WAG 03-13-02-c: Determination of Family Care Barrier

PM 03-13-02-c

If the client claims they are unable to work due to the medical condition of a related child under age 18 or a spouse living in the home, do the following:

1. (FCRC) Enter Item 80 Code 156 DRD on Form 552 with the month and year the client claimed a barrier, and SUP. BY. 'P' to indicate a family care barrier request is pending.
2. (FCRC) Complete Medical Evaluation - Social Information (Form 183B) based on the client's statements, worker's observation, and other available information.
   1. If determination is requested for a school-age child, request a copy of a Family Service Plan (FSP) or Individualized Education Plan (IEP), and school attendance records.
3. (FCRC) Request medical information to support the client's claim that the spouse's or child's medical condition prevents full-time employment.Use the most current version of Form 183A.  
   1. Identify the medical providers the spouse or child has used in the past 12 months. Acceptable medical providers are physicians, psychologists or psychiatrists.
   2. If the client has current (within past month) medical reports from a provider which address the condition which the client states makes them unable to work, go to 8.
   3. If the client does not have current medical reports from a provider, ask the spouse or person legally responsible for the child to sign a Consent to Release Medical Records (Form 4701H) for each provider. Make a copy of the consent form for the case record. Complete the top section on page 1 of Medical Evaluation - Physician's Report (Form 183A); use a separate Form 183A for each provider. Send Form 183A and Form 4701H to each provider.
   4. If the person was treated at a Veteran's Administration facility, also ask them to sign Request to Veteran's Administration (Form 1301). Check the box to specify that Medical Data is being requested. Attach Form 1301 to Form 4701H and send to the VA.
   5. If the person was recently incarcerated in an Illinois Department of Corrections facility, also ask them to sign Authorization for Release of Information (Form IL426-4517) to get information from DOC. Specify the type of information being requested. Attach Form IL426-4517 to Form 4701H and send to DOC.
   6. If the spouse or child has not received treatment within the past 3 months, set up an appointment for a medical examination with their physician or physician of their choice who is an approved Medicaid provider. If the person has mental health issues, set it up with an approved Medicaid psychiatrist. Go to step 4a.

      Example: Ms. A applies for TANF and is interviewed on 06/01. She claims a family care barrier due to her husband's disability. Her husband's last visit to a doctor was on 01/15. Since Mr. A has not received treatment within the last 3 months, set up an appointment for him with his physician. 

4. (FCRC) If the medical information has not been received after 30 days, contact the provider to determine the status of the request.
5. (FCRC) If the information is not received within 45 days from the date the forms were sent to the provider, set up an appointment for a medical examination with their physician or physician of their choice who is an approved Medicaid provider. If the person has mental health issues, set it up with an approved Medicaid psychiatrist.

   Example: Ms. B applies for TANF and is interviewed on 06/15. She claims a family care barrier due to her child's medical condition. The child was seen by a physician on 06/01. The caseworker completes the top section on Form 183A; Ms. B signs Form 4701H. The forms are sent to the child's physician.

   On 07/31, the forms have not been returned. Set up an appointment for Ms. B's child with the physician. 

   1. Complete Referral for Medical Examination (Form 1864) in triplicate. Attach Form 183A, a copy of signed Form 4701H, and Letter to Medical Provider About Care (Form 4216A) to the original and first copy of Form 1864; give or send these forms to the client to be given to the medical provider. File the 2nd copy of Form 1864 in the case record.
   2. Set a control to follow up after the appointment.
   3. If the person misses the appointment without good cause, send Form 2827 denying the request for a family care barrier. Engage the client in work and training activities. No additional action is needed.
   4. If the person misses the appointment and claims good cause, help them reschedule it.
   5. If the person keeps the appointment, wait for the provider's report.
6. (Provider) Completes a medical exam on the person who has a medical condition and enters the findings on Form 183A. If the person who has a medical condition was referred by Form 1864, keeps the first copy of Form 1864 for the provider's records.
7. (FCRC) Returns the completed Form 183A to the sending office. If the person who has a medical condition was referred by Form 1864, also returns the original Form 1864 and completed Form 2360.
8. (FCRC) Complete Client Assessment Unit (CAU) Memorandum (Form 183F).
   1. Use latest version of Form 183F.
   2. Complete Referred Person's Name with the name of the person whose medical records are being submitted. 
   3. Check TANF Medical Condition.
   4. Check Family Medical Care Barrier.
   5. Check either Qualifying Spouse, or Child under age 18. 
9. (FCRC) Prepare a packet with Form 183F, Form(s) 183A and related medical records, Form 183B, Form(s) 4701H, and all medical information from previous CAU determinations. Make and keep a copy of the packet. Mail the original packet to: Client Assessment Unit
   PO Box 19492
   Springfield, IL 62794-9492
10. (FCRC) If a decision is urgently needed, call CAU at (217) 524-8190 for permission to fax the packet.
11. (CAU) Completes Form 183C showing:
    • the decision regarding the family care barrier or a request for more information, and
    • if approved, a medical review date, when needed.
12. (CAU) Returns the entire packet with Form 183C to the FCRC.
13. (FCRC) When CAU requests more information, attempt to obtain it. Set up additional appointments or request test results, as needed. Resubmit the entire packet to CAU with the additional information. (See steps 2 - 9.)
    1. If the client does not provide the required additional information, do not resubmit the packet to CAU. Send Form 2827 denying the request for a family care barrier. Engage the client in work and training activities. No additional action is needed.
14. (FCRC) When CAU makes a decision, take appropriate case action.
    1. Notify the client of the decision by sending Form 2827. When CAU approves the Family Care Barrier, also send YOUR TANF TIME LIMIT (Form 4335) if you reduce the TANF counter.
    2. If CAU approves the Family Care Barrier, update Form 552 as follows:
       • Item 60 -Reduce the TANF counter for each adult for any months that were counted during the CAU approval process if the counter was 60 or less when the barrier was requested.
       • Item 73 -In ACM or IPACS, enter code M for care of child or code Q for care of spouse for the person who is providing the full-time care. In AIS, enter FC (Family Care Child) or FS (Family Care Spouse) on TANF/REFUGEE CAF SCREEN #24A, WORK EXPERIENCE/REGISTRATION REQUIREMENTS.
       • Item 80 -If code 156 is not already present, enter code 156 DRD with the review month and year under PERSONS and code 3 (Family Care) under SUP. BY.
    3. If CAU finds the client is not needed to provide full-time care and no other barriers exist, delete Item 80 Code 156 and update the client's RSP and engage the client in appropriate work and training activities. Unless the client appeals CAU's determination, or there is additional medical information included, do not resubmit the same packet to CAU.
15. (FCRC) When Form 1864 and/or Form 2360 are received with Form 183A or copies of medical records, complete Invoice-Voucher (Form C-13). Enter the person's name, case name and number, and a statement that the exam or records were needed to determine a TANF Family Care barrier. Leave the payment amount and signature areas blank.
16. (FCRC) Attach Form 1864 and/or Form 2360 to the Form C-13 and send to:

