This manual release obsoletes policy memorandum, The New ACA Adult Group, dated 05/07/14.
Currently there are a number of persons being incorrectly enrolled as ACA Adults. This manual release is to assist staff in being able to correctly determine eligibility for ACA Adult, Family Health Plans (FHP) and Aid to the Aged Blind and Disabled (AABD).
A person may not be enrolled as an ACA Adult if the:
- person is age 65 or older; or
- person is age 18 or younger; or
- person has Medicare;
- person is eligible as a parent/caretaker relative or pregnant woman; or
- person is eligible for Former Foster Care.
The ACA Adult Group
Effective January 1, 2014, the Affordable Care Act (ACA) established a new federal eligibility group for medical coverage for adults. Public Act 98-0104 authorizes Illinois to allow medical coverage under this new group.
Spouses may be included on the same ACA Adult case. Establish a separate case for unmarried adults who apply together.
Example: Mom applies for herself and her 21 year old son. Neither Mom, nor her son are tax filers. They both potentially qualify for the ACA Adult program. Since they are not part of the same tax filer household, the adult son must file a separate application.
A case is split only when the same application can be used to determine eligibility for all of the cases involved. When the same application cannot be used to determine eligibility for all of the cases involved, persons who need to apply separately are denied. See PM 02-04-03 for more information about who can sign an application.
- age 19 through 64;
- Illinois resident (PM 03-02-00);
- meets Social Security number requirement (PM 03-11-00);
- meets U.S. citizenship or immigration requirements (PM 03-01-00);
- does not qualify for Family Health Plans;
- does not qualify for Former Foster Care; and
- is not receiving Medicare.
A person, who applies for or receives ACA Adult, automatically assigns to HFS their rights to medical support or other third party medical payments.
Modified Adjusted Gross Income (MAGI) budgeting is used when determining eligibility for an ACA Adult. Refer to Manual Release #15.19, Modified Adjusted Gross Income (MAGI) Budgeting for Medical, dated 07/29/15 (updated 08/18/15), policy memo, Verifications for Medical Programs, dated 10/03/13 (updated 05/28/14) and PM 08-03-00.
To qualify for ACA Adult, the household income must be at or below 138% of the FPL (133% plus a 5% disregard). There is no spenddown for persons in the ACA Adult eligibility group.
Verification of income for 30 days prior to date of application is required for determining medical eligibility.
Persons eligible for ACA Adult are not eligible for medical extensions under Family Assist (FA).
Resources (assets) are exempt for the ACA Adult group.
Identifying an ACA Adult Case
ACA Adult cases are assigned Category 94. They look like a FHP case. A category 94 case is ACA Adult when item 25 is coded "K" and item 28 is coded "W".
Funeral and Burial
Funeral and burial is not a covered service under the ACA Adult group.
Eligible persons may receive retroactive medical coverage beginning three months prior to the month of application per PM 17-02-05-a.
No Disability Determination Required
Having a disability is not a factor of eligibility for the ACA Adult group. Do not complete a Client Assessment Unit (CAU) determination for persons who are eligible for ACA Adult. Applicants who have a disability may be enrolled in the ACA Adult group.
Persons who are currently enrolled in AABD Spenddown may be eligible for ACA Adult if:
- income is at or below 138% of the FPL; and
- they are not enrolled in Medicare; and
- they are age 19 through 64; and
- they are not a parent or caretaker relative of a minor child living with them.
Note: When an ACA Adult becomes potentially eligible for AABD, review PM-02-07-03-i for determining when verification of resources is required.
Emergency Medical for Ineligible Non-Citizens Under ACA Adult
Emergency medical for persons who do not meet U.S. citizenship/immigration requirement may be approved under the ACA Adult group, if all other factors of eligibility are met. Refer to PM 06-05-00.
Although individuals must meet citizen/immigration criteria for 'regular' eligibility under the ACA Adult group, the Affordable Care Act adds ACA Adult to the medical groups covered under Emergency Medical for Noncitizens not meeting Immigration status.
Case Maintenance for the ACA Adult Group
A person becomes ineligible for ACA Adult in the following circumstances:
- reaches age 65;
- is enrolled in Medicare;
- is a parent or caretaker relative of a child living in the home;
- has income that exceeds 138% of the FPL; or
- no longer meets the financial and non-financial eligibility criteria.
There is no spenddown option for persons in ACA Adult.
When a spouse moves out of the home of an active ACA Adult case, delete the spouse using TAR 07.
