WAG 19-02-03-b: Proving Eligibility

IES Phase 2 Process

Upon implementation of the Integrated Eligibility System (IES) phase 2, the process for completing a redetermination is changed. The Medical REDE process is described in PM 19-02-04.

See WAG 19-02-03-a for the procedure to process an AABD Cash REDE.

Legacy Process

Updated with Policy Memo, Changes to the Illinois Medicaid Redetermination Project (IMRP) Revised

Updated with Policy Memo, Update to the Illinois Medicaid Redetermination Project (IMRP) for SSI and Medical Extension Cases

Updated with Policy Memo, AABD Medical Central REDE Clarification

Forms used for AABD Cash cases:

AABD Redetermination Report Form (Form 643G), which applies to community cases but not to sheltered care cases, is centrally sent to cases which do not receive SNAP. These cases are listed on PAL with message "REDE FORM 643GC CENTRALLY MAILED. DUE BY MM/DD/YY"; or
Redetermination - Group Care/Sheltered Care (Form 1229). Complete for long term care and sheltered care cases.
Budget Computation Worksheet (Form 553A). Attach to Form 643G.
Form 157C. Centrally sent if there is a decrease in the amount of benefits or if benefits are being canceled.

Forms used for AABD Medical cases:

Redetermination - Group Care/Sheltered Care (Form 1229) for NH, SLF and sheltered care cases.
Nursing Home/Supportive Living Facility Redetermination Report Form (Form 1229A) is sent by Maximus, an external vendor and part of the Illinois Medicaid Redetermination Project (IMRP), to the customer and/or the customer's representative for NH and SLF cases. This includes customers in Medical Field Operations (office 200).
AABD MANG Computation Sheet - Community Case (Form 2382A) for Community Medical cases; or
Nursing Home/Supportive Living Facility Resource Calculation (Form 2500) for NH and SLF cases.
Qualified Medicare Beneficiary (QMB) - Computation Sheet (Form 2382M) for QMB Only or SLIB Only.
Form 157 if benefits are being canceled. Form 157 must identify the reason for the action being taken and refer to the correct policy.
Notice of Changes During the Enrollment Period or Eligibility Period - MANG Community Case (Form 2434A) if the case status changes from Regular to Spenddown.
Notice of Change - MANG Long Term Care Case (Form 2434C) for changes in the spenddown amount and case status for NH and SLF cases.

REDE Completed by FCRC

Always use electronic sources to verify proof of income when available. This includes SOLQ, The Work Number and AWVS. Run an Illinois Secretary of State (SoS) Residency Match through Option O in the ACM system.

Simplified Processing for Determining Income and Resource Eligibility for Medical Benefits

This policy applies to Community and Long Term Supports and Services (LTSS) clients.

Accept receipt of Supplemental Security Income (SSI) as verification of financial eligibility for both income and resources for individuals who are receiving SSI.
Accept the individual's current written statement declaring that their resources are below the resource standard for the program, unless questionable, when their verified income is at or below 100% Federal Poverty Level (FPL).
Accept information reported on a redetermination form as a current written statement of resources.
Verify resource transfers for all individuals receiving LTSS.

Cases that do not qualify for Simplified Processing

Review the case record and/or Summary of Case Information (Form 1376/Form 1376C) to determine what information needs verification. Consider Form 1376/Form 1376C part of the case record.
Review the current Form 552 and the current computation sheets [AABD MANG Computation Sheet-Community Case (Form 2382A); Nursing Home/Supportive Living Facility Resource Calculation (Form 2500); or Qualified Medical Beneficiaries/Specified Low-Income Medical Beneficiaries (Form 2382M) for QMB Only and SLIB Only cases].

a. Community Cases (Excluding Sheltered Care Cases)

