12/07/2022
Summary
- Effective 11/30/2022, Illinois introduces a new partial medical benefit program to provide family planning and family planning related services to individuals not otherwise eligible for and enrolled in full Medicaid or other state funded medical coverage other than spenddown cases.
- Household size will always be 2.
- A new application is not required for individuals already receiving medical: all Family Planning services are covered under full medical. Existing customers may choose to opt-in to Family Planning. Details can be found under the Opt-In section of this manual release.
- This manual release explains the difference between the opt-in and the standalone application process.
- Individuals must not be pregnant at the time of application.
- Only the applying individual's income will be counted.
- Presumptive eligibility will be available when applying through approved providers.
- This manual release explains the redetermination process for the Family Planning program.
- This manual release explains covered benefits under the Family Planning program.
- Introduction to Family Planning
- Opt-In vs. Standalone Applications
- Opt-In
- Standalone
- Family Planning Response = Not Provided
- Application Signature Requirements
- Temporary Medical Benefits
- Backdating
- Nonfinancial Eligibility
- Financial Eligibility
- Family Planning Presumptive Eligibility
- FPPE and MPE
- Case Changes
- Becoming Eligible for Full Medical Coverage
- Application Association/Case Merge
- Redeterminations
- Reinstatements
- Correspondence
- Federal Facilitated Marketplace (FFM) Referrals
- Family Planning MANGP Codes
- Appeals
- Covered Benefits
- Manual Revisions
Introduction to Family Planning
Effective 11/30/2022, Public Act 102-0665 (SB0967) established a new eligibility group for family planning services for individuals of any age and gender who are not pregnant at the time of application. The Family Planning (FP) program covers services and supplies to prevent or plan pregnancy; education for preconception and fertility awareness; and medical, diagnostic and treatment services through family planning face to face visits.
The FP Eligibility Determination Group (EDG) size will always be 1 (customer) with a household size of 2, even if there are more than two people in the household or when there is only one person in the household. IES will automatically create this EDG and household size for FP cases.
Example 1: Individual lives in household with three dependents. Individual requests the Family Planning program for each person listed on application. Each individual has an EDG size of 1 and household size of 2.
Example 2: Individual lives alone and applies for Family Planning. Individual has an EDG size of 1 and a household size of 2.
Opt-In vs. Standalone Applications
Applicants can apply for Family Planning services by opting in or by a standalone application process.
Family Planning applications adhere to the same processing times as other non-disability medical applications (45 days).
Opt-In
Customers newly applying must select 'Yes' to both Healthcare coverage and the Family Planning program to opt-in when applying for full medical. Each individual included on the application may opt-in or not. Customers are able to do this via paper applications or abe.illinois.gov "Apply for Benefits" (AFB) screen.
An opt-in application will be first assessed for full medical coverage eligibility. If applicant is not eligible for full medical coverage, or is approved for a spenddown medical coverage case, the applicant would then cascade into a Family Planning determination.
Customers already receiving medical benefits who did not opt-in to Family Planning at time of application may do so before their case redetermination by requesting through their local office or at time of redetermination by selecting the FP opt-in option on the redetermination form. Adding Family Planning opt-in ensures existing customers will be assessed for FP if they lose full coverage.
When an individual requests to opt-in complete the following steps in IES:
- Navigate to 'Program Request-Individuals' page in IES.
- Select pencil to edit for each individual requesting under the Program-Individuals Summary section.
- Select 'Yes' for the question, "If this person is not eligible for the medical programs listed above, would you want to be considered for Family Planning Coverage", for each individual requesting opt-in coverage.
Example 1: Applicant starts an application for himself in Apply for Benefits (AFB) via ABE online. On both the Program selection and Individual pages he selects 'Yes' to both Healthcare Coverage and the Family Planning program. Applicant is now considered an opt-in Family Planning application.
Example 2: Applicant starts an application in AFB via ABE for herself and her spouse. On the Program Selection page, applicant selects 'Yes' for both Healthcare Coverage and the Family Planning Program. On the individual screens, applicant selects 'Yes' for both Healthcare Coverage and the Family Planning Program for herself, but selects 'Yes' for Healthcare Coverage and 'No' for Family Planning for her spouse. Applicant is now considered an opt-in Family Planning application whereas her spouse is not.
