MR #16.12: Certification Periods for Medical Programs

Illinois Department of Healthcare and Family Services Illinois Department of Human Services

08/15/16

Summary:

Under IES Phase 2, the initial 12 month certification period for medical programs will be set in the following manner:
- By adding eleven months to either the month of application or the first month of eligibility for: All Kids Assist, FamilyCare Assist, Moms & Babies, ACA Adult, AABD medical, Health Benefits for Workers with Disabilities (HBWD), and Veterans Care (VC).
- For All Kids Share and Premium, the initial 12 month certification period will continue to start with the first ongoing month of eligibility.
At redetermination, a new certification period usually starts with the first month after the current certification period ends, however it may start earlier when enough information is available to renew medical eligibility without violating continuous eligibility policy for children.
Certification periods may be different for different programs and different medical eligibility determination groups (EDGs) within one IES case.
There are special medical certification period rules for deemed newborns and pregnant women.
Whenever possible, align the certification periods for the different programs/EDGs within an IES case.
Continuous eligibility for a child is aligned with the child's 12 month medical certification period.
This release clarifies that a task is created in IES when an electronic 'Death Match' is received that is not an exact match.
This release also clarifies that a person, if eligible, must be enrolled in the Health Benefits for Persons with Breast or Cervical Cancer (BCC) program rather than the ACA Adult program when the HFS BCC Unit receives the application from the Illinois Breast and Cervical Cancer Program (IBCCP).

Medical Certification Periods
Initial Certification Period- IES Phase 2
1. All Kids/FamilyCare Assist, Moms & Babies, ACA Adult, AABD, HBWD and VC
  1. Individual is Eligible in Application Month
  2. Eligibility Starts a Month after the Application Month
2. All Kids Share and Premium Levels 1 & 2
Resetting Certification Periods at REDE
1. Hard Stop Message for Certain Early REDEs
Deemed Newborns and Pregnant Women
1. Deemed Newborns
2. Pregnant Women
Aligning Medical Certification Periods on Active Cases
Continuous Eligibility for Children and the Medical Certification Period
Consolidated Death Match
BCC Program Clarification
MANUAL REVISIONS
Forms referenced

Medical Certification Periods

All HFS Medical programs other than 'Health Benefits for Persons with Breast or Cervical Cancer (BCC)' and 'Medical Extensions' have a 12 month certification period. Since deemed newborns have continuous eligibility through age one, they have a certification period of 13 months (from month of birth to month they reach one year old).

Program	Certification Period
Medical Extensions	4 months if due to spousal support 12 months if due to earned income with quarterly reports due in the 4th and 7th months
BCC	3 months for precancerous condition 6 months for cervical cancer 12 months for breast cancer or recurrent metastasized cancer
Deemed Newborns	13 months
All other Medical	12 months

Initial Certification Period- IES Phase 2

Under IES Phase 2, the initial 12 month certification period for medical programs will be set in the following manner.

All Kids/FamilyCare Assist, Moms & Babies, ACA Adult, AABD, HBWD and VC

Individual is Eligible in Application Month

Eleven months will be added to the month of application to determine the 12 month certification period. Backdate months are not part of the initial 12 month period.

Example: A family applies on 1/16/17 and is certified for FamilyCare Assist and All Kids Assist medical benefits on 2/10/17. They receive backdated benefits for Oct., Nov., and Dec. 2016. Their initial 12 month certification period is January through December 2017.

Eligibility Starts a Month after the Application Month

The 12 month certification period begins with the first month of eligibility when an individual is not eligible for the month of application, and is eligible beginning with a month after the application month.

Example: A family applies on 1/16/17 and is over income for the month of January, but qualifies for FamilyCare Assist and All Kids Assist effective February. Their initial 12 month certification period is February 2017 through January 2018.

All Kids Share and Premium Levels 1 & 2

Since eligibility for All Kids Share and All Kids Premium is always determined prospectively, the first month of the 12 month period continues to start with the first month of ongoing eligibility.

Example: If an All Kids Share EDG is certified on February 1st, the first month of coverage would be March and the approval period would be March through February of the following year. However, if the All Kids Share EDG was certified on February 18th (after March cut-off) the 12 month period would be April through March of the following year.

All Kids Share and Premium EDGs will not be aligned with other EDGs at application/Intake.

