WAG 06-25-04
Case Maintenance
An individual becomes ineligible for ACA Adult in the following circumstances:
- reaches age 65; or
- is enrolled in Medicare; or
- is a parent or caretaker relative of a child living in the home; or
- has income that exceeds 138% of the FPL; or
- No longer meets the financial and nonfinancial eligibility criteria.
There is no spenddown for persons in ACA Adult.
ACA Adults are not eligible for extended medical.
Case Changes
Review eligibility for other medical programs when an individual in an ACA Adult case reports one of the following:
- a newborn is reported and the newborn lives with the parent or caretaker relative; or
- children move into the home with the parent or caretaker relative; or
- the individual turns age 65; or
- the individual begins receiving Medicare.
Note: For pregnant women, the ACA Adult case may remain active until the birth of the newborn.
Do not require a new application when customer reports a change. To add a spouse to an ACA Adult case the customer must complete Form 243C, Request for Medical Benefits for Another Family Member(s) . Process request taking the following actions:
- ask tax status/relationship questions; and
- verify income to determine eligibility under MAGI methodology;
- complete a case write-up regarding the request.
Change Case from ACA Adult to FHP
Who is eligible for the Family Health Plan (FHP)?
In addition to meeting Illinois residency, social security number requirement and U.S. citizenship, immigration status and income standards an individual must be:
- pregnant women;
- children (age 18 or younger); or
- parents or caretaker relative of children under the age of 18 with minor children living in the home.
Answer the following questions when changing an ACA Adult to FHP.
Question: Is this individual a parent or caretaker relative with minor children in the home and receiving ACA Adult?
If yes, review for FHP. Parents and caretaker relatives with minor children in the home are not eligible for ACA Adult.
If the individual is determined ineligible for FHP, consider AABD eligibility. Refer to the section below on "Reviewing Eligibility for AABD ".
When reviewing income eligibility for FHP refer to 
PM 08-03-00.
Change Case from FHP to ACA Adult
There are times when a parent or caretaker relative is no longer eligible for medical under FHP. This occurs when:
- the only eligible child(ren) moves out of the home; or
- the only eligible child turns 18.
The parent or caretaker relative may be eligible for ACA Adult when the only eligible child turns age 18. The 18 year old remains eligible until he/she turns age 19 due to continuous eligibility. Determine eligibility for ACA Adult for the parent or caretaker relative.
ACA Adult Cases with SNAP-Age 65 or Receiving Medicare
A report will be generated that will identify existing ACA Adult cases that contain individuals who are age 65 or older and those who receive Medicare. This report will be issued to each FCRC. The caseworker must review eligibility and determine if an individual on the list is eligible for other medical groups.
Caseworkers must review eligibility for ACA Adult when changes are made to the case.
Answer the following questions when changing an ACA Adult to AABD due to Medicare or age:
Question 1: Is the individual on Medicare?
If yes, review eligibility for FHP and AABD. If the individual is on Medicare they are not eligible for ACA Adult.
Question 2: Is the individual age 65 or older?
If yes, review eligibility for FHP and AABD. The individual is not eligible for ACA Adult.
AABD Budgeting
AABD does not use MAGI budgeting when determining eligibility. Income that is exempt under MAGI budgeting is not exempt for AABD. Unlike FHP and ACA Adult cases resources are not exempt for AABD. See PM 02-07-03-i and PM 07-02-00.
Reviewing Eligibility for AABD
Refer to PM-02-07-03-i for simplified processing when determining eligibility for AABD . When changing a case from ACA Adult to AABD, due to the person turning age 65 or receiving Medicare, review the income on the existing ACA Adult case. Determine from the chart below the verifications required in order to determine AABD eligibility:
| Type of Income |
What to send customer |
Worker Action |
| Individual Receiving SSI |
Nothing |
Approve for AABD |
| Individual receiving SSA only and income is at or below 100% FPL and income is verified |
Form 267
HFS 2378DR
|
Allow the individual 10 days to respond. |
| Individual receiving income other than SSA and income is at or below 100% FPL |
Form 267
Income (Last 30 days)
HFS 2378DR
|
Allow the individual 10 days to respond. |
| Individual receiving SSA only and SSA is over 100% FPL |
Form 267
2378VR
|
Allow the individual 10 days to respond. |
| Individual receiving other income (not SSI or SSA) over 100% FPL |
Form 267
Income (Last 30 days)
HFS 683
|
Allow the individual 10 days to respond. |
Send Form 267 with the appropriate form (listed above) requesting the needed information. When the customer returns the appropriate forms complete the following steps:
- Review returned documents. Determine eligibility for AABD.
- Review household composition to determine who to include in the standard. Refer to PM 15-06-02-c. Complete HFS 2382a, AABD MANG Computation Sheet-Community Case. Be sure to upload documentation.
- Cancel the ACA Adult case (suppress the cancellation notice if the person will be approved for another program).
- Set up an AABD case in IES, if eligible. Send the necessary approval notices.
If the requested information is not received within 10 days, cancel the ACA Adult case. Send Form 360C, Notice of Decision.
Note: When an individual who was receiving SSI income is placed in non-pay status, verification of income and resources is required. Simplified processing does not apply to this individual although they may still be eligible for AABD.
Consider HBWD (Health Benefits for Workers with Disabilities) when an individual is determined eligible for AABD spenddown, and has earned income, pays FICA, and is aged 16-64. See PM 15-08-00 regarding AABD Spenddown.
Change Case from AABD to ACA Adult
Individuals enrolled in AABD Spenddown whose income is over 100% FPL but not more than 138% of the FPL may be eligible for ACA Adult. If a person is enrolled in AABD Spenddown, review the person's eligibility for the ACA Adult group. Take the following actions:
- Ask tax status/relationship questions and verify income to determine eligibility under MAGI methodology.
- Process the determination of ACA Adult eligibility in IES and complete a write-up in IES regarding the request to review for ACA Adult eligibility.
SNAP Benefits
When a medical case, with SNAP changes to a different medical case, add the remainder of the SNAP approval period to the new medical case. Issue a new Link Card.
If the case is determined no longer eligible for medical, cancel the medical case and open a SNAP only case for the remainder of the SNAP approval period.
If medical benefits are canceled due to failure to provide requested information, set up a separate SNAP case for the remainder of the SNAP approval period and issue a new Link Card.
A person in a Family Health Plan (FHP) case can be in a facility for up to 3 months and stay in the FHP case. If care is needed for more than 3 months, the client must be removed from the FHP case and eligibility determined separately for the person in the facility and the other persons on the case.
