Illinois Department of Healthcare and Family ServicesIllinois Department of Human Services

10/24/17

Action Memo

Summary:

  • Unlike the legacy system, IES does not allow a medical case to remain active with an overdue redetermination (REDE).
  • The REDE due dates for medical cases that are overdue at Go Live will be reset to prevent IES from inappropriately canceling medical benefits.
  • IES will be unable to track REDEs that are due in October through December 2017; therefore, medical REDE due dates for these months will also be reset to avoid inappropriate cancellation.
  • Staff must process the medical-only REDEs that are due in October, November and December 2017 using the following procedures:
    • Returned medical-only REDE forms that were sent by Maximus will continue to be entered into MaxIL through January 2018.
    • When the client returns the REDE, any resulting changes must be completed in Case Change Mode and documented in IES case notes.
    • If the REDE information indicates that a child should be moved to a higher cost program, the child's benefits should be corrected using the Eligibility Override function in IES. This action will override the continuous eligibility that was provided to the child when the REDE due date was reset.
    • If the REDE is not returned, or a child is ineligible per the REDE information, staff will need to cancel the EDG using the 'Client Requested Cancellation' reason, suppress the IES notice, send a manual notice and document the activity in IES case notes.
  • Other situations where medical REDE due dates will be reset are:
    • The REDE due date for deemed newborns will be when the child reaches one year old. 
    • The due date for pregnant women will be reset to the month that 60 day post-partum period ends in situations where the REDE would have been due before the end of the post-partum period.

  1. How is the CDB Medical REDE Due Date Determined on Medical Cases at Go Live?
  2. Which Medical REDE Due Dates Are Changing at Go Live?
  3. REDEs Due in October, November or December 2017 on Medical-only Cases
  4. Examples
  5. Forms referenced

Federal regulations (42 CFR 435.930) require states to continue to furnish Medicaid benefits to eligible individuals until they are found to be ineligible. Unlike the legacy system, IES does not allow a medical case to remain active with an overdue REDE. At Phase 2 conversion, IES would auto-cancel medical benefits with overdue REDEs for which IES does not have evidence that the client cooperated. To prevent IES from inappropriately canceling medical benefits, REDE due dates for certain cases will be reset during IES Phase 2 data conversion. 

How is the CDB Medical REDE Due Date Determined on Medical Cases at Go Live? 

  1. If there is a date in Form 552 Item 32- Case Certified, that date is considered as the CDB REDE due date.
  2. If there is no date in Item 32, 12 months is added to the Item 30- last REDE date, or to Item 31- Last Opening date to arrive at the CDB REDE due date.

Which Medical REDE Due Dates Are Changing at Go Live?

Medical-only If the REDE is overdue (due before October 2017) or is due in October, November or December 2017, then the year of the REDE due date is changed to be due in 2018. The month stays the same.
Medical with SNAP not subject to MPR If the REDE is overdue (due before October 2017) or is due in October, November or December 2017, then the year of the REDE due date is changed to be due in 2018. The month stays the same.
Medical with SNAP subject to MPR Medical REDE due dates are aligned with the SNAP REDE due date which is converted AS-IS from CDB.
Deemed Newborns The medical REDE will be due when the child reaches 1 year old.
Pregnant Women If the certification period would end before the end of the 60 day post-partum eligibility period, the medical REDE due date will be reset to be due when the 60 day post-partum period ends.

REDEs Due in October, November or December 2017 on Medical-only Cases

Notices for medical-only REDEs due in October through December 2017 will have been sent by Maximus prior to IES Phase 2 Go Live. Since they will not be tracked in IES, the REDE due dates for these cases will be reset similarly to the overdue cases to prevent inappropriate cancellations. Redetermination forms that are returned will be entered into the MaxIL system through January 2018. Documents contained in Max IL will continue to be uploaded to Content Manager through January. Max IL will no longer be available after 1/31/2018.

Most medical-only REDEs will be processed by the Medical Management Unit (MMU), Medical Field Operations (MFO), and the All Kids Unit (AKU). These procedures apply to all offices that have medical-only REDEs due during this period:

  1. Caseworkers must pull cases from MaxIL for review and will document the outcome in IES case notes.
  2. Since IES will already have reset the certification period, any resulting changes to the case must be entered into IES as a change action. The action will be effective for the ongoing processing month. A client notice will be generated from IES for changes processed through IES.
  3. If the REDE information indicates that a child should be moved to a higher cost program, the child's benefits must be corrected using the Eligibility Override function in IES. This action will override the continuous eligibility that was provided to the child when the REDE due date was reset. This function requires supervisory approval.
  4. If the REDE is not returned, or a child is ineligible for medical benefits per the REDE information, staff must cancel the EDG using the 'Client Requested Cancellation' reason, suppress the IES notice and send a manual Notice of Change (Form 157) to the client using the appropriate notice reason.
  5. All actions taken must be documented in IES case notes, and copies of notices and REDE forms not stored in IES must be scanned and uploaded to the case.
  6. Continue to document case results in MaxIL through January 15, 2018. Enter 'Continued' when medical benefits will continue at the same benefit level with no changes. This will ensure that a continuation notice is sent by MaxIL.
    Additional instructions about REDEs not processed by January 15th will be forthcoming.

Note: The first REDE mailing generated by IES will occur in November 2017 for REDEs that are due in January 2018. These REDEs, as well as all REDEs with dates that have been reset for January 2018 and later, will be tracked and processed in IES using the process described in PM 19-02-04. Some cases may be identified as a Potential Merge case after conversion; see PM 04-06-02 for more information about merging cases.

Examples

Example 1: A REDE was due for a medical-only case in August 2017, or in any earlier year for the month of August. At conversion, the REDE due date is reset to August 2018.

Example 2: A REDE will be due for a medical-only FamilyCare and All Kids Assist case in November 2017. At conversion, the REDE due date is reset to November 2018. The REDE form mailed by Maximus is returned with requested proofs and entered into MaxIL. The MMU worker pulls the REDE information and enters the updated income information into IES as a change action. The change results in the adult being canceled and the child is determined eligible for All Kids Share. To override the 12 month continuous eligibility period that was provided to the child when the REDE date was reset at conversion, the worker uses the Eligibility Override function to move the child from All Kids Assist to Share for the remainder of the certification period. The actions taken as a result of the REDE are documented in IES case notes.

Example 3: A REDE was due in March 2017 for a Family Assist case containing a pregnant woman. The pregnant woman's expected due date is in March 2018. At conversion, the REDE due date for the pregnant woman is reset to May 2018 (after her 60 day post partum period). The REDE due date for the other family members is reset to March 2018.

Example 4: A medical with SNAP subject to MPR was due for a medical REDE in July 2017, and is due for a SNAP REDE in November 2017. At conversion, the medical REDE due date is reset to November 2017. On November 1st, the client appears at the FCRC for the SNAP REDE. The worker processes the SNAP and medical REDEs at the same time.

Example 5: A medical with SNAP subject to MPR was due for a medical REDE in July 2017, and is due for a SNAP REDE in November 2017. At conversion, the medical REDE due date is reset to November 2017. The client does not respond to the SNAP REDE notice and both SNAP and Medical benefits end effective 12/01/2017. The client cooperates with the SNAP and medical REDEs on 12/11/17. The worker reinstates benefits and medical benefits are restored without a break in benefits per PM 19-04-02.

[signed copy on file]

James T. Dimas
Secretary, Illinois Department of Human Services

Felicia F. Norwood
Director, Healthcare and Family Services

Forms referenced

  • Form 157