Example: A family with 2 adults and 2 children applies for SNAP and medical on Feb 1st. On Feb. 25th the family is determined eligible for SNAP for all 4 members, and All Kids Share for the 2 children. The SNAP certification period will start in February (the month of application). However, the All Kids Share certification period will start in March.

When appropriate, we may align the EDGs when a redetermination is completed on one of the programs/EDGs.

Resetting Certification Periods at REDE

At redetermination, a new medical certification period usually starts with the first month after the current certification period ends, however it may start earlier when enough information is available to renew medical eligibility without violating continuous eligibility policy for children (see PM 18-05-01).

Programs	Medical Cert Periods
Medical only (1 EDG or all medical EDGs due same time)	The new 12 month period starts with first month after the current certification period ends
Medical & SNAP (REDE due at same time)	The new 12 month period starts with first month after the current certification period ends.
Medical & SNAP (Medical REDE due before SNAP REDE)	The new 12 month period starts with first month after the current certification period ends.
Medical & SNAP (SNAP REDE due before Medical REDE)	Use SNAP data to REDE the medical EDGs and align the cert period with SNAP, unless a child subject to continuous eligibility would move to a higher cost program (such as from All Kids Assist to Share, or All Kids Share to Premium), or would become ineligible. If aligned, the new 12 month period starts with first month after the current SNAP certification period ends.
Medical only (multiple Medical EDGs, with different REDE due dates)	When first EDG comes due, use data to REDE all medical EDGs and align the cert periods unless a child subject to continuous eligibility would move to a higher cost program (such as from All Kids Assist to Share, or All Kids Share to Premium), or would become ineligible. If aligned, the new 12 month period starts with first month after the current certification period ends for the EDG that is due, and for any other medical EDGs that are aligned with the medical EDG that is due.

Programs

Medical Cert Periods

Medical only

(1 EDG or all medical EDGs due same time)

The new 12 month period starts with first month after the current certification period ends

Medical & SNAP

(REDE due at same time)

The new 12 month period starts with first month after the current certification period ends.

Medical & SNAP

(Medical REDE due before SNAP REDE)

The new 12 month period starts with first month after the current certification period ends.

Medical & SNAP

(SNAP REDE due before Medical REDE)

Use SNAP data to REDE the medical EDGs and align the cert period with SNAP, unless a child subject to continuous eligibility would move to a higher cost program (such as from All Kids Assist to Share, or All Kids Share to Premium), or would become ineligible.

If aligned, the new 12 month period starts with first month after the current SNAP certification period ends.

Medical only

(multiple Medical EDGs, with different REDE due dates)

When first EDG comes due, use data to REDE all medical EDGs and align the cert periods unless a child subject to continuous eligibility would move to a higher cost program (such as from All Kids Assist to Share, or All Kids Share to Premium), or would become ineligible.

If aligned, the new 12 month period starts with first month after the current certification period ends for the EDG that is due, and for any other medical EDGs that are aligned with the medical EDG that is due.

Example 1: The Teague family receives FamilyCare, All Kids Assist and SNAP benefits. All EDGs have the same certification period of Oct 2015 through Sept 2016. A REDE is completed and certified on Sept 6, 2016 for medical and SNAP. The new medical and SNAP certification periods are Oct 2016 through Sept 2017.
Example 2: The Ianni family has an All Kids Share EDG with a cert period of Oct 2015 through Sept 2016, and a SNAP EDG with a cert period of May 2016 through April 2017. A medical REDE is completed and certified on Sept 6, 2016. The new certification period for the Share EDG is Oct 2016 through Sept 2017. The cert period for the SNAP EDG is not changed.
Example 3: The Reed family has a SNAP EDG with a cert period of Oct 2015 through Sept 2016. Mr. Reed receives AABD medical and Mrs. Reed gets ACA Adult benefits. Both medical EDGs have a cert period of Jan 2016 through Dec 2016. A SNAP REDE is completed on Sept 6, 2016. Since the worker has enough information to REDE the medical EDGs as well, a REDE is processed for all EDGs. The medical cert periods are aligned with SNAP, and the new certification period for all EDGs is Oct 2016 through Sept 2017.
Example 4: The Eaton family receives All Kids Assist for Nick with a cert period of Oct 2015 through Sept 2016. They also receive All Kids Share for Nelly with a cert period of Nov 2015 through Oct 2016. On Sept 6th a REDE is completed for Nick who will be certified for All Kids Share. Using the same information, a REDE is also completed for Nelly who continues to qualify for All Kids Share. The EDGs are aligned and the new cert period for both children is Oct 2016 through Sept 2017.
Example 5: The Diaz family receives All Kids Assist for Stevie with a cert period of Oct 2015 through Sept 2016, and All Kids Premium Level 1 for Sally with a cert period of Dec 2015 through Nov 2016. On Sept 6th a REDE is completed for Stevie who will be certified for All Kids Premium Level 2. His new cert period is Oct 2016 through Sept 2017. Based on Stevie's REDE, Sally would also move to Premium Level 2. However, due to continuous eligibility policy, a REDE cannot be completed for Sally at this time.
When Sally is due for a REDE in November, both children continue to be eligible for All Kids Premium Level 2, and the worker completes a REDE for Stevie as well. Both Stevie and Sally will have a new cert period of Dec 2016 through November 2017.

