- Effective January 1, 2014, Illinois expanded medical coverage to adults, age 19 through 64 years, under the new ACA Adult Program.
- Disability is not a factor of eligibility for the ACA Adult group.
- Spouses may be included on the same ACA Adult case.
- Modified Adjusted Gross Income (MAGI) budgeting is used when determining eligibility for the ACA Adult group.
- ACA Adults are eligible for medical backdating no earlier than January 2014.
- Emergency medical for non-citizens may be approved under the ACA Adult Program.
- Maximus will send redetermination forms to ACA Adults turning age 65 or ACA Adults who will begin receiving Medicare.
- Individuals enrolled in AABD Spenddown may choose ACA Adult, if eligible.
- New MANG P Code, G8, identifies ACA Adult.
- Swapping a case to FHP or ACA Adult must be done in the IPACS.
- Resources must be verified when changing case from the ACA Adult to the Aid to Aged, Blind and Disabled (AABD). A new link card must be issued if the person is receiving SNAP benefits under a new category.
- Add the remaining SNAP approval period when opening a new case as a result of changing client from one program to another.
- There are new system codes specifically for ACA Adult cases.
- HFS 3704, Important News You Can Get Help to Buy Health Insurance, is mailed with the denial or cancellation notices.
- Funeral and burial is not a covered service for ACA Adults.
- Long term care supports and services (LTSS) includes nursing home, Supportive Living Program (SLP) and Community Care Program (CCP) services.
- Supportive Living Facility (SLF) is now Supported Living Program (SLP).
- Individuals eligible under the ACA Adult program may receive LTSS.
- Transfer of resource policy applies to ACA Adults in LTC.
- HFS 3654, Additional Financial Information for Long Term Care Applicants, must be completed for persons requesting LTC.
- The New ACA Adult Group
- MAGI Budgeting
- Medical Backdating
- Resources (Assets)
- No Disability Determination Required
- Emergency Medical for Ineligible Non-Citizens
- Long Term Care Services and Supports
- Treatment of resources (assets) for persons enrolled in ACA Adult when requesting LTSS
- Funeral and Burial
- Acting on Reported Changes
- Change Case from ACA Adult to FHP
- Change Case from FHP to ACA Adult
- Change Case from ACA Adult to AABD
- Change Case from AABD to ACA Adult
- SNAP Benefits
- Persons No Longer Eligible for FHP
- System Changes
- Marketplace Referral
- Forms Referenced
The New ACA Adult Group
Effective January 1, 2014, the Affordable Care Act (ACA) establishes a new federal eligibility group for medical coverage for adults. Public Act 98-0104 authorizes Illinois to provide medical coverage under this new group. Adults may qualify, if they meet the following criteria:
- age 19 through 64;
- Illinois resident (PM 03-02-00);
- meet Social Security number requirement (PM 03-11-00);
- meet U.S. citizenship or immigration requirements (PM 03-01-00);
- do not qualify for Family Health Plans;
- do not qualify for Former Foster Care;
- are not eligible for Medicare; and
- income is at or below 138% (133% + 5% disregard) of the federal poverty level (FPL). ACA Adult cases are not eligible to be enrolled in spenddown.
Modified Adjusted Income (MAGI) budgeting is used when determining eligibility for the ACA Adult group. Refer to policy memo, Modified Adjusted Gross Income (MAGI) Budgeting for Medical, dated 09/26/13.
Retroactive medical coverage is available per PM 17-02-05 for ACA Adult when a customer requests medical benefits. Medical backdating may begin no earlier than 01/01/14. When a customer requests medical backdating prior to 01/01/14, customer must be determined eligible for AABD, FHP or CountyCare.
Follow income verification policy described in the policy memo, Verifications for Medical Programs, dated 10/02/13. When authorizing medical backdating beginning 01/2014, only request additional verification for backdate months when reported income for those months is different than current monthly income, and the difference affects eligibility.
Resources (assets) are exempt for the ACA Adult.
When an ACA Adult becomes potentially eligible for AABD resources must be verified when determining AABD eligibility.
