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02/13/13

Summary:

  • The Illinois Save Medicaid Access and Resources Together (SMART) Act (PA 97-0689) requires the state to use electronic data verification to aid in the timely redetermination of medical eligibility. The law also requires that Healthcare and Family Services (HFS) contract with an external vendor to enhance the integrity of redeterminations of medical eligibility.
  • Effective 01/02/13, the Illinois Medicaid Redetermination Project (IMRP) establishes new procedures for the external vendor and the HFS All Kids and Department of Human Services (DHS) Family Community Resource Center (FCRC) staff to assure accurate and timely completion of medical redeterminations.
  • HFS has contracted with Maximus to serve as the external vendor under IMRP. Maximus has subcontracted with Health Management Systems (HMS). Maximus and HMS provide the electronic cross-match information and operate the IntegriMatch System used for IMRP.
  • Only state caseworkers redetermine medical eligibility. However, based on the verifications it obtains, Maximus makes recommendations concerning whether a customer continues to be eligible for medical benefits.
  • Maximus posts information to the IntegriMatch System for use by state caseworkers in conducting redeterminations. This information includes verified data on customer's income, resources, Illinois residency and, if previously unverified, citizenship or immigration status with a recommendation concerning eligibility.
  • Maximus also posts images of documents it obtained to the IntegriMatch System where they are viewable by caseworkers. At a later date, imaged documents will also be loaded into Content Manager for use by caseworkers.
  • Caseworkers use the information posted by Maximus and other information available to them to redetermine on-going eligibility for medical assistance.
  • Until further notice, caseworkers must run ACID using SSN and name file clearances for all persons in the case before approving a medical-only case for continued eligibility. Take appropriate action if duplicate coverage is found.
  • Maximus contacts medical-only customers if the cross-matched data is insufficient to make a recommendation of continued eligibility. Maximus will use only state-approved notices and guidelines when contacting customers.
  • Maximus contacts medical-only customers if the cross-matched data is insufficient to make a recommendation of continued eligibility. Maximus will use only state-approved notices and guidelines when contacting customers.
  • Starting in April, 2013, SNAP/medical and cash cases will select for the IntegiMatch the month prior to the month the REDE is due. Maximus will post the electronic information to IntegriMatch for DHS caseworkers to use when processing REDEs.
  • For medical with SNAP or cash cases, Maximus will enter a recommendation concerning medical eligibility if a high probability that the case is no longer eligible is found through the initial cross-matches.
  • Maximus does not contact customers who receive cash, SNAP or QMB/SLIB/Q-1 only benefits.
  • Under the law, DHS/HFS staff must complete a redetermination and post the final results of their work to the IntegriMatch worker portal within 20 business days of the date Maximus entered the recommendation.
  • All cases, including those for whom eligibility continues unchanged, will now receive a notice upon completion of the redetermination.
  • Beginning December 2012, most centrally generated medical redetermination notices are no longer mailed to the customer by the state; Maximus will notify customers as necessary.
  • Redetermination procedures for Illinois Healthy Women, Veterans Care, Health Benefits for Workers with Disabilities, Health Benefits for Persons with Breast or Cervical Cancer and medical benefits for Asylum Applicants and Torture Victims remain the same.

The Illinois Save Medicaid Access and Resources Together (SMART) Act (PA 97-0689) requires the state to use electronic data verification to aid in the timely redetermination of medical eligibility. The law also requires that HFS contract with an external vendor to enhance the integrity of redeterminations of medical eligibility. Effective 01/02/13, the Illinois Medicaid Redetermination Project (IMRP) establishes procedures for the external vendor and the HFS All Kids and DHS Family Community Resource Center (FCRC) staff to assure accurate and timely completion of medical redeterminations. Healthcare and Family Services (HFS) has contracted with Maximus to serve as the external vendor under IMRP. Maximus has subcontracted data cross matching and some system support to Health Management Systems (HMS). Maximus and HMS provide the electronic cross match information and operate the IntegriMatch System used for IMRP.

Maximus does not redetermine eligibility for any state program.

  1. Selection Process
  2. Data Verification Process
  3. Snap/Cash Cases Processing
  4. Recommendations
  5. Caseworker Response to Recommendations
  6. Caseworker Action when Redetermination Differs from Recommendation
  7. Paper Redetermination Forms
  8. New Forms

Selection Process

Electronic data cross-matches will be conducted for customers receiving medical benefits in the following programs:

  • Family Health Plans (FHP);
  • TANF and AABD cash;
  • Aid to the Aged, Blind and Disabled (AABD); and
  • Long Term Care (LTC).