Hard Stop Message for Certain Early REDEs

IES will not permit a REDE to be certified early for a medical EDG in certain situations. A REDE cannot be processed early for Medical Extension EDGs. The second situation where the REDE cannot be processed early is when a change would result in a child under age 19 being canceled or moved to a higher cost medical program before the current certification period ends. In these situations the following 'hard stop' message will appear on the certification page: "Early redetermination cannot be processed for one or more EDGs. Please process redetermination after cutoff in the month prior to the certification end date."

Example 1: The Wong family receives All Kids Assist for Jill and John with a certification period of January through December 2016. A REDE form is mailed to the family on November 1st with a response due by December 1, 2016. The customer responds through the ABE member portal on 11/03/16 and uploads all required verifications. The income has increased and the children now qualify for All Kids Premium level 1.
On 11/05/16, the worker attempts to certify the REDE. Since IES is still processing for the ongoing month of December, the last month of the current certification period, the 'hard stop' message will appear on the certification page. The worker cannot certify the REDE until after cutoff (11/16/16). On 11/16/16, the worker certifies the REDE for the effective month of January. The new All Kids Premium Level 1 certification period is January through December 2017.
Example 2: The O'Brian family receives FamilyCare for Mr. and Mrs. O'Brian and All Kids Assist for Pat and Meghan with a certification period of January through December 2016. A REDE form is mailed to the family on November 1st with a response due by December 1, 2016. The customer responds through the ABE member portal on 11/03/16 and uploads all required verifications. The income has increased slightly and the children will continue to qualify for All Kids Assist, however the parents are now over the FamilyCare income level.
On 11/05/16, the worker certifies the REDE. Since the children will not move to a higher cost program, the system will allow the REDE to be processed early and will set a new All Kids Assist certification period of January through December 2017. However, since IES is still processing for the ongoing month of December, the adults will be canceled effective December 2016. IES will transmit their case information to the Marketplace.

Deemed Newborns and Pregnant Women

Deemed newborns and pregnant women receive a period of continuous eligibility under policy that is separate from the policy regarding continuous eligibility for children under age 19 that is described in PM 18-05-01.

Deemed Newborns

Newborns whose mother was covered for HFS medical benefits for the newborn's birth are deemed eligible and are continuously eligible for medical benefits until they are a year old regardless of changes in income. Rather than aligning a deemed newborn's certification period with the other medical EDGs on a case, the newborn's cert period will be set to end after they turn 1 year old.

Note: This is a change from what was described in the 'Batch Actions and PAL Codes in IES' manual release dated 5/04/16. Since their cert period will be aligned with their 1st birth date, the 'Newborn Batch Action' that was described in the earlier release will not be required.

Example: Ms. G receives FamilyCare for herself and All Kids Assist for her 5 year old son, Carl. The certification periods for the FamilyCare and Assist EDGs are Jan through Dec 2017. In April 2017 she reports that she had a baby, Judith, born April 5th. Judith is added for medical benefits effective April 2017. The last month of Judith's cert period will be April 2018.
When Ms. G and Carl are REDE'd the following December, an income increase is reported. Ms. G is canceled due to being over income, Carl goes to All Kids Share, and Judith continues as a deemed newborn for the remainder of her certification period.

Pregnant Women

Under the Moms & Babies program, pregnant women are eligible through their 60 day post partum period regardless of income changes (see PM 06-09-05).

