MR #14.31: Reinstating Medical Cases Canceled at Redetermination

Helping Families. Supporting Communities. Empowering Individuals.

Illinois Department of Healthcare and Family ServicesIllinois Department of Human Services

11/24/14

Summary:

  • Public Act 98-0651 and the Affordable Care Act require the State to reinstate medical benefits that were canceled at redetermination for non-cooperation when the client cooperates within 3 months (or 90 days if longer) after the effective date of the cancelation.
  • Review eligibility for a medical case when the client cooperates with the redetermination by submitting all required documents prior to end of the third month (or 90 days if longer) following the last day of coverage. 
  • If the client cooperates timely and as long as all other factors of eligibility for medical benefits are met, reinstate the  case.
  • The benefit level may change at reinstatement, based on factors of eligibility, just as it would have if the client had responded timely.
  • If the case is eligible for reinstatement, the effective date of reinstatement is retroactive to the first day for which coverage had been canceled. Therefore, the case is reopened with no loss in benefits.
  • Do not reinstate a case if the client cooperates more than three months (or 90 days if longer) after the effective date of cancelation.
  • If the client has not cooperated within 3 months (or 90 days if longer) following the last day of coverage, the client must reapply to be reviewed for medical benefits' eligibility.

Example 1: Mr. S was canceled effective July 1, 2014 for failure to return the redetermination form. Mr. S must cooperate with the redetermination process by close of business September 30 (31 days in July, 31 days in August and 30 days in September equal 92 days) to be reinstated, with no loss of benefits if he remains eligible. If he cooperates October 1 or later, he must reapply.

Example 2: Ms. X returns her redetermination form timely but her medical benefits are canceled effective February 1, 2015 for failure to cooperate by returning requested pay stubs. Ms. X must cooperate by submitting pay stubs by close of business May 1, 2015 (28 days in February, 31 days in March and 30 days in April equal only 89 days) to be found eligible to be reinstated effective February 1 with no loss in benefits. Ms. X can cooperate on May 1 and be reinstated effective February 1 if otherwise eligible.

MANUAL REVISIONS

[signed copy on file]

Michelle R.B. Saddler

Secretary, Illinois Department of Human Services

Julie Hamos

Director, Illinois Department of HealthCare and Family Services