No Disability Determination Required
Having a disability is not a factor of eligibility for ACA Adult Program. Do not complete a Client Assessment Unit (CAU) determination for persons who are eligible for ACA Adult. Applicants who are eligible for both AABD Community and ACA Adult should be enrolled in ACA Adult.
Persons who are currently enrolled in AABD Spenddown may be eligible for ACA Adult if:
- income is at or below 138% of the FPL; and
- they are not enrolled in Medicare; and
- they are under the age of 65.
Emergency Medical for Ineligible Non-Citizens
Emergency medical for persons who do not meet the citizenship/immigration requirement may be approved under the ACA Adult Program, if all other factors of eligibility are met. Persons who meet all eligibility criteria for the ACA Adult program, except for citizen/immigration criteria, can receive emergency medical services for the period of the emergent need. Refer to PM 06-05-00.
Note: Although individuals must meet citizen/immigration criteria for 'regular' eligibility under the ACA Adult program, the Affordable Care Act did not change the existing rules regarding the Emergency Medical for Non-citizens program.
Long Term Care Services and Supports
Individuals eligible under the ACA Adult program can receive nursing home care or other long term care supports and services (LTSS), if needed. ACA adults who need LTSS must meet the screening requirements in PM 20-08-04. ACA Adults are eligible for the Supportive Living Program (SLP) and Department on Aging Community Care Program (CCP). A disability determination is not required for an ACA Adult to qualify for LTC services and supports.
Note: Supportive Living Facility (SLF) is now Supportive Living Program (SLP).
Although persons receiving LTC under the AABD Program are required to pay towards the cost of their nursing home care, ACA Adults are not required to pay for the cost of their care when residing in a LTC facility. Do not complete a post-eligibility determination of eligibility for ACA Adults. SLP residents must pay the facility for their room and board.
Persons receiving LTSS under ACA Adult are not allowed to divert income to their spouse or children who live in the community. Use the ACA Adult income standard for 1 person to determine eligibility for LTSS.
Treatment of resources (assets) for persons enrolled in ACA Adult when requesting LTSS
ACA Adults do not have to provide information about current resources for medical eligibility. ACA Adults must complete HFS 3654, Additional Information for Long Term Care Applicants, to be eligible for LTSS which are nursing home, SLP and CCP services. Caseworkers must review HFS 3654 to determine if an unallowable transfer has occurred in the 60 months prior to the application for LTSS. Refer to LTC-ADI, as appropriate. Refer to PM 07-02-20. For unallowable transfers, apply the penalty the same as for AABD LTC. Transfer to an annuity or a trust is considered as a transfer of assets. Refer to PM 07-02-20-b. Failure to submit the completed form will result in a denial for LTC services. Review WAG 07-02-20 .
Do not file a lien or estate claim on ACA adults who are applying for LTSS.
Funeral and Burial
Funeral and burial is not a covered service under the ACA Adult Group.
Acting on Reported Changes
Review eligibility for FHP or AABD when a client reports one of the following:
- a newborn is reported;
- children move into the home;
- the person turns age 65; or
- the person begins receiving Medicare.
Note: For pregnant women, the ACA Adult case may remain active until the birth of the newborn.
Do not require a new application when customer reports a change. To add a spouse to an ACA Adult case the customer must complete Form 243C, Request for Medical Benefits for Another Family Member(s) . Take the following actions:
- ask tax status/relationship questions and verify income to determine eligibility under MAGI methodology.
- Process request if eligible; and
- complete a write-up in IES regarding the request.
Change Case from ACA Adult to FHP
Determine if the individual is eligible using MAGI budgeting. Refer to policy memo, Renewal Processing & MAGI Calculator, dated 03/21/14.
Only one transaction is required when changing an ACA Adult case to a FHP case. Process the case in IPACS.
- Enter TA 34 Item 3
- Process an action to add a child. Refer to WAG 06-09-06a.
- Enter a dash (-) in Item 28 (removing the "W")
- Enter a dash (-) in Item 25 (removing the "K")
No notice is sent. A new application is not required.
For FHPs, if no change in income is reported use the income currently reported. If a change in income is reported enter the case in IES as if it were a new application and run eligibility. Send Form 1721, if additional information is needed.
