The Illinois Department of Healthcare and Family Services (HFS), Division of Medical Programs is responsible for administering healthcare coverage for adults and children who qualify for Medicaid. The DHS Family Community Resource Centers (FCRCs) determine Medicaid eligibility based on HFS criteria and determines eligibility for medical SNAP and cash services.
Individuals must enroll in Medicaid to ensure payment to providers for services delivered. Medicaid enrollment enables the individual to receive covered services included in the Medicaid State Plan, in addition to waiver services. After initial enrollment, individuals must maintain Medicaid enrollment.
A. Confirming Individual Medicaid Eligibility
Any service provider who is assisting a recipient and has an Authorized Representative form on file and ISC agencies may call the HFS Toll Free Provider hotline during state working hours to verify an individual's Medicaid enrollment. Providers and ISC agencies may make up to six inquiries per call. The toll-free number is 1-800-842-1461. When using the automated system, caller must:
- Enter their Medicaid provider identification number. The identification number is generally the 9-digit Federal Employer Identification Number (FEIN) or Social Security Number (SSN) followed by:
- 100 for Adult Waiver
- 400 for Children's Support Waiver
- 700 for Children's Residential Waiver
(e.g., 123456789100 (FEIN/SSN + 100)
- Enter the individual's Medicaid Recipient Identification Number (RIN) and the month of service for which they need eligibility information.
Callers who do not know the individual's RIN may talk with a Provider hotline staff member. To confirm eligibility when speaking with a staff member, callers must provide the individual's name, birthdate and SSN.
B. Special Medicaid Benefits Eligibility for Children
Children who are determined clinically eligible for either of the Children's Waivers who are under the age of 19 can apply for Medicaid under special eligibility rules that can waive family income for families who would not otherwise qualify for Medicaid benefits for their child, based on the parent's income.
The ISC agency that determines clinical eligibility for the Children's Waivers can assist families to apply for Medicaid for their child. For children found clinically eligible for the waivers and for whom funding is authorized, ISC agencies will follow special procedures to help the family apply for Medicaid benefits. This will ensure the child's Medicaid application is given special handling. Please contact the ISC agency in your area for more information about the Children's Waiver Medicaid application process.
The ISC agency assists young adults determined to be eligible for the Children's Waiver to apply for Medicaid benefits as an adult through the local DHS office. Please contact your ISC agency for more information about the Medicaid application for young adults.
C. Medicaid Redeterminations
The term "Medicaid Redetermination" is a generic term used to describe two (2) separate redetermination processes. Redeterminations are required annually. Completion of two (2) annual redeterminations are required to ensure individuals receiving DD Waiver services remain eligible for Medicaid.
- Process and Procedures:
- 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 EligibilityPDF 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 and 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 NeedsPDF (DDPAS-5) form [IL462-4428] or the Redetermination of Medicaid DD Waiver EligibilityPDF 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.
- Medicaid Benefit Enrollment and Medical Renewal Process (Medical/Cash/SNAP)
The process for completing this Redetermination is as follows:
The individual, guardian, if applicable, 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 NoticePDF" [IL444-1893].
- 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.
- 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, if applicable, or approved representative, as well as any residential provider of the annual redetermination date if known.
- Remind the individual, guardian, if applicable, or approved representative, as well as any residential provider 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, if applicable, 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.
- 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 their 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.