Illinois Department of Healthcare and Family ServicesIllinois Department of Human Services

04/25/2016

Policy Memo

Supplements MR #14.19,Reopening Denied Medical Applications dated 03/21/14.

Summary:

  • Re-open policy applies to all medical applications
  • Re-open a denied medical application when the application was denied due to failure to provide requested verifications and all the missing verifications are received within 60 days from date of denial.
  • Always use the original application date to re-register the application.
  • A medical application can only be re-opened once.
  • Do not apply the 30 day extension policy or grant an extension for third party delay during the re-open process. When a medical application with SNAP is denied for failure to provide requested verifications, review SNAP re-open policy.
  • Only re-register the application when all originally requested verifications are received within 60 days from date of denial.
  • Long Term Care-Asset Discovery Investigation (LTC-ADI) is responsible for reviewing verifications received for denials based on LTC-ADI directive.
  • Re-open policy is separate from the appeal process.

  1. 60 Day Re-Open Policy
    1. Medical Applications with SNAP
  2. When Missing Verifications are Provided
  3. Re-open Process
  4. When Denial is Based on LTC-ADI Directive
    1. Referring Re-Opened Applications to LTC-ADI
  5. Appeal Process
  6. Examples
    1. Examples for Re-opening SNAP benefits on a Medical Case
  7. [signed copy on file]
  8. Forms referenced

60 Day Re-Open Policy

When the denial of a medical application is based on failure to provide verifications in order to determine eligibility, allow the applicant the opportunity to provide requested verifications within 60 days from date of denial notice.

Use the original application date to re-register the application. Do not require a new application. Do not re-open an application that has already been re-opened once and was denied a second time for failure to provide verifications needed to determine eligibility.

Do not apply the 30 day extension policy during the re-open process for persons applying for Long Term Supports and Services (LTSS). See MR #14.36, Requesting Resource Information for Long Term Care Cases, dated 12/16/14. An extension due to third party delay may be granted when a decision cannot be made on an initial application within the allotted time frames (PM 17-01-01, PM 02-07-02-b). Third party delay extensions do not apply during the re-open process.

Medical Applications with SNAP

When the medical application includes a request for SNAP and the request for SNAP is denied due to failure to provide verifications see SNAP reopen policy (PM 17-04-03-d).

When Missing Verifications are Provided

To be considered for 60 day re-open, missing verifications must be received within the 60 day time frame. The office receiving the verifications is responsible for making sure the verifications are clearly marked with date of receipt.

Cooperation with the 60 day re-open policy is based on the date verifications are received and not the date verifications are reviewed.

Re-open Process

Re-Registering the Application

When a medical application is denied for failure to provide requested verifications and all missing verifications are received within 60 days from date of denial re-register the application and determine eligibility. If determined ineligible, based on the verifications received, deny using the appropriate denial reason.

If additional verifications are required to determine eligibility, send HFS 267/267LTC, Instructions to Client (Long Term Care)and allow 10 calendar days to receive the additional verifications. The caseworker may allow more time to get needed verifications if requested. If more time is needed send a second HFS 267/267LTC to allow an additional 10 calendar days. If verifications are not received by the final due date, deny the application for failure to provide verifications.

When the denial for failure to provide verifications is based on an LTC-ADI directive, LTC-ADI is responsible for determining if the application should be re-registered.

All Verifications Not Received

Do not re-open a denied medical application when ALL originally requested verifications are not received within 60 days from date of denial notice.

When Denial is Based on LTC-ADI Directive

When an application is denied for failure to provide verifications and the denial is based on an LTC-ADI directive, the LTC-ADI unit is responsible for reviewing the missing verifications. Email verifications to LTC-ADI at HFS.OIG.LTC-ADI@illinois.gov. Make sure the date of receipt of the verifications is clearly marked.

Note: On the subject line of the email, note verifications are for denied application.

LTC-ADI will notify the caseworker if the application has to be re-opened. Do not re-register the application until notification from LTC-ADI is received.

After LTC-ADI requests the application be re-opened, LTC-ADI will send a revised directive at the conclusion of their review.

Referring Re-Opened Applications to LTC-ADI

Re-opened applications, not initially referred to LTC-ADI, may be referred during the re-open process when the referral criteria is met. Complete HFS 3654A, Long Term Care-Asset Discovery Investigation Referral Form and in remarks indicate that the reason for the referral is based on verifications received during the 60 day re-open process. Email the following documents to LTC-ADI at HFS.OIG.LTC-ADI@illinois.gov :

  • HFS 3654A;
  • verifications; and
  • HFS 267LTC requests.