Example 3: Applicant applied for full medical only, without opting-in to Family Planning, and was determined eligible. Three months later the applicant calls the FCRC to request Family Planning opt-in to be added to the case. Caseworker makes the update through Case Change on the "Program Request-Individuals" page in IES. At redetermination the case will now cascade to Family Planning determination if determined ineligible for full medical.
Example 4: Applicant starts an application in AFB via ABE. Applicant selects 'Yes' to Healthcare Coverage and 'No' to the Family Planning program. Application is for full medical coverage and Family Planning eligibility will not be determined if applicant is found ineligible for healthcare coverage.
Reminder: If the individual(s) applies for full medical and is approved without a spenddown, s/he is not eligible for the Family Planning program. In this instance, IES will not cascade to Family Planning. If the individual chose Family Planning opt-in their preference will be saved so that if they lose full coverage in the future, the system will determine Family Planning eligibility at that time.
Standalone
A standalone application occurs when an individual applying selects "Yes" to Family Planning and "No" to Healthcare Coverage. Only determine eligibility for Family Planning services when the applicant is not requesting full healthcare coverage.
Family Planning Response = Not Provided
Applications submitted before the program started did not offer the option of applying for Family Planning. When the application does not contain the Family Planning option, select 'Not Provided' on the "Register Program-Program" page in IES. This includes paper applications and addition requests without the option listed.
If an electronic application is received which does not contain an option to apply for Family Planning, IES will automatically code the program request to the value 'Not Provided'. If a paper application is received in which the Family Planning services question was left blank, use the 'Not Provided' value in IES for Family Planning. The value 'Not Provided' is equivalent to a 'No' for program request. Individuals will not be determined for Family Planning eligibility when 'Not Provided' is selected.
Example 1: Caseworker receives an application which does not contain the option to request the Family Planning program and the applicant does not make any comment regarding wanting to apply for Family Planning. Caseworker will select the 'Not Provided' value in IES on the "Register Program-Program" page for all individuals on the application.
Example 2: Caseworker receives a paper application which has Family Planning as a program option. The applicant did not mark either "Yes' or 'No' for the Family Planning program. Caseworker selects 'Not Provided' on the "Register Program-Program" page in IES.
Application Signature Requirements
Family Planning standalone and opt-in applications should follow standard medical application signature requirements. Please see PM 02-04-03: Who Signs the Application for more information.
Temporary Medical Benefits
Applications submitted only requesting Family Planning are not eligible for temporary medical.
Applications requesting Healthcare Coverage and Family Planning will be considered for temporary medical coverage if applicable. Temporary medical is full coverage and is not limited to Family Planning services. Please see PM 17-03-03:Medical Applications for more information.
Backdating
Eligible individuals may receive retroactive coverage beginning three months prior to the month of application for full Family Planning applications.
Family Planning Presumptive Eligibility cannot be backdated.
Applications dated prior to 11/30/2022 can still be eligible for Family Planning and Family Planning backdated months. Applicants must indicate they want to apply for Family Planning and prior months.
Nonfinancial Eligibility
- Illinois resident
- U.S. citizen or qualified immigrant
- Can be any age
- Can be any gender
- Cannot be enrolled in any other non-spenddown state funded full medical coverage plan
- Cannot be pregnant at the time of application (only self-attestation required)
Note: Third Party Liability (TPL) does not affect FP eligibility.
Financial Eligibility
Modified Adjusted Gross Income (MAGI) budgeting is used when determining eligibility for Family Planning. Please refer to PM 08-03-00: MAGI Budgeting for more information.
MAGI budgeting is applied for all Family Planning determinations. This includes:
- Individuals who opt-in, including individuals cascading from non-MAGI groups into Family Planning
- Individuals who apply using the standalone application
Example: Customer, age 67, applies for full medical benefits and opts-in for Family Planning. Non-MAGI budgeting is used to determine eligibility for AABD. Customer is denied AABD due to income and IES cascades into Family Planning determination using MAGI budgeting rules.
