Continuous Coverage Ends 3/31/2023 and Medical Redeterminations Resume

04/13/2023

Policy Memo

Summary:

This memo provides guidance for resuming redeterminations and the end of the continuous coverage requirement.The process of conducting annual customer redeterminations for medical cases will resume in April 2023 and continue each month going forward.

1. Public Health Emergency Flexibilities During the Unwinding Overview
2. PHE Flexibilities Continuing
3. PHE Flexibilities Discontinued
4. Resumption of Medical Redeterminations
5. Ex-Parte Redetermination Process
6. Form B Medical Redetermination
7. Returned Medical Redeterminations
8. Review of Resources at Redetermination
9. Processing a Redetermination on a Medical Case with an Override
10. Case Comments
11. Additional Considerations for Processing Medical Redeterminations
    1. Aging Out
    2. Case Merge
    3. Spenddown - Processing AABD Income and Resource Spenddown at Redetermination
       1. Entering Bills and Receipts in IES
    4. Long Term Care Cases - Asset Discovery Investigation (ADI) Referrals
    5. Undeliverable Mail
12. Processing Late Redeterminations and Reinstating Medical Cases Canceled at Redetermination
13. Referrals to the Marketplace
14. Appeals - Advance Notice and Fair Hearing Rights
15. Applications Processed after March 31, 2023
16. References

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Public Health Emergency Flexibilities During the Unwinding Overview

Beginning in March 2020, the Families First Coronavirus Response Act (FFCRA) required states to keep individuals enrolled through the public health emergency (PHE) as long as they were eligible on March 18, 2020 or were determined eligible later.

The Consolidated Appropriations Act, 2023 was signed into law on December 29, 2022, and included a set end date (March 31, 2023) for the Medicaid continuous coverage requirement. The law removes the connection between the PHE and the continuous coverage requirement for medical cases.

The end of the continuous coverage requirement requires states to resume medical redeterminations and end medical coverage for ineligible individuals following a redetermination.

Prior to the completion of a full redetermination, medical cases will remain open with their overrides in place in the same manner as they have during the public health emergency. No existing medical cases may close prior to going through a full redetermination except in the instances of a customer's death, moving out of state, or requesting the closure of their case. In addition, medical coverage cannot be terminated due to undeliverable mail unless an out of state forwarding address is received and verified or the mail is sent to a customer that is verified as deceased.

Individuals currently in met spenddown will remain in met status until a redetermination is completed.

New applications processed after March 31, 2023, are not subject to the continuous coverage requirement. Coverage may be terminated due to changes in circumstances on a medical case if the application for that case was approved on April 1st, 2023, or later. Overrides will not be added to any new medical cases approved April 1st, 2023, or later

Review the charts below for detailed information on the PHE flexibilities.

PHE Flexibilities Continuing

PHE Flexibilities Discontinued

Resumption of Medical Redeterminations

Process & Key Dates

The redetermination process for all medical programs resumes in April 2023. Customers with certification periods ending June 30, 2023 will be the first to receive redetermination related notices by mail and to their ABE Manage My Case (MMC) account.

Redeterminations will be sent to all active cases over the course of 12 months. Medical certification periods have been aligned whenever possible to SNAP, Cash, or other medical EDGs on the case.

* Redeterminations will be sent according to the end of their current certification period.

The table below illustrates key dates in the redetermination process for the first several months.

Below is a table to use when deciding what actions may be taken and when for medical cases or EDGs.

Ex-Parte Redetermination Process

Each month medical cases due for redetermination are reviewed to determine whether eligibility can be determined using electronically available verifications.

If eligibility can be electronically verified using available sources and the customer remains eligible, Form A is sent informing the customer of their ongoing coverage for the next year. This is known as ex-parte.

The Form A notice informs the customer of the information used to determine their eligibility. If the information is correct, the customer does not need to do anything to continue medical benefits. If the information is not correct, the customer is to return the redetermination form with changes. When a Form A redetermination is returned it is treated as any other redetermination and requires processing by the caseworker. For more details on the ex-parte process, refer to PM 19-02-04-a

The ex-parte redetermination process is enhanced to include new sources of data and is now available to more customers.