Persons Incorrectly Receiving ACA Adult
There are persons currently active on ACA Adult cases that are not eligible as ACA Adults. This happens because of the following reasons:
- Persons who receive both ACA Adult and SNAP benefits are not sent the necessary forms when they are turning age 65 or become eligible for Medicare in order to determine eligibility for medical assistance under FHP or AABD.
- ACM and IPACS had allowed ACA Adult cases to have Medicare. Edits that would have prevented this were not initially included. The process relied on the caseworkers to review eligibility criteria prior to making changes to the case. New edits have been added, effective April 4, 2017. However it is still very important for caseworkers to carefully review eligibility criteria.
- IPACS allows ACA Adult coding to be added to a FHP case when deleting all children from the case and adults are over the age 64 or receive Medicare. A new edit has been added, effective April, 4 2017. However it is still very important for caseworkers to carefully review eligibility criteria.
- Caseworkers do not always review age and Medicare status when updating ACA Adult cases. System edits have been added but caseworkers should review eligibility prior to making case changes.
Review eligibility for FHP or AABD when a person 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 person turns age 65; or
- the person 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 a customer request that a spouse be added to an ACA Adult case. The customer must complete Form 243, Request for Medical Benefits for Another Family Member(s). Take the following actions:
- ask tax status/relationship questions; and
- verify income to determine eligibility under MAGI methodology;
- process request if eligible; and
- 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 a person must be:
- pregnant woman;
- child (age 18 or younger); or
- parent/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 person 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.
When the ACA Adult case needs to be changed to Family Health Plans, cancel the ACA Adult case, suppress the notice in Item 39 and open the Family Health Plans case reusing the same basic ID number.
If a change in income is reported, enter the case in IES as if it were a new application and run eligibility. Send Form 1721, if additional information is needed.
If the person is determined ineligible for FHP, consider AABD eligibility. Refer to the section below on "Reviewing Eligibility for AABD ".
When reviewing eligibility for FHP refer to Manual Release, Modified Adjusted Gross Income (MAGI) Budgeting for Medical, dated 07/29/15. Caseworkers are required to complete a manual calculation to determine MAGI eligibility.
Example 1: Mary, age 67, has two grandchildren living in the home. Since Mary is over the age of 64 she is not eligible for ACA Adult. Due to minor children living in the home she may be eligible for FHP. If Mary is not eligible for FHP, review for AABD. See section on "Reviewing Eligibility for AABD".
Example 2: Sue, age 35, is currently in the ACA Adult eligibility group. She reported that her minor child moved into the home. Sue is no longer eligible for ACA Adult. Review eligibility for FHP. If Sue is not eligible for FHP, review for AABD. See section on "Reviewing Eligibility for AABD".
Example 3: An ACA Adult reports a newborn. The newborn is potentially eligible for Moms and Babies because the mother was receiving Medicaid under ACA Adult. Review PM 06-09-01. If they are eligible for FHP, change the case level coding as described above.
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 for FHP up to age 19 due to continuous eligibility. Determine eligibility for ACA Adult for the parent or caretaker relative. If the parent or caretaker relative is eligible for ACA Adult, open the case in IES using the date of discovery as the application date.
- Enter TA 34 in item 3
- Process the deletion. Refer to WAG 18-03-11-d.
- Enter "W" in item 28
- Enter "K" in item 25
Actions can only be processed in IPACS.
Illinois Medicaid Redetermination Project (IMRP) -Medical Only
The Illinois Medicaid Redetermination Project (IMRP) sends redetermination forms to ACA Adults turning age 65, 18 year olds on FHPs turning 19 years old, and ACA Adults who will begin receiving Medicare. The redetermination form must be completed and signed. The central unit will review the returned redetermination form and determine eligibility for the new case. Refer to Policy Memo, Changes to the Illinois Medicaid Redetermination Project (IMRP) revised, dated 02/06/2014.
For AABD, use regular AABD budgeting. Request verification of resources for AABD, if required. Review PM 02-07-03-i regarding simplified processing. MAGI budgeting does not apply to AABD cases. MAGI budgeting does apply to an 18 year old in FHP who is turning 19 years old and being considered for the ACA Adult group.
Cancel the current case after eligibility has been determined for a different eligibility group. Prior to Phase II implementation, staff must register the redetermination in order to establish a new case in IES. Approve if determined eligible for medical in a different program and suppress the notice.
ACA Adult Cases with SNAP-Turning 65 or Receiving Medicare
A report will be generated that will identify existing ACA Adult cases that have persons 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 a person on the list is eligible for other medical groups.