The Family Planning income limit is 213% (208% plus 5% disregard) of the Federal Poverty Level (FPL).
Only the income of the applicant is counted towards the Family Planning income calculation and the household size is always 2, regardless of other members living within household.
Resources/assets are exempt for Family Planning.
Family Planning Presumptive Eligibility
Family Planning Presumptive Eligibility (FPPE) is available to customers applying through providers approved and trained by HFS. Only approved providers may determine eligibility for FPPE. This process will mirror the Medicaid Presumptive Eligibility (MPE) process for pregnant women. The same providers who are eligible to be MPE providers are eligible to be FPPE providers. FPPE providers will use the same presumptive eligibility online portal they use for MPE.
FPPE providers will determine eligibility for FPPE based on:
- applicant attestation to not being currently pregnant.
- applicant attestation to IL residency.
- applicant attestation of current monthly income meeting standard limit of household size of 2.
- verification that individual is not currently enrolled in full medical program coverage.
All regular family planning services and related services are available under FPPE. FPPE will provide immediate temporary coverage from the day the individual signs the application and continues through the last day of the following month. If the individual applies for ongoing medical and/or Family Planning benefits, FPPE will continue until a decision is made on the full application.
FPPE coverage cannot be backdated.
The All Kids unit will be responsible for processing FPPE requests.
Customers may only receive two presumptive eligibility periods within one calendar year. All types of presumptive eligibility are included when determining the limit (MPE, FPPE, Adult PE, Child PE).
Example 1: On October 1 customer A signs the FPPE application and the FPPE provider determines the customer eligible. The application will be electronically submitted to the All Kids bureau. The benefit begin date is October 1 and will continue to November 30th.
Example 2: On October 31 customer B signs the FPPE application and the FPPE provider determines the customer eligible. The application will be electronically submitted to the All Kids bureau. The benefit begin date is October 31st and will continue to November 30th.
Example 3: Customer C applies for FPPE and the provider determines them to be ineligible. The individual is denied at the provider's location. Nothing is transmitted to IES.
Note: Pregnant individuals are not eligible for FPPE.
FPPE and MPE
It is possible for Family Planning Presumptive Eligibility (FPPE) and Medical Presumptive Eligibility (MPE) to overlap in IES. This may happen when an individual first receives FPPE and then becomes pregnant during the presumptive eligibility period, or when an individual receiving MPE is no longer pregnant. Both IES and MMIS will accept the overlap in these benefits. MMIS will prioritize MPE coverage over FPPE since it is the more comprehensive coverage. There is no need to terminate FPPE or MPE in IES if this occurs.
Case Changes
Individuals become ineligible for the Family Planning program in the following circumstances:
- Individual moves out of state
- Individual's income exceeds Family Planning limit
- Individual enrolls in full state or federal non-spenddown medical coverage
Cases determined ineligible for Family Planning coverage will close the next effective month.
Note: If individual has an active Family Planning case and later reports a pregnancy which is added to the case in IES, Family Planning coverage should not close. When redetermination is performed, the FP coverage will be systematically closed by IES. Active pregnancy will only disqualify an individual requesting FPPE, initial FP coverage and at redetermination of FP.
TIP: If individual wants to be determined for full coverage to receive pregnancy benefits, the individual must submit an application requesting full medical coverage.
Becoming Eligible for Full Medical Coverage
If a customer reports changes that would make them eligible for full medical coverage and they would like to be determined for full medical coverage, they must submit a new application for determination. If the customer is found eligible and approved for full medical benefits, Family Planning will end the next effective month.
Application Association/Case Merge
Family Planning applications and cases may be associated/merged with other applications/cases only when the head of the household is the same. Associations and merges must follow all other current association/merge policy. Please refer to MR #17.17: IES Case Composition, Office Functions Changes and FHP Updates and the following Job Aid for more information.
Redeterminations
Family Planning cases will be certified for a 12 month period. The first REDE for a Family Planning case is due 12 months from the calendar month in which the case is approved.
Family Planning redeterminations will only assess continued eligibility for Family Planning coverage, regardless if full medical was requested on initial application. Family Planning redetermination forms will be sent at the same time and using the same processes as other medical redeterminations. Only the questions relevant to the Family Planning program will be included on the redetermination form. The Family Planning program is eligible to be considered for Form A (ex-parte rede) to continue their FP benefits without manually completing a redetermination form.