• The Asset Verification System (AVS) is added as a verification source when determining the type of redetermination required. This will allow more non-MAGI cases to be eligible for Form A. The AVS system provides verification of resources for the non-MAGI population. A file is sent to AVS each month for customers due for redetermination. The file is returned within 10 days. Information received from AVS is then electronically used to assist in the determination of Form A/B. When resources are found to be below the resource limit the individual may be considered for Form A, when resources are found to be above the resource limit for the individual will receive Form B.
• Households with zero income may now be eligible for Form A - during the unwinding period a case with no current income on the case (earned or unearned) and no income found in AWVS may be considered for Form A. Authority for this strategy is through an approved waiver and is approved for the unwinding period only at this time. The unwinding period in Illinois ends June 2024.
• When a case requiring resource review receives a response of "no accounts found" from AVS, that response may be considered verification of no resources when determining Form A or Form B. This authority is provided through an approved waiver and is approved for the unwinding period only at this time.
• SNAP income may be used as a data source for medical in the ex-parte process. This is newly programmed and is a permanent change.

Reminder: A customer who receives a Form A redetermination is renewed but may still report changes to their case. Refer to PM 19-02-04-c for details.

Form B Medical Redetermination

Form B is the redetermination form that requires a customer response. Form B is sent when the customer is not eligible for ex-parte renewal. The actual form sent to the customer depends on the benefits being received. Form B process sends either a 643 or 1893 form. A medical case is sent Form B if the case:

• Does not qualify for ex-parte redetermination; or
• Is excluded from ex-parte redetermination. For more details review MR #16.08: Auto-REDE for Medical Programs

Customers must complete and return the Form B redetermination by the due date. Medical only cases will receive a 643, and medical customers who also receive SNAP or Cash will receive an 1893. See PM 19-02-04-b.

Refer to Processing Redetermination in IES Job Aid for additional instructions.

REMINDER: The receipt of a customer's redetermination form typically creates a task in an Initiate Redetermination queue. However, a task is created and placed in the Changes/Misc Queue when a redetermination form 1893, form 2381B or form 643A is received and the "REDE Received Date" is already populated in IES. If additional redetermination forms are received the caseworker needs to review for any information that was not included on the first redetermination form. Changes made using the additional redetermination form should be detailed in the case comment.

Returned Medical Redeterminations

All redeterminations returned by the customer must be reviewed and worked. Redeterminations returned before cutoff of the month due will result in a received date being populated in IES to prevent automatic closure. The existing override on the medical EDGs will end systematically the night the received date is entered. Ending the override will allow a determination based on the entries made when processing the redetermination.

Review the redetermination form, all verifications submitted, and run all clearances.

All entries in Data Collection must be reviewed and the case updated as needed. The override should prevent coverage from being lost prior to end of the medical certification period.

During the continuous coverage unwind, self-attestation of income is acceptable if electronic verification isn't available when determining medical benefit eligibility. The caseworker needs to review the information on the redetermination form, run clearances to retrieve electronically available income sources, review case comments and other documentation in the ECR for reported income. Use the information provided on the redetermination form when electronic verification is not available and other income verification documents were not provided. Select the applicable verification values from below:

• Earned Income - use AWVS as the verification value.
• Unearned Income - Select Other Acceptable.
• Self-Employment - Select Other Acceptable.
• Incurred medical expenses - Select Medical Only for Program in the TOA dropdown.

A VCL is still required when:

• Income questions are left blank on the redetermination form
• Income is indicated on the redetermination form and no amount is declared, no verification is provided and no electronic verification is found
• The difference between the reported income is less than the applicable medical program standard and the electronic verification obtained is more than the applicable medical program standard and the difference is not within the reasonable compatibility limit.

Reminder: A case cannot close due to failure to return requested information if the VCL was sent prior to the redetermination process. The caseworker needs to review the ECR to see if the requested documentation was received. If the requested information was not received and is still needed after the receipt of the customer's redetermination form, a new VCL needs to be sent prior to the completion of the redetermination. This includes if a VCL was sent requesting a 3654 form.

Review of Resources at Redetermination

Illinois will resume the resource test effective May 12, 2023. Resources must be reviewed as part of the redetermination process. The new resource limit per case is $17,500.00. This is not a per person limit; the limit is the same no matter the number of individuals on the case. Current resources must be verified and entered in IES on the appropriate Resource screens.

A VCL should be sent if additional information is required to verify resources. Resource records should be entered to reflect the current resources.

Customers turning age 65 at the time of redetermination require a resource review before being approved for a non-MAGI eligibility group. Resource questions will be included on the redetermination form for AABD customers age 65 and over who receive Form B. Customers turning age 65 are asked to report their resources for the first time as a condition of eligibility (unless otherwise exempt).