    Illinois Department of Healthcare and Family Services
    Bureau of Claims Processing - Pricing Unit
    PO Box 19106
    Springfield, IL 62794-9106 

17. (HFS) Handles pricing and payment to the provider.
18. (FCRC) File the CAU packet (including Forms 183A, 183B, 183C, 183F, and medical records) and a copy of Forms 2827 and 4335 in the case record.
    • Example: On 03/03/04 a client with TANF counter of 36 reports she cannot participate in work and training activities because her daughter, age 10, has muscular dystrophy and requires her full-time care. Complete Request for Status Review (Form 2826) in duplicate and give the client a copy. Complete Form 183B with information about the daughter's medical condition, background, daily schedule, and care provided by the client. Ask client to sign Form 4701H. Send Form 183A and Form 4701H to the daughter's physician with Form 4216A as a cover letter.
    • When Form 183A is returned, complete Form 183F requesting an assessment for TANF - Family Care Medical Barrier (child). Send Forms 183F, 183A, 183B, and copy of signed Form 4701H to CAU. The client is not required to participate in work and training activities during this process.
    • CAU approves the family care barrier and returns Forms 183A and 183B with Form 183C on 04/15/04. The FCRC enters code M in Item 73 for the client effective 05/04. Subtract 2 months from her TANF counter, since 03/04 and 04/04 were counted during the determination process. Revise the RSP to include care of the daughter and to remove work and training activities in which the client does not want to participate.

    Send the client Notice of Decision on Status (Form 2827) telling her the request was approved, Form 4335 telling her about the reduced and stopped counter, and a copy of the revised RSP. 

Appeal of CAU Determination

When CAU denies the barrier request, and the client files a timely appeal, enter Item 80 Code 156 with SUP. BY code A on the 552. Enter the month and year the customer filed the appeal. The appeal is considered timely if filed within 60 days after the date of Form 2827.

See PM 01-07-00 for policy on Appeal Rights and Fair Hearings.

Conduct a pre-hearing meeting following the procedure for appealing a "Not Disabled" determination. See PM 01-07-07-b.

The case will select for Code X on the PAL four months after the date entered with message "REVIEW MEDICAL BARRIER STATUS. APPEAL", and will continue to appear each subsequent month until Code 156 is deleted, or updated with a new SUP. BY code. See WAG 19-06-01-l.

If the appeal affirms CAU's determination, engage the client in work or training activities unless another barrier exists. Unless there is additional medical information included, do not resubmit the same packet to CAU.

Example 1: Mr. B's request for a family care barrier was denied by CAU on 5/22/11. He files an appeal on 6/3/11. The worker enters Item 80 Code 156 with SUP. BY Code A and date 06/11. The case selects for Code X on the PAL every month beginning with the report for 10/11. The appeal is heard on 01/18/12 and the hearing officer finds in favor of Mr. B, with a review to take place in 3 months. The worker enters code Q in Item 73, and updates Item 80 Code 156 with SUP. BY Code 3 and 04/12 in the date to show the barrier was approved.

Example 2: CAU found Mrs. D not eligible for a family care barrier based on a Form 183A dated 3/1/11 from her husband's physician. Mrs. D appealed the determination. The hearing officer upheld CAU's determination. When meeting with Mrs. D to engage her in a work activity, she continues to claim she cannot work due to her husband's condition. As the hearing officer's ruling is final, she is subject to sanction if she does not cooperate with the work activity. Do not resubmit the Form 183A dated 3/1/11 to CAU without additional information