REDE forms are sent to medical only community cases through the IMRP process. Redes for cases with cash or SNAP are completed with the cash or SNAP review.
If additional information is required to verify eligibility, the FCRC can send Form 1721 or the IMRP Information Request Notice. Allow the client 10 days to return the information. If the client requests additional time to provide the information, follow the same procedures as for an initial application in PM 02-07-02b. An extension can also be granted in an unusual situation which makes it difficult for the client to cooperate within the 10 days. Send Form 1721 to document the information still needed and the new due date. Document the extension in the case record. If requested information is not provided, cancel medical assistance for anyone to whom the missing information applies. If proof of income deductions or medical expenses is not provided, do not allow the deduction. If the case is ineligible without the deduction or expense, cancel the medical assistance.
For REDEs completed other than the yearly REDE, a redetermination form is not required. Document in the record how the REDE was completed.
Always review TPL information at each REDE and complete Health Insurance Report (Form 1442), if necessary.
Complete electronic clearances for each known multiple SSN not listed on Form 552.
For noncitizens, verify immigration status through SAVE if it has not been done previously or the status is subject to change.
If the customer wants help in scheduling appointments for Healthy Kids Services or in obtaining transportation to and from Healthy Kids Services, complete a Healthy Kids Request Card (Form 2280). Enter the date the customer asked for the help in the box in the lower right-hand corner of Form 2280.
Send the completed Form 2280 to:

Healthy Kids
PO Box 19103
Springfield, IL 62794-9103
If the customer fails to provide necessary information by the due date, cancel the case for failure to cooperate.

b. NH, SLF, and Sheltered Care Cases

(1) NH and SLF Cases

Maximus will send Nursing Home/Supportive Living Facility Redetermination Report Form (Form 1229A) to NH and SLF customers. The mail date and requested return date are listed on the PAL for the month the REDE is due. Form 1229A is sent on the 20th day of the calendar month in which it is printed, or the first working day thereafter. The form is due back to the Illinois Medicaid Redetermination Project by the 21st day following the mail date, or the first work day following the 21st day. For all cases, a copy of Form 1229A will be sent to the the customer's representative. Twenty-one (21) days will be allowed to return the completed form and provide the verification needed. If the due date of a centrally mailed REDE form differs from the due date of a REDE manually sent to a representative, use the later due date. Form 1229A must be signed by the person providing the information.

If Form 1229A is not returned by the requested date and the customer is capable of providing information, obtain answers to the questions during the visit to the NH or SLF. If verifications are needed, give or send a request for the needed verifications. Send a copy to the customer's representative and a copy to the facility where they live, see PM 02-07-02. Allow 10 days for the return of the needed information. Maximus assists the customer as necessary.
If additional information is needed from the customer, send Form IL444-1721 Instructions to Client. Allow the client 10 days to return the information. If the client requests additonal time to provide the information, follow the same procedures as for an initial application, give 30 day extension if requested PM 02-07-02b. Send Form 1721 to document the information still needed and the new due date. If requested information is not provided, cancel medical assistance for anyone to whom the missing information applies. If proof of income deductions or medical expenses is not provided, do not allow the deduction. If the case is ineligble without the deduction or expense, cancel the medical assistance.
If Form 1229A is not returned by the requested date and the customer is incapable of providing information, Maximus assists the customer in obtaining any needed verifications. If the customer has a representative, Maximus sends a request for additional information.
NOTE: Accept a representative's statement of the competence or ability of the customer to provide information. However, if the person's statement is questionable or if the customer does not have someone acting on his or her behalf, the FCRC is to make the determination of the customer's ability to provide information. Document in the case record whether the customer is capable or incapable of providing information.
If the customer's representative fails to provide needed information requested, initiate action to cancel the case.
To REDE cases in NH and SLF, use Redetermination - Group Care/Sheltered Care (Form 1229) to record case information.

(2) Sheltered Care Cases

Use Form 1229 to record case information for REDE of all sheltered care cases.

c. Completion of the REDE

After all necessary information and verifications are obtained, review and document eligibility and complete the authorization and reporting of the REDE.

Central Redetermination

Each month the Department receives SSI information from the Social Security Administration (SSA) through the SSI/SDX system. It is compared to customer information for AABD Community, NH, and SLF (non-spenddown) cases.

A Form 552 is produced by the system for each Community or LTC case which is centrally REDEd. The form shows the actual month and year in which the central REDE was completed in Item 30. TA 30 is entered in Item 3. Item 32 is updated to show a date 12 months from the previous date in Item 32. The message CENTRAL REDETERMINATION COMPLETE is printed in Item 93. For certain cases where data does not match, an exclusion code is centrally entered in REMARKS on Form 552 (see WAG 22-14-03-b). Central REDEs are not completed for these cases.