To prevent future errors, edits have been recently added in IPACS and ACM that will prevent entering "K" in item 25 when the case includes an individual who has Medicare and the Medicare coding is entered on the case by the worker. An error message, "Code K invalid for item 25. Individual has Medicare, review for AABD eligibility." will display.
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 person on Medicare?
If yes, review eligibility for FHP and AABD. If this person is on Medicare they are not eligible for ACA Adult.
Question 2: Is the person age 65 or older?
If yes, review eligibility for FHP and AABD. This person is not eligible for ACA Adult.
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, review the income on the existing ACA Adult case. Determine from the chart below the verifications required in order to determine eligibility for the AABD group:
|Type of Income
||What to send to the client
|Person receiving SSI
||Approve for AABD
|Person receiving SSA only and income is at or below 100% FPL and income is verified
HFS 2378DR/HFS 2378DRS
|Allow the client 10 days to respond.
|Person receiving income other than SSA and income is at or below 100% FPL
Request verification of income (Last 30 days)
|Allow the client 10 days to respond.
|Person receiving SSA only and SSA is over 100% FPL
HFS 2378VR/HFS 2378VRS
|Allow the client 10 days to respond.
|Person receiving other income (not SSI or SSA) over 100% FPL
Income (Last 30 days)
HFS 643 (Rede)
|Allow the client 10 days to respond.
Send Form 1721 with appropriate form (listed above) requesting needed information. When the client 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) before opening the AABD case.
- Set up an AABD case. If enrolled in regular AABD, process in IES. If enrolled in spenddown, process case in IPACS. Send the necessary approval notices.
If requested information is not received within 10 days, cancel the ACA Adult case. Send Form 360C, Notice of Decision.
Note: When a person who was receiving SSI income is placed in non-pay status, verification of income and resources is required. Simplified processing does not apply to these persons although they may still be eligible for AABD.
Health Benefits for Workers with Disabilities (HBWD)
Persons with disabilities can work and not fear losing medical benefits due to spenddown. See PM 06-24-00. Consider HBWD (Health Benefits for Workers with Disabilities) when a person is determined eligible for AABD spenddown when the individual is:
- age 16-64; and
- has earned income, and
- pays FICA.
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 as a new application and complete a write-up in IES regarding the request to review for ACA Adult eligibility.
- If a the person is determined eligible for as an ACA Adult, stop and cancel AABD spenddown in IPACS before approving the ACA Adult case in IES. Suppress the AABD cancellation notice. Send the central approval notice for the ACA Adult case.
Example: Mr. Smith is enrolled in AABD Spenddown. His spenddown is $302 each month. Mr. Smith's income is below 138% of the FPL. A new application is not required. Follow the above steps to determine his eligibility for ACA Adult.
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.
Long Term Services and Supports (LTSS) for Persons Enrolled in ACA Adult
ACA Adults are eligible to receive Long Term Services and Supports (LTSS). LTSS includes Nursing Home (NH), Supportive Living Program (SLP) and Department on Aging (DoA) Home and Community Based Services (HCBS). This policy applies to persons requesting LTSS who are applying for medical assistance and persons who are already receiving medical assistance.
To receive LTSS under the ACA Adult group the person:
- Does not have to be determined disabled,
- Can have an adjudicated disability as long as they don't receive Medicare,
- Must meet ACA Adult income requirements (138% of FPL),
- Does not have a resource limit,
- Must meet the screening requirements described in PM 20-08-04,
- Must complete HFS 3654 and provide requested verification of resource transfers.
When an ACA Adult requests LTSS:
- Always use a one person standard,
- Require completion of HFS 3654/HFS3654S and verify resource transfers. Do not request verification of current resources,
- Do not send Form IL 444-0008, to Bureau of Collections because lien and estate claims are not applicable to the ACA Adult group.
Resource/Income Transfers for ACA Adult requesting LTSS
To be approved for LTSS, ACA Adults and their spouses are required to report and verify transfers of resources and income during the lookback period.
Resource transfer requirements:
- Lookback period is 60 months.
- Lookback period may be reduced.
- Reduction cannot be less than 12 months.
- Duration of lookback period should be based on information reported on HFS 3654 and resource documentation provided when LTSS is requested.
- Beginning month of the lookback period is the month prior to the month of application.
- When medical backdating is requested, the beginning month of the lookback period is still the month prior to the month of application.
When Not to Approve for LTSS
Do not approve an ACA Adult for LTSS when the person doesn't cooperate with the resource/income transfer requirements.
For NH and SLP
- Do not treat the person as residing in an NH or SLP.