Based on the cross-matches, medical cases with a higher likelihood of being ineligible will be selected for review by Maximus first, regardless of when the redetermination is due. Evidence of potentially ineligible cases includes the following:

  • high unreported income and resources,
  • primary residency in another state,
  • benefits received from another state,
  • case includes a child who turned 19 and is not otherwise eligible,
  • has an overdue expected due date (EDD), or
  • has an overdue rede for cash or medical.

Under IMRP, review of cases as they come due for annual redeterminations will be phased in.

Data Verification Process

Maximus reviews the case information currently reported on the Client Data Base (CDB) and completes an electronic data search based on certain identifying information. For medical-only cases, when electronic information is not available or information conflicts with reported information or the information is insufficient to make a recommendation, Maximus sends the customer an Information Request Form. In all communication with customers, Maximus will be identified as IMRP.

The customer has 10 business days to provide the requested verifications. If the customer provides the information within 10 business days, Maximus enters a recommendation based on program rules. Maximus will recommend cancellation if the customer fails to provide the requested verifications within 10 business days or if the customer provides information incompatible with continuing eligibility.

Income, resources, Illinois residency and, if not already verified, citizenship or immigration status are verified electronically whenever possible. Information obtained by Maximus is made available to DHS/HFS staff through the Web-based IntegriMatch System. Maximus makes recommendations concerning continued eligibility based on electronic verifications and any information provided by the customer.

Maximus enters a recommendation in the IntegriMatch System based on information such as:

  • income changes,
  • loss of employment,
  • new or change in employment,
  • additional unreported income,
  • loss of Illinois residency,
  • immigration status not verified,
  • whereabouts unknown,
  • excess countable resources identified, and
  • change in household composition.

Maximus also reports other key information discovered such as:

  • change of address,
  • verified social security number (SSN),
  • new Third Party Liability (TPL), and
  • other persons in the household (including step-parent's SSN).

For long term care cases, Maximus makes a preliminary calculation of the penalty period for non-allowable transfers.

All Kids Rebate cases will be reviewed by Maximus and will have a recommendation entered in IntegriMatch, but will also continue to receive the All Kids Rebate Redetermination Form.

Cases suspected of fraud may be referred by Maximus to the HFS Office of Inspector General (OIG) via the IntegriMatch System.

Snap/Cash Cases Processing

Starting in April, SNAP cases with medical and cash cases select for the IntegriMatch in the month prior to the month the rede is due so information is available when DHS staff is processing the REDE. The Maximus system will display results of electronic data matches and DHS caseworkers will use this information as well as other information provided by the customer to determine continued eligibility. Maximus will put a recommendation concerning on-going eligibility for medical in IntegriMatch only for cash or SNAP cases with medical that are determined to be high priority due to the likelihood of being in error. The recommendation will only be based on electronic data available. Per current policy, the FCRC may be required to request additional information from the customer to determine eligibility for those programs. Maximus will not send an Information Request Form to persons who receive cash, SNAP or QMB/SLIB/Q-1 only benefits.

Recommendations

Maximus makes one of the following recommendations for each medical-only case reviewed:

  • Continue Benefits
    • When available information supports continuation of medical coverage for the same program, Maximus recommends the case remain eligible for the current medical program.
  • Cancel Benefits
    • When the electronic information supports cancellation (for example, verified income is higher than the program standard), Maximus mails a Notice of Prospective Ineligibility to the customer requesting an explanation or different information. The customer has 10 business days to contact Maximus to provide requested information. If the customer fails to contact Maximus within 10 business days, Maximus recommends canceling the case with the appropriate reason.
  • Change Benefits
    • When the information supports the case being eligible for a different program or someone in the case is no longer eligible, Maximus recommends a program change.

Caseworker Response to Recommendations

All verifications, images of documents and notices used by IMRP are stored in the IntegriMatch System and are available for viewing by DHS/HFS staff.  At a later date, document images will also be available in Content Manager. Caseworkers also view the IMRP recommendation in the IntegriMatch System.

To conduct redeterminations, DHS/HFS staff reviews all case information available in the IntegriMatch System. Until further notice, caseworkers must run ACID using SSN and name file clearances for all persons in the case before approving a medical-only case for continued eligibility. Caseworkers take appropriate action if duplicate coverage is found. Caseworkers may initially need to run additional clearances if a required verification does not appear in IntegriMatch. DHS/HFS staff will continue to process redeterminations using ACM or IPACS.

DHS/HFS staff must report the disposition of each case in IntegriMatch within 20 business days after receiving the recommendation.