Appeal Process

Re-open policy does not affect the client's right to appeal the decision made on the medical application or change any deadlines for filing an appeal (PM 01-07-01)

The reopen process is separate from the appeal process.

Examples

Example 1: Bob's medical application is denied due to income on 02/02. On 03/01, Bob provides information that his income has decreased. The caseworker does not re-open the application because the original denial was not due to failure to provide requested verification. Bob is advised to reapply because his circumstances have changed.

Example 2: Kim's medical application is denied for failure to provide verifications on 05/14. On 07/05, the caseworker receives some of the missing verifications. Kim fails to provide all the requested verifications by the 60th day. The application is not re-registered and remains denied due to failure to provide verifications.

Example 3: Tim lives in the community and applies for medical assistance. HFS 267 is sent requesting verification. His application is denied on 03/05 for failure to provide requested verifications by the due date. On 04/01 Tim provides the missing bank account verification. The bank account balance exceeds the resource limit. The caseworker re-opens the application because all missing verifications have been received but the application is then denied because he is over the resource limit and reports he has no medical expenses that could be used to meet spenddown.

Example 4: Kathy moves into a supportive living facility and applies for medical assistance. Her application is denied on 08/30 for failure to provide requested verifications. Kathy sends the missing information on 10/02. Upon review of the bank account information, the caseworker discovers an account that was not originally reported. The application is re-opened because all the originally requested verifications have been received. The caseworker sends HFS 267LTC for verification of the additional account. The verification is received before the due date and the caseworker is able to approve the application.

Example 5: Refer to Example #4, Kathy doesn't provide the verification about the additional account by the due date and she does not contact the caseworker to request additional time. The caseworker denies the application for failure to provide financial information needed to determine eligibility. Kathy will have to submit a new application because her original application has already been re-opened once.

Example 6: Mary's medical application is denied due to failure to provide verifications. The denial notice is dated 05/15. Mary files an appeal. The verifications Mary has failed to provide include a bank statement and life insurance policy. On 07/05, the caseworker receives the missing bank statement but not the life insurance verification. The caseworker does not re-open the application because all the missing verifications were not received by the 60th day. Mary's appeal request is separate from the re-open process.

Example 7: Refer to Example #6, the caseworker receives the missing life insurance information on 08/01. Because receipt of the missing verification is past the 60 day timeframe, the application remains denied.

Example 8: Paula files a medical application on 02/14 and requests backdating. The application is denied 03/12 for failure to provide requested verifications. She files an appeal. On 4/1, Paula provides all the requested verifications within 60 days of the date of the denial notice and the caseworker is able to determine eligibility, the caseworker re-opens the application using the original application date and approves the application with medical backdating. Paula withdraws her request for an appeal hearing because the reason for the appeal request has been resolved with the reopening of her application.

Example 9: Ted applies for medical assistance after moving into the nursing home on 08/15. The application does not meet criteria for referral to LTC-ADI. Ted's application is denied on 10/31 for failure to provide verifications. The caseworker receives all of the missing verifications on 11/2. After reviewing the verifications, the caseworker discovers that one of the bank accounts had recently been closed with a balance of $100,000. The $100,000 transfer meets criteria for referral to LTC-ADI. The caseworker re-registers the application and refers it to LTC-ADI.

Examples for Re-opening SNAP benefits on a Medical Case

Example 10: Mrs. T filed a SNAP and medical application on 02/25. The application is denied 03/12 due to failure to provide verifications. On 03/20, she provides all requested verifications. The caseworker re-opens both the SNAP and medical application using the original application date. Authorize SNAP benefits from 02/25 because the information was provided within the first 30 days.

Example 11: Ms. W files a SNAP and medical application on 02/14 and requests backdating. The application is denied 03/12 due to failure to provide verifications. On 03/20, the office receives all the requested verifications and has everything needed to determine eligibility. The caseworker re-opens the medical application using the original application date and approves the application with medical backdating. The caseworker also re-opens the SNAP application and prorates SNAP benefits beginning 03/20 because they provided the missing verifications after the 30th day but within 60 days.

[signed copy on file]

James T. Dimas.
Secretary-designate, Illinois Department of Human Services

Felecia F. Norwood
Director, Healthcare and Family Services

Forms referenced

  • HFS 3654A
  • HFS 267/267LTC