle R.B. Saddler

Secretary, Illinois Department of Human Services

Julie Hamos

Director, Illinois Healthcare and Family Services

Forms referenced:

  • 243C
  • 360C
  • 1721
  • 2378H
  • 2378KC