It is important that the caseworker actually consider the information available before acting on the case. Maximus does not change the recommendation once it is entered into the IntegriMatch System. It is particularly important to be alert for information that may have become available after Maximus made its recommendation. DHS/HFS caseworkers must document in the IntegriMatch System notes field any additional information sent in by the customer after the recommendation is entered in IntegriMatch.

DHS/HFS staff will continue to cancel cases, change program coverage, if appropriate, and send all cancellation or change notices. Maximus will send the Continuation Notice on medical cases that remain eligible with no changes. This notice will be sent after the DHS/HFS caseworker conducts the redetermination and enters "continuation" as the result in the IntegriMatch System.

Caseworker Action when Redetermination Differs from Recommendation

When the disposition resulting from the redetermination differs from the recommendation, the DHS/HFS caseworker must enter the reason for the difference in the IntegriMatch System and document the reason in the notes field. Caseworkers may copy and paste the 514 recording into the notes field in IntegriMatch to save time.

Caseworkers choose one of the following reasons in the IntegriMatch System to explain why the disposition differs from the recommendation:

  • additional income identified,
  • counted household members not included in the case,
  • did not include all countable assets,
  • did not include all household members in the case,
  • included income that should not have been counted,
  • included non-countable assets,
  • incorrect asset review and calculation for this case,
  • incorrect budgeting applied,
  • Post recommendation: Household Member Change - such as change in household members resulting from marriage, birth or death - after the recommendation was made.
  • post recommendation: Income Change - change occurred after the recommendation was made, 
  • post recommendation: Citizenship - citizenship, immigration or legal status was verified after the recommendation was made, 
  • post recommendation: Residency Proof - proof of residency provided after recommendation.

If the recommendation to cancel was due to failure to verify citizenship, follow

PM 03-01-01-b to determine whether customer showed a good faith effort. If good faith effort is established, do not cancel benefits.

Paper Redetermination Forms

The following cases do not receive a paper redetermination form in the mail.

  • All Kids Assist;
  • All Kids Share and Premium;
  • Family Health Plans; and
  • AABD

The following cases continue to receive a paper medical redetermination form:

  • Nursing Home;
  • Supported Living Facility;
  • All Kids Rebate;
  • Medical extension;
  • Health Benefits for Persons with Breast or Cervical Cancer (BCC);
  • Department of Children and Family Services (DCFS);
  • Health Benefits for Worker's with Disabilities (HBWD);
  • Illinois Healthy Women (IHW);
  • Veterans Care;
  • Asylum Applicants and Torture Victims;
  • Medicare Savings Program (QMB, SLIB, QI-1) only; and
  • Out-of-State Foster Care.

Maximus sends form HFS 1229A, Nursing Home/Supportive Living Facility Redetermination Report Form to customers residing in a nursing home or SLF. For the other cases that continue to receive a medical redetermination form, the current process will remain unchanged. In these cases, DHS will continue to send form IL 444-1721, Instructions to Recipient, to request necessary information from the customer.

New Forms

The following forms may be mailed to customers by Maximus:

  • Redetermination Notice (Cover Letter)

Notice is mailed to LTC/SLF customers along with Form 1229A.

  • Prospective Ineligibility Notice

Notice is sent when there is conflicting or insufficient information.

  • Information Request Notice

Additional information is needed.

  • Continuation Notice

Approve with no change.

  • Authorization Request (Cover Letter)

Request to share information.

  • Authorization to Share Information Form

This form must be completed and returned.

Customers will be instructed to mail completed forms and any requested verification to:

Illinois Medicaid Redetermination Project

PO Box 1242

Chicago, Illinois 60690-1242

If a customer contacts HFS or DHS regarding an IMRP notice, staff consults the IntegriMatch System to determine where the customer is in the IMRP process. If the 10 business day response period for the customer has not elapsed, the IntegriMatch System Status will show "Review in Progress", refer the customer to the Illinois Medicaid Redetermination Hotline at 1-855-458-4945 (TTY: 1-800-123-4567). The call is free. If HFS or DHS staff receives IMRP-related information during this period, fax the information to the Maximus IMRP unit at 1-855-394-8066.

If Maximus has already made a recommendation on a case, the caseworker must take the additional information into account when redetermining eligibility.

HFS and DHS staff will continue to send form IL 444-0157, Notice of Change, when required and continue to apply any policies related to reinstatement and appeal rights.


[signed copy on file]

Michelle R.B. Saddler

Secretary, Illinois Department of Human Services

Julie Hamos

Director, Illinois Department of Healthcare and Family Services