**This policy memo clarifies and updates Policy Memo: COVID-19 Pandemic Response Ensuring Access to Care dated 03/21/2020
Due to the Families First Corona Virus Response Act, all individuals who are receiving Medical benefits should continue to get benefits until the emergency is over. In order to maintain eligibility, an eligibility override will be systematically established for every approved, ongoing medical record to maintain the current eligibility level.
When a spenddown is met in March 2020 or later, the spenddown will continue to be met for every month the emergency continues.
A change has been made in IES to allow mass updates for cases containing an override. Mass updates will be applied and will certify unless there is another exception encountered.
Updates to Active Medical EDGs
- An eligibility override record will be inserted on all currently active and newly approved Medical EDGs until the emergency ends.
- Eligibility summary should show an approved ongoing EDG(s).
- The override will be applied when eligibility is run in IES beginning with the month of March 2020 or later when the individual was approved after March.
- A case comment stating "Medical Eligibility Override was approved to prevent medical closure from occurring due to the Families First Coronavirus Response Act: ILIES-261740" will be inserted.
- A data fix will be applied to each newly approved case each night to prevent closure of newly eligible individuals.
- No closures should occur unless one of the following occurred:
- moved out of state; or
- someone is deceased; or
- cancellation is requested
- Transitions should not occur. This includes if an individual would transition to a lower-cost program since all premiums and co-pays are also being removed during this time.
- Only supervisors or central office users can end or delete eligibility override records.
How to Close a Case
Do NOT close a medical EDG unless it meets one of the three situations listed below:
- moved out of state; or
- someone is deceased; or
- cancellation is requested by the customer
To close the case for one of these reasons follow these instructions:
- Enter the necessary information in Data Collection.
- Run eligibility.
- Click on the Exception Summary tab in Eligibility Summary.
- Edit the existing override(s) and enter an end date (should be the day before the current effective month - if the effective ongoing month is May, enter 04/30/2020).
- Send to your supervisor to approve the override change.
- Rerun eligibility and certify the closure.
AABD SPD Cases
Beginning with March 2020, when a spenddown is met for one month, all months going forward should also be met. If the customer met spenddown in the month of March 2020 or after, they should continue to remain in met status until the emergency is over. A data fix will be applied each night in IES to maintain the met status.
Review Eligibility Summary
Always review eligibility summary to ensure there are no gaps in coverage.
- Since IES can only run eligibility for 12 months at a time, eligibility may have to be ran to include months that were never previously ran for eligibility.
- Please review the job aid Processing Benefit Periods More Than 12 Months for further instructions.
REMEMBER: During this emergency, IES is programmed to maintain the current Medical TOAs and will not transition to a different program. The override should be ended or deleted when necessary and only by the supervisor. Contact a supervisor when the override must be changed.
Removing Override due to Lesser Coverage
There are only a few circumstances when the override should be removed so the TOA can transition. This is when the Medical coverage previously authorized provided less or no coverage such as a LTC resource reduction.
Examples for when the override should be deleted or ended:
Transitioning from a NH SLF SPD to LTC NH TOA.
- The override should end when the resource reduction is over and the TOA should transition to a LTC NH or LTC SLF TOA.
- Example: A case change action is taken on the case on 04/08/2020. The resource reduction ends effective 04/01/2020. The override record should be updated with an end date of 03/31/2020. This should result in the NH SLF SPD TOA closing effective 03/31/2020 and the LTC NH TOA approved effective 04/01/2020.
Transitioning from SLIB to QMB TOA.
- The override should end when the individual qualifies for QMB and when the TOA should transition from SLIB to QMB.
- Example: A case change action is taken on the case on 04/10/2020. The individual previously qualified for SLIB, however due to an income decrease they are now eligible for QMB effective 04/01/2020. The override record should be updated with an end date of 03/31/2020. This should result in the SLIB TOA ending 03/31/2020 and the QMB TOA approved effective 04/01/2020.
Transitioning from AABD community to LTC
- The override should end when the individual should be approved for LTC services.
- Example: The individual was previously approved for AABD community. They entered a LTC facility and should be approved for LTC services on 05/01/2020. The override should be updated with an end date of 04/30/2020. This should result in the LTC NH/SLF TOA approved effective 05/01/2020 and the AABD TOA closed 04/30/2020.
If an OIG directive or an appeal FAD was received and the TOAs need to change
- The override should end based on the OIG directive or FAD decision.
- Example: The individual was approved with an AABD SPD TOA effective 01/01/2020. An appeals FAD decides that the individual should be approved AABD effective 01/01/2020. The override should be deleted to allow all the edges to transition to AABD correctly.
NOTE: Only when the override prevents coverage from being given in the above circumstances should it be deleted.
[signed copy on file]
Grace B. Hou
Secretary, Illinois Department of Human Services
Director, Healthcare and Family Services