Addendum 3.5 - Determining Financial Eligbility for PPC

Date:

Client Last Name:

First:

M.I.

Cornerstone ID:

Address:

City:

State:

Zip:

Sex:

DOB:

Present Age:

Prenatal or Pediatric Primary Care (PPC) services paid for by the Illinois Department of Human Services (IDHS) through the Family Case Management (FCM) program are available to pregnant women and children, whose family income is at or below 318% of the Federal Poverty Level, otherwise uninsured, and unable to enroll in Medicaid services due to religious reasons.

The following questions will lead to the appropriate determination of eligibility for PPC services to be billed to FCM.

  1. Is the client currently active in Medicaid or a Medicaid Managed Care Organization (MCO)?
    1. Yes (well child services must be billed to Medicaid or the MCO as appropriate)
      1. If yes, record Medicaid or MCO ID Number:
    2. No (proceed to question 2)
  2.  Does the client currently have private health insurance coverage?
    1.  Yes (well child services must be billed to the private insurance agency)
      1. If yes, record Private Health Insurance Provider:
    2. No (proceed to question 3)
  3. Determine the total gross household income before deductions of income tax, social security, etc., and the number of family members supported by this income. (Refer to the current Income Eligibility Guidelines at 318% of the Federal Poverty Level (FPL) matrix. Match family size income levels by the appropriate column.)
      1. Family Income monthly or annually
      2.  Number of family members supported by income
    1. Does the family meet the income guideline of being at or below 318% FPL?
      1. Yes (continue to question 4)
      2. No (refer the client to the Marketplace, or request payment for services from the client)
  4. Is the client unable to apply for Medicaid through the state of Illinois based on current religious beliefs?
    1.  Yes (Client is eligible for basic primary care services through PPC program)
    2.  No (Complete an MPE application or refer the client to the IDHS local office for a Medicaid Eligibility Determination).