Individuals with Disabilities/Blindness Who are Determined Ineligible for ACA Adult

Helping Families. Supporting Communities. Empowering Individuals.

Illinois Department of Healthcare and Family Services

Illinois Department of Human Services

07/30/15

Policy Memo

Summary

  • Determine eligibility for AABD medical when an individual is determined income ineligible for ACA Adult due to MAGI budgeting and has an adjudicated disability or claims to have a disability. 
  • IES will automatically create an AABD Eligibility Determination Group (EDG) when a person, who receives SSI, is determined ineligible for ACA Adult due to MAGI budgeting.  The system will approve the AABD EDG because verification of income and resources is not required for persons receiving SSI due to simplified processing rules. 
  • IES will automatically create an AABD EDG when a person whose individual verified income (not SSI), is at or below 100% of the FPL, has an adjudicated disability or claims to have a disability and has been determined income ineligible for ACA Adult due to MAGI budgeting.
  • IES will automatically create an AABD EDG for potential spenddown eligibility when a person whose verified monthly income is over 100% of the FPL, has an adjudicated disability or claims to have a disability and has been determined income ineligible for ACA Adult  due to MAGI budgeting.
  • Review the question on the ABE application regarding "Blind and Disability" when a person is determined income ineligible for ACA Adult due to MAGI budgeting. If the person has a disability or claims to have a disabling condition that has lasted or is expected to last 12 months and it prevents the person from working, create an AABD EDG.
  • Review the disability question on HFS 2378H, Mail-In Application for Medical Benefits. If the person answered "yes" to the question "Is anyone applying blind or have a disability?" and has been determined income ineligible for ACA Adult due to MAGI budgeting, create an AABD EDG.
  • Refer to Manual Release #14.33, Simplified Processing for Determining Income and Resource Eligibility for Medical Benefits, dated 12/08/14.
  • Complete a determination for AABD medical when a person, age 18, has a disability or claims to have a disability, and is determined income ineligible for All Kids due to MAGI budgeting.
  • If IES denies eligibility for ACA Adult, based on income, a message text will appear on the Eligibility Screen that will instruct the caseworker to create an AABD medical EDG.  The new message will read "'Individual Name' is financially ineligible for ACA but may be eligible for AABD benefits.  Please navigate to the Assets-Question screen to enter asset details and issue HFS 2378DR or HFS 2378VR ".  The form generated will be based on verified income. (The forms displayed in IES are incorrect.  Use the forms indicated in this memo)
  • Submit a referral packet to the Client Assessment Unit (CAU) for a determination of disability when an applicant claims to have a disability and the disability has not been adjudicated. Refer to WAG 03-08-01.
  • Send HFS 2378VR (pdf), Resource Information, to obtain information on resources for persons when verified income is over 100% of the FPL.
  • Send HFS 2378DR (pdf), Declaration of Resource Information, to obtain a declaration of resources when verified income is under 100% of the FPL (excluding SSI).
  • Authorize medical backdating according to PM 17-02-05-a: Backdating Medical (All Program Except All Kids S/P/R) when approving an application or reopening a denied application. 
  1. When to Determine Eligibility for AABD
  2. Disability Question
  3. Processing AABD
    1. SSI Only
    2. Income at or below 100% FPL (Not SSI)
    3. Income over 100% FPL
  4. CAU Referral
  5. Persons who are ineligible for All Kids
  6. Medical Backdating
  7. Questions?
  8. Forms Referenced

When to Determine Eligibility for AABD

Determine eligibility for AABD medical for a person who has an adjudicated disability or claims to have a disability and has been determined income ineligible for ACA Adult. When using MAGI budgeting rules, income that would not be counted for AABD is counted for ACA Adult. MAGI budgeting can cause the person to be ineligible for ACA Adult but the person may be eligible for AABD medical because income under the AABD program is counted differently. Review eligibility for AABD medical when a person:

  • has been denied ACA Adult due to income exceeding 138% of the Federal Poverty Level (FPL); and
  • has income from other household members budgeted; and
  • has an adjudicated disability or claims to have a disability.

Refer to Manual Release #14.33, Simplified Processing for Determining Income and Resource Eligibility for Medical Benefits, dated 12/08/14.

Disability Question

When an application is submitted through ABE, review the question on the ABE application regarding "Blindness and Disability".  If the person indicates on the ABE application that they have a disability or claims to have a disabling condition that has lasted or is expected to last 12 months and it prevents the person from working. IES will automatically create an AABD EDG when ACA Adult is denied if the caseworker answers yes to the question in IES claiming the person is disabled.   

When the individual submits the HFS 2378H, Mail-In Application for Medical Benefits, review the disability question, "Is anyone applying blind or have a disability?" If the person answers "yes" to the question IES will automatically create an AABD EDG when ACA Adult is denied if the caseworker answers yes to the question in IES claiming the person is disabled.

When IES denies eligibility for ACA Adult a message text will appear on the screen that will instruct the caseworker to build an AABD EDG. The new message will read "'Individual Name' is financially ineligible for ACA but may be eligible for AABD benefits. Please navigate to the Assets-Question screen to enter asset details and issue HFS 2378DR (pdf) or HFS 2378VR (pdf)". The form sent to the customer is based on verified income. (The forms displayed in IES are incorrect. Use the forms indicated in this memo).

HFS 2378DR and HFS 2378VR are sent manually.  These forms are not centrally generated.

Processing AABD

SSI Only

IES will automatically create an AABD Eligibility Determination Group (EDG) when a person, who receives SSI, is determined ineligible for ACA Adult due to MAGI budgeting. Accept receipt of Supplemental Security Income (SSI) as verification of financial eligibility for both income and resources for individuals who are receiving SSI. Approve AABD medical.