Example: An ACA Adult request medical coverage for a child under age 18 who is now living with her/him.
Change Case from FHP to ACA Adult
- Enter TA 34 in Item 3
- Process the deletion. Refer to WAG 18-03-11-d.
- Item 28 enter "W"
- Item 25 enter "K".
Actions can only be processed in IPACS.
Example: A FHP case containing only an adult only can be changed to ACA Adult if eligibility under FHP no longer exists.
Change Case from ACA Adult to AABD
As part of the Illinois Medicaid Redetermination Project (IMPR), Maximus will send redetermination forms to ACA Adults turning age 65 or ACA Adults who will begin receiving Medicare. Consider the rede form to be an application for AABD. The review form must be signed to establish a new case. The central unit will review the returned rede form and determine eligibility for the new case. Refer to Policy Memo, Changes to the Illinois Medicaid Redetermination Project (IMRP) revised, dated 02/06/2014.
For AABD, use regular AABD budgeting. Request verification of resources for AABD. MAGI budgeting does not apply to AABD budgeting. Cancel the ACA Adult case using TAR G6 after the customer has been determined eligible for AABD. Staff must register the rede as a new application and approve if determined eligible.
Example: Individuals who begin receiving Medicare are no longer eligible for medical benefits as ACA Adults.
Change Case from AABD to ACA Adult
Individuals enrolled in AABD Spenddown, whose income is over 100% FPL but not more than 138% of the FPL, may be eligible for ACA Adult. If a person, enrolled in AABD Spenddown requests ACA Adult review eligibility. Take the following actions:
- Ask tax status/relationship questions and verify income to determine eligibility under MAGI methodology.
- Process ACA Adult determination in IES as a new application and complete a write-up in IES regarding the request to review for ACA Adult program.
- If a person is determined eligible for ACA Adult, stop and cancel AABD spenddown in IPAC before approving the ACA Adult case in IES. Suppress the notice.
- Approve ACA Adult in IES no earlier than effective January 2014.
Example: Mr. Smith is enrolled in the AABD Spenddown Program. His spenddown is $302 each month. Mr. Smith's income is below 138% of the FPL. Mr. Smith requested to be enrolled in the ACA Adult Program. A new application is not required. Follow the above steps to determine eligibility for ACA Adult.
When an ACA adult case with SNAP changes to an AABD case or an AABD case changes to an ACA Adult case, add the remainder of the SNAP approval period to the new case. Issue a new Link Card.
Persons No Longer Eligible for FHP
When a FHP case is canceled due to no eligible child in the home, review case for ACA Adult eligibility. This includes cases where the last eligible child turns age 18.
Refer to Policy Memo, Changes to the Illinois Medicaid Redetermination Project (IMRP) revised, dated 02/06/2014.
ACA Adult cases are assigned under category 94 (adult-only case) and item 25 is coded with a "K". Spouses may be included in the same ACA Adult case. Separate cases are established for unmarried adults who apply together such as a parent and an adult child who are in the same tax household.
ACA Adult cases are not eligible to be enrolled in spenddown. Type Action Reason (TAR) K4 may be used to deny or cancel an ACA Adult case when income exceeds 138% FPL. Use TAR K4 when income exceeds the standard with the following type action:
Denial (TA 05)
Approve and Cancel (TA 10); and
Cancellation (TA 22).
Form 360C or Form 157C is generated when TAR K4 is coded in Item 33 with the following message: You do not qualify for medical benefits because your income is over the limit. TAR "K4" will not send a SNAP notice.
New MANG P code, G8, identifies an ACA Adult.
Persons determined ineligible for medical are referred to the Health Insurance Marketplace for insurance. Form HFS 3704, Important News You Can Get Help to Buy Health Insurance, is mailed with the denial or cancellation notice. A special message will appear on Form 360C and Form 157 when TAR K4 is used telling the customer to refer to the enclosed marketplace flyer.
[signed copy on file]
Michelle R.B. Saddler
Secretary, Illinois Department of Human Services
Director, Illinois Department of HealthCare and Family Services