When an active recipient is reported to be pregnant, IES may reset the last month of her certification period to ensure that benefits do not end prior to the anticipated end of her post partum period.
When a person who is pregnant is being added to the case, she may receive a separate certification period to ensure that benefits do not end prior to the anticipated end of her post partum period, rather than aligning her cert period with the other medical EDGs on the case.
When a pregnant woman has a certification period that ends after her post partum period, IES will trigger a Batch Action to rerun eligibility when her post partum period ends to determine whether she can continue to receive medical benefits (see PM 19-08-00).

Aligning Medical Certification Periods on Active Cases

When a person is added for medical benefits to an IES case with existing medical benefits, IES will align the added individuals' certification period with the certification period of the existing medical EDG.

When a new program is added to an active IES case, the system aligns the certification periods in the following order:

Program added	Existing Program	Result
MSP EDG	Active Medical	align Medicare Savings Plan (MSP) with existing medical cert period
Medical EDG	Active Medical	align new medical EDG with existing medical cert period
Cash EDG	Active Medical	align medical EDG with new cash EDG (REDE done)
Medical EDG	SNAP	align medical EDG with existing SNAP EDG (REDE done)
SNAP	Medical	align medical EDG with new SNAP EDG (REDE done)

Example 1: The Aguilar family receives FamilyCare and All Kids Assist benefits with certification periods of July 2016 through June 2017. Mr. Aguilar begins receiving Medicare benefits and qualifies for QMB effective Jan 2017. The new QMB/MSP certification period is aligned with the FamilyCare EDG and will end June 2017.
Example 2: Mr. Zack, age 66, receives AABD medical and has a certification period of July 2016 through June 2017. His 14 year old grandson, George, moves in with him in September and Mr. Zack requests medical benefits for George. George is approved for All Kids Assist starting in September and his certification period is aligned with Mr. Zack's with an end date of 06/30/17. When George is added to the IES case, Mr. Zack is certified under the FamilyCare program because he is George's caretaker relative. Mr. Zack's certification period is not changed.
Example 3: Ms. Tower receives All Kids Share benefits for her two children. Her certification period is August 2016 through July 2017. In November she loses her job and requests TANF assistance. She is approved for TANF for herself and her two children. Due to the receipt of TANF benefits, the family is deemed eligible for FamilyCare and All Kids Assist. The medical benefits are aligned with the new TANF certification period. Since the children are moving from All Kids Share to a lessor cost program, All Kids Assist, setting a new certification period for the children is not a violation of continuous eligibility policy.
Example 4: The Cruz family receives FamilyCare and All Kids Assist benefits with a certification period of July 2016 through June 2017. In October the family requests SNAP benefits. The income verification provided with the SNAP application shows that family income is increased to the All Kids Share level. The family is approved for SNAP with a certification period of October 2016 through September 2017. Mr. and Mrs. Cruz' medical benefits are canceled and they are referred to the Marketplace. Due to continuous eligibility policy, the children continue to receive All Kids Assist through June 2017.

Continuous Eligibility for Children and the Medical Certification Period

Once determined eligible, a person under age 19 is eligible for medical benefits for 12 months. The 12 month continuous medical eligibility period begins with the first month of their certification period. In addition to the 12 month certification period, a child qualifies for continuous eligibility from the first back date month in which they qualify for All Kids Assist or AABD medical.

This applies to All Kids Assist, Share and Premium as well as children enrolled in AABD medical. Under continuous eligibility, a child's medical benefits cannot be terminated or moved to a higher cost medical program (such as from All Kids Assist to All Kids Share or Premium) due to a change in income or household size during the certification period. However, a child may be redetermined and assigned a new certification period if the child qualifies for the same level of benefits, or the change results in a lessor cost medical program (such as from All Kids Premium to All Kids Share or Assist).

Consolidated Death Match

IES receives information from various sources for customers who may have passed away. Sometimes, IES is able to confirm exact matches and in those cases will auto-process the match. A task "Client Presumed Deceased" will be created in the Changes/Misc EDM queue when IES is unable to auto-process the match in situations where an exact match cannot be confirmed. This is a change from what was described in the 'Batch Actions and PAL Codes in IES' manual release dated 5/04/16, and is updated in WAG 19-08-00.

BCC Program Clarification

A person who may otherwise qualify for the ACA Adult program must be enrolled in the BCC program rather than the ACA Adult program if the HFS BCC Unit receives the application from the Illinois Breast and Cervical Cancer Program (IBCCP), and the person qualifies for BCC.