- Code Box 20 using a 16.
- Do not process an admit in MMIS.
- Do not treat the person as receiving DoA services.
- Code Box 20 using a 16.
Persons who fail to cooperate with LTSS may still be approved, if eligible, for medical benefits.
The LTSS spouse and the community spouse may transfer resources and income for ACA Adults to each other in any amount without penalty. See PM 07-02-20-b for additional guidance on allowable transfers.
Unallowable Transfers and Penalty Periods
Penalty periods are applied when an ACA Adult requesting LTSS transfered resources or income for less than fair market value during the lookback period. A transfer of resources or income occurs when a person or his/her spouse (regardless of who has an interest in the resources or income) buys, sells, or gives away real or personal property, or changes the way property is held, PM 07-02-20 and PM 07-02-20-c.
Penalty Period Coding
For NH and SLP
- Enter code 398 in item 80 with month/year of beginning penalty period
- Enter Code 399 in item 80 with month/year of ending penalty period
- Enter 16 in item 20
- Set a control to change item 20 coding at end of penalty period
Referrals to Long Term Care - Asset Discovery Investigation (LTC-ADI)
Refer LTSS applications and redeterminations to the Office of Inspector General (OIG) Long Term Care-Asset Discovery Investigation (LTC-ADI) unit when referral for criteria is met. To review criteria for referral, see Medical Morsel - Changes to Criteria for Referrals to Long Term Care - Asset Discovery Investigation Unit.
Post-Eligibility Determination for ACA Adult and LTSS
Income and current resource amounts are not used in LTSS post-eligibility determination for ACA Adults. When determining post-eligibility for LTSS for an ACA Adult the following allowances are not applied:
- Community Spouse Maintenance Needs Allowance (CSMNA),
- Community Spouse Resource Allowance (CSRA),
- Family Maintenance Needs Allowance (FMNA).
For NH and SLP
- Completion of HFS 2500 is not required,
- Enter $0.00 for patient credit amount in MMIS.
Note: SLP residents are still required to pay the facility for their room and board amount but the room and board amount is not entered into MMIS.
Type Action Reason (TAR) K4 may be used to deny or cancel an ACA Adult case when income exceeds 138% FPL. Use TAR K4 when income exceeds the standard with the following type action:
- Denial (TA 05)
- Approve and Cancel (TA 10); and
- Cancellation (TA 22).
Form 360C or Form 157C is systematically generated when TAR K4 is coded in item 33 and Item 39 is coded 00, with the following message is: You do not qualify for medical benefits because your income is over the limit. TAR "K4" will not send a SNAP notice.
New ACA Adult Case Edits in IPACS and ACM
Effective 4/4/17, new edits are in place in ACM and IPACS that will prevent staff from taking certain actions on ACA Adult cases when there is someone on the case no longer eligible for the ACA Adult eligibility group due to age or Medicare.
When an ACA Adult case has Medicare or is under age 19 or age 65 or older, the following Type Actions (TA) will be blocked by an edit:
- TA 12/98- quick reinstatement;
- TA 30- REDE;
- TA 31- change action; and
- TA 34- additions.
When an ACA Adult case has Spenddown codes 390/392 in Item 80, the following Type Actions (TA) will be blocked by an edit:
- TA 12/98- quick reinstatement; and
- TA 30- REDE
The following Type Actions (TA) will be allowed so that the cases can be updated:
- TA 34- deletions to remove the individual due to Medicare or age
- TA 31/42-address change
- TA 31 to remove spenddown
Note: When a Former Foster Care individual has a baby, the baby is eligible for Moms & Babies as a newborn. Set up a separate case for the newborn, do not add the baby to the Former Foster Care case. A Former Foster Care case is a category 94 with code J in item 25.
Persons determined ineligible for medical assistance are referred to the Health Insurance Marketplace for insurance. HFS 3704, Important News You Can Get Help to Buy Health Insurance or HFS 3704/S is sent centrally with cancellation notice.
- Form 243
- Form 360C
- HFS 683
- HFS 2378DR/S
- HFS 2378VR/S
- HFS 2500
- HFS 3654/S
- HFS 3704/S
Policy References to CountyCare
The CountyCare waiver ended 12/31/13. This release removes references to CountyCare that appear in the Policy Manual (PM) and Worker's Action Guide (WAG) pages. CountyCare ended with the enactment of the Affordable Care Act (ACA) effective 01/01/14.
[signed copy on file]
James T. Dimas
Secretary, Illinois Department of Human Services
Felicia F. Norwood
Director, Healthcare and Family Services