Please see table below for common Family Planning redetermination scenarios.
| Current Coverage |
Scenario |
Form Type |
| Family Planning |
Eligibility for Family Planning is confirmed using electronic data sources and case information. |
IES will send Form A - no response is required. The certification will be extended one year if no response is received. |
| Family Planning |
Eligibility cannot be determined electronically. |
IES will send Form B - Response is required.
If redetermination is received - process the rede or send a VCL as appropriate. If the customer remains eligible when the rede is completed a new 12 month certification period will be established.
|
If a redetermination is being completed on a full medical case and the individual opted in for Family Planning, they can cascade down and be evaluated for Family Planning if no longer eligible for medical programs. Customers may be eligible for auto-redetermination. Please see PM 19-02-04: Medical REDE in IES for more information.
Please see table below for full medical redetermination scenarios in respect to Family Planning.
| Current Coverage |
Scenario |
Form Type |
| Medical |
Individual receiving ongoing Medical and the redetermination process finds them ineligible for medical but individual opted-in. |
IES will send Form B. After Form B is returned and processed through IES, individual will be evaluated for Family Planning if no longer eligible for medical benefits. |
| Medical |
Individual receiving ongoing medical and opted-out for Family Planning. Redetermination process finds individual ineligible for medical. |
IES will send Form B. Individual will NOT be evaluated for Family Planning. |
Reinstatements
Family Planning benefits may be reinstated within 90 days of coverage loss when the customer supplies necessary information. Reinstatements may occur under the following circumstances:
- Customer was receiving FP benefits, lost benefits due to failure to respond to redetermination and redetermination form is returned within the 90 day time frame.
- Customer receiving FP benefits loses coverage for failure to respond to a VCL. Customer provides necessary information within the 90 day time frame.
A customer who loses full medical coverage for a reason that allows reinstatement and who opted into Family Planning may be assessed for FP if the customer is determined ineligible for full medical during the reinstatement process.
Correspondence
The following forms have been updated to reflect the inclusion of the FP program
-New medical program fragments for Family Planning
-New denial reasons: Pregnancy
-Opt In/Opt Out option for Family Planning
-Opt In/Opt Out option for Family Planning
*Pending update to include FP program as an option
Federal Facilitated Marketplace (FFM) Referrals
Denied Family Planning cases will be referred to the FFM for the same denial criteria as full medical cases including the following instance:
- Individual applied for Medical and Family Planning: Medical was denied and Family Planning was approved.
Family Planning MANGP Codes
- FG=Family Planning Presumptive
- FI=Family Planning Standalone Application
- FJ=Family Planning Opt-in
Appeals
Family Planning appeals can be filed by a customer or caseworker. Please refer to PM 01-07-00: Appeal Rights and Fair Hearings for more information.
Covered Benefits
The Family Planning program will cover family planning and family planning related services to prevent or plan pregnancy, provide preconception and fertility awareness, education and provide evidence-based medical, diagnostic and treatment services.
Family planning services are limited to services and supplies whose primary purpose is family planning. Examples of family planning services include an annual preventive exam, contraceptive counseling, all FDA-approved methods of contraception, permanent methods of birth control (tubal ligation or vasectomy), basic infertility counseling, pap tests, cervical cancer screening, and STI, STD, HIV, and HPV testing.
Family planning-related services are services and supplies provided as part of or as follow-up to a family planning visit. Examples of family planning-related services include follow-up testing for abnormal tests, follow-up treatment for non-chronic diseases, STI and STD drugs and treatment, prescribing and management of HIV medications (PrEP), prescription prenatal vitamins and folic acid, HPV and Hepatitis B and C vaccines, screening mammograms, BRCA genetic counseling and testing, treatment of contraception-related complications, post-sterilization procedure lab work, and transportation services to family planning visits. Abortion care is covered.
Manual Revisions
Grace B. Hou
Secretary, Illinois Department of Human Services
Theresa Eagleson
Director, Illinois Department of Healthcare and Family Services