Example 1: John Smith applied for medical benefits on 01/14/14. Mr. Smith is expected to be claimed as a tax dependent on his father's tax return. Mr. Smith reported that he receives SSI. Due to MAGI tax filer rules, his father's income is counted when determining eligibility for ACA Adult. Mr. Smith is determined ineligible for ACA Adult due to his father's income. Since Mr. Smith receives SSI, he is eligible for medical under the AABD program. His father's income is not counted for AABD budgeting. Mr. Smith was denied medical benefits under the ACA Adult Program due to MAGI budgeting and because the applicant was receiving SSI at the time of application. Receipt of SSI is accepted as verification of financial eligibility.  Approve for AABD medical. Authorize medical backdating according to PM 17-02-05-a.

Income at or below 100% FPL (Not SSI)

IES will automatically create an AABD EDG when a person whose individual verified income (not SSI), is at or below 100% of the FPL, has an adjudicated disability or claims to have a disability and is determined income ineligible for ACA Adult due to MAGI budgeting 

Example 2: Mary Jones files an application on 02/05/14 for medical benefits. She is claimed as tax dependent by her mother. Mary receives Social Security disability income in the amount of $973 monthly. Mary was determined ineligible for ACA Adult based on MAGI tax filing rules. Since Mary is receiving disability and her verified income does not exceed 100% of the FPL, IES will build an AABD medical EDG. A Verification Check List (VCL) will be created and HFS 2378DR, Declaration of Resources, will be mailed to applicant. Verification of resources is not required since her verified income is at or below 100% FPL. Accept applicant's statement of reported resources if the applicant's declared resources are under the resource standard. Verify resources if declared resources are over the AABD resource standard. Approve for AABD or AABD spenddown, if all other factors of eligibility are met. Authorize medical backdating according to PM 17-02-05-a.

If verified income is at or below 100% (not SSI), IES will generate a Verification Checklist (VCL).  The caseworker sends Form 267 and HFS 2378DR, Declaration of Resource Information, to the customer. The applicant only has to declare resources, not verify them. Determine eligibility using declared resource amount. Deny medical request if the customer fails to return HFS 2378DR within 10 calendar days.

Income over 100% FPL

IES will automatically create an AABD EDG for potential spenddown eligibility when a person whose monthly income is over 100% of the FPL, has an adjudicated disability or claims to have a disability and has been determined income ineligible for ACA Adult  due to MAGI budgeting.

Example 3: Susan Hill filed an application on 01/15/14 for medical benefits. She is expected to be claimed as a tax dependent by her father. Susan receives $1000 in Social Security disability each month. She was determined ineligible for ACA Adult based on MAGI tax filing rules. IES will build an AABD EDG. IES will create a VCL and send HFS 2378VR, Resource Information, to the applicant. Since Susan's income exceeds 100% FPL she must provide verification of her resources and any medical bills. Determine eligibility for AABD or AABD spenddown. Authorize medical backdating according to PM 17-02-05-a.

If income is over 100% and the person does not receive SSI, IES will generate a Verification Checklist (VCL) and send Form 267 and HFS 2378VR, Resource Information, to the customer. The applicant must verify resources.

CAU Referral

When an applicant claims to have a disability and the disability has not been established a CAU determination is required. Request medical records from the applicant.  Submit a referral packet to the Client Assessment Unit (CAU) for a determination of disability. Refer to WAG 03-08-01.

Example 4:  Amy Lewis filed an application on 01/15/14 for medical benefits.  She expected to be claimed as a tax dependent by her father. Amy indicated on her application that she has a disability.  Amy has no income.  She was determined ineligible for ACA Adult based on MAGI budgeting.  Amy is ineligible for ACA Adult but claims to have a disability.  SOLQ indicates that Amy has filed a disability claim with SSA.  IES will build an AABD EDG. A VCL will be created and will send Form 267, Instructions To Customer (Cash, Medical and SNAP Assistance) and HFS 2378DR, Declaration of Resources and request medical records.  Complete a referral to Client Assessment Unit (CAU) for a determination of disability according to WAG 03-08-01-Establishing Disability.  If the applicant is determined disabled and all other factors of eligibility are met, approve for AABD.  Authorize medical backdating according to PM 17-02-05-a

Persons who are ineligible for All Kids

The FCRC determine eligibility for AABD when a person, under age 19, has an adjudicated disability or claims to have a disability, and is determined income ineligible for All Kids due to MAGI budgeting.

If the FCRC becomes aware of this situation and medical was denied due to MAGI budgeting, reopen the application and review eligibility for AABD. Approve case in IPACS.

Example 5: John Hill is age 18 and receives SSI.  John is expected to be claimed as a tax dependent on his father's tax return.  He was determined ineligible for FHP due to his father's income.  Accept receipt of Supplemental Security Income (SSI) as verification of financial eligibility for both income and resources for individuals who are receiving SSI. Approve AABD medical.

Medical Backdating

Authorize medical backdating according to PM 17-02-05-a: Backdating Medical (All Programs Except All Kids S/P) when approving or reopening a denied application.

  • HFS 2378VR (pdf), Resource Information, is sent to the applicant when verified income is over 100% FPL.
  • HFS 2378DR (pdf), Declaration of Resource Information, is sent to the applicant when verified income is at or below 100% FPL. 

Questions?

Questions about case processing in IES should be directed to your IES Expert. If staff have questions about case progression, they may call the Bureau of Medical Eligibility and Special Programs (BMESP) at 217-557-7158.

[signed copy on file]

James T. Dimas

Secretary, Illinois Department of Human Services

Felicia F. Norwood

Director, Illinois Department of Healthcare and Family Services

Forms Referenced

Form 267

Form 1721

HFS 2378DR

HFS 2378VR