Medicaid Redeterminations

Illinois Department of Human Services

Division of Developmental Disabilities

Information Bulletin

DD.19.012 FINAL

Purpose:

The term "Medicaid Redetermination" is a generic term used to describe two (2) separate redetermination processes. This Informational Bulletin serves to clarify the term "Medicaid Redetermination" and the two types of redeterminations required annually. It's also intended to establish and clarify the roles and responsibilities for the completion of the two (2) annual redeterminations to ensure individuals receiving DD Waiver services remain eligible for Medicaid.

Background:

For individuals receiving DD Waiver services, there are two (2) annual redeterminations which need to be completed. Those being:

  1. The Level of Care Redetermination ("Clinical") and
  2. The Medicaid Benefit Enrollment and Medical Renewal Process ("Medical/Cash/SNAP").

The purpose of the Level of Care Redetermination is to conduct a level of care/Waiver eligibility redetermination for continuing eligibility of services to everyone in the three (3) DDD Waivers. The purpose of the Medicaid Benefit Enrollment and Medical Renewal Process is to maintain uninterrupted eligibility for Medical, Cash and SNAP benefits in order to continue receiving DDD Waiver services.

ISC agencies are the Conflict of Interest free service coordination (service coordinator) entities and are essential to Illinois Developmental Disability service system. Service coordination includes maintaining the PUNS database, conducting Pre-Admission Screens, providing Individual Service and Support Advocacy to people in a DDD Waiver and providing service coordination to Bogard class members. It also includes, but is not limited to, conducting outreach, serving as the front line for information and assistance to help individuals and families navigate the system, ensuring informed choice, developing and monitoring a person's Plan, linking individuals to services and addressing problems related to outcomes and quality.

Process and Procedures:

  • (1) The Level of Care Redetermination (Clinical)

The process for completing this Redetermination is as follows:

At least annually, a service coordinator will conduct a level of care/Waiver eligibility redetermination for continuing eligibility of services to everyone in the three (3) DDD Waivers. This redetermination is for waiver claiming and is summarized and documented on the Redetermination of Medicaid DD Waiver Eligibility form [IL462-0952; formerly the DD-1213.1].

The annual level of care redetermination can be performed during the time of the annual review of the Personal Plan; however, the redetermination must never be allowed to expire. If the redetermination and the Personal Plan process cannot be scheduled during the same time, the Independent Service Coordinator (ISC) must perform the redetermination on or before its next due date, regardless of the timing of the Personal Plan process. The timeliness of the redetermination is of critical importance, as it will be monitored by the federal government: Centers for Medicare & Medicaid Services (CMS), and state government: the Illinois Department of Healthcare and Family Services (HFS) and The Illinois Department of Human Services (IDHS) Division of Developmental Disabilities (DDD). No redetermination may be allowed to become out of date, it must be completed within 365 days of the date on the most recent Determination of Intellectual Disability or Related Condition & Associated Treatment Needs (DDPAS-5) form [IL462-4428] or the Redetermination of Medicaid DD Waiver Eligibility form [IL462-0952] , documenting the need for an ICF/IID level of service (sometimes referred to as active treatment for developmental disability). The IL462-4428 or IL462-0952 must be maintained in the individual record. Not only will the ISC complete and document the Level of Care Redetermination, the ISC must also report the annual redeterminations in the Reporting of Community Services (ROCS) system.

  • (2) Medicaid Benefit Enrollment and Medical Renewal Process (Medical/Cash/SNAP)

The process for completing this Redetermination is as follows:

The individual, guardian or approved representative will receive two (2) Illinois Medical, Cash and SNAP Redetermination Notices in the mail every year. The notices contain a return address from the Illinois Department of Human Services (IDHS), Family and Community Resource Center (commonly known as FCRC or local office) or the Illinois Department of Healthcare and Family Services (HFS). These are the two (2) Illinois entities which handle Redeterminations. It is crucial the individual, guardian (if applicable) or approved representative complete and return the Medical, Cash and SNAP Redetermination Notice within the specified time frames in order to avoid interruption or loss of Medicaid status and Waiver services. The form used for this process is titled "Medical, Cash and SNAP Redetermination Notice" [IL444-1893].

  1. The first mailing from HFS is a notice the redetermination date is approaching and the Illinois Medical, Cash and SNAP Redetermination Notice will arrive in approximately two (2) weeks.
  2. The second mailing from HFS contains the actual Illinois Medical, Cash and SNAP Redetermination Notice. This form will already contain the individual's name and date of birth; it will also contain a barcode in the upper right-hand corner. To complete the redetermination process, the individual, guardian (if applicable) or approved representative must:
    • Complete the preprinted Illinois Medical, Cash and SNAP Redetermination Notice.
    • Attach any verifications and/or documentation requested.
    • Sign the form.
    • Return the form and any verifications and/or documentation by the date indicated on page 3, #11 of the form.

When necessary, the ISC should assist persons enrolled in a DDD Waiver with the Illinois Medical, Cash and SNAP Redetermination Notice as to avoid any interruption in eligibility or coverage. For everyone enrolled in a DDD Medicaid Waiver service, the ISC should:

    • Remind the individual, guardian or approved representative, as well as any residential provider of the annual redetermination date if known.
    • Remind the individual, guardian or approved representative, as well as any residential provider that they will (or inquire if they already have) receive an Illinois Medical, Cash and SNAP Redetermination Notice as described above.
    • Help resolve cancelled Medicaid cases. Any time the ISC becomes aware the individual is not eligible or the Medicaid case has been cancelled, the ISC must take the following steps:
      • Identify the reason for cancellation.
      • If the case is cancelled and the redetermination has been sent in, contact the FCRC/local office liaison identified by DDD.
      • If the case is cancelled and the redetermination has not been sent in, the ISC must contact the FCRC/local office liaison identified by DDD to request a new Illinois Medical, Cash and SNAP Redetermination Notice is issued.
      • If there is no resolution to the Medicaid Medical, Cash or SNAP redetermination issues, contact the identified Medicaid benefits liaison within the DDD.
    • If the individual, guardian or approved representative is unable to successfully complete the Illinois Medical, Cash and SNAP Redetermination Notice, the ISC should assist as needed. A provider agency can also assist the individual, guardian or authorized representative in completing and returning the form.
  • Spenddown
    • The Notice of DHS Community-Based Services form/HFS 2653 (commonly known as the Spenddown form) must be completed by a provider agency or the Home-Based Services Employer of Record. The Estimated Monthly Cost to be filled in on this form can be found on the DHS/DDD Rate sheets, which is the second page of the DDD Award Letter. The provider must forward a copy of the form to the ISC agency. It is the ISC agency's responsibility to provide assistance and information as needed to the provider agency or the Home-Based Services Employer of Record. The ISC is not required to send this form to IDHS but should maintain the Notice of DHS Community-Based Services form/HFS 2653 in the individual's file.

The Division wishes to emphasize the importance of a system of supports to assist individuals and families in maintaining Medicaid eligibility.

Effective Date: Immediately

This Information Bulletin reflects current policy and processes. If you have questions regarding this subject information, please contact dhs.dd.medirede@illinois.gov.