Please refer to PM 07-02-00: Aid to the Aged, Blind, and Disabled for more information on exempt and nonexempt resources.

As a part of their resource review, staff will need to review AVS results when processing a redetermination.

A report of the search results will be found in the electronic case record (ECR) referenced as "AVS Search Results Days 1 thru 10". The report provides a total of the verified resources, list of account owners and the banks that were searched along with real property results.

• Caseworkers should only use the AVS Web Portal for months needed to make an eligibility determination that were not included in the AVS report.
• If a bank account is reported and no results are found in AVS:
  • A VCL must be sent requesting verifications based on program eligibility rules.
• If a bank account is reported and results are found in AVS, a VCL is not needed.
  • Use AVS bank balances as statements.
• Refer to MR #19.09 Asset Verification System for more guidance on issuing a VCL for resources.

Refer to PM 02-7-03-n for additional guidance on AVS.

Processing a Redetermination on a Medical Case with an Override

Medical cases have remained open during the PHE using an override. In order to effectively process a redetermination, the override will need to be ended. To reiterate, the override will be end dated, not deleted. PHE overrides should never be deleted to avoid retroactive loss of coverage for the customer.

A data fix will be used to systematically end date overrides the last day of the certification period for medical redeterminations in three ways:

• Each day, a data fix will end the override on a case with a redetermination received date. The end date will be the last day of the current certification period (for the first round of redeterminations this would be June 30, 2023).
• Another data fix will run monthly to add an end date to overrides for cases processed at cutoff, including:
• Ending the override on Form A cases that did not have a reported change so their coverage will extend for their next cert period.
• Ending the override for Form B cases with no redetermination received date, allowing the benefits to close effective the next month.

Cases that have been redetermined on or after May 1, 2023 will no longer have overrides for the medical benefits.

There will be times when a worker will need to request the override be ended manually. Examples include:

• The Data Fix did not correctly end the override on the case when the redetermination was received.
• The Redetermination needs to be processed immediately and the worker cannot wait for the nightly Data Fix.
  • When there is a red "Y" in the certification status column for the ongoing month that is not yet certified the override is still in place.

To end an override manually, follow these instructions:

• Enter the necessary information in Data Collection.
• Run eligibility. If there is a red Y present for the ongoing benefit period, the override is still in place and must be ended manually.
• Click on the Exception Summary tab in Eligibility Summary.
• Edit the existing override(s) and enter an end date (should be either the last day before the current effective month (if processing a redetermination late) or the last day of the current certification period when processing the rede timely).
  • Example 1: Certification period end date is 06/30/2023, redetermination is being processed before cut off for July benefits (cut off is June 15, 2023). End the override 06/30/2023 and process the redetermination effective July 2023.
  • Example 2: Certification period end date is 06/30/2023, redetermination is being processed after cut off for July benefits (cut off is June 15, 2023). End the override the day before the current effective month. Submit the override update to your supervisor using the "Request Override" button.
• Notify your supervisor of the need to approve the override change.
• After supervisor approval, rerun eligibility and certify.

See screenshot below for further instructions.

IMPORTANT REMINDER: Never delete the override. The override should be ENDED not DELETED. This is to ensure there are no gaps in coverage.

Case Comments

Case comments are a very important step when a redetermination has been completed. Case comments are vital for keeping records and informing individuals of recent actions taken on a case. The case comment should include detailed information on the following:

• Any new or updated information found on redetermination form
• Information found on clearances
• Date the redetermination was received and date completed
• Household member changes (example: 19 yr. old, someone moved out or in, etc.)
• Approved representative information (new or removed)
• List of all information and documentation received
• Actions taken on case (ending override, VCL, etc.)
• Eligibility changes
• Provide details of all temporary flexibilities which were used to determine eligibility

Please refer to PM 01-04-01: Case Records for additional information on case comments.

Additional Considerations for Processing Medical Redeterminations

Some medical redeterminations will require additional forms or verifications beyond the basic income and asset information discussed in the sections above. This section discusses the additional work involved with processing a case that is aging out from All Kids, transitioning into AABD, and meeting a Spenddown.

Aging Out

Many customers that turned age 19 during the PHE did not receive form 643A and are currently active on their family's case. When the individual is due for redetermination a 643A form will be sent for the 19+ year old along with the redetermination form for the other individuals on the case.

When the 19+ year old is not the spouse of the head of household, or is not claimed as a tax dependent, a 643A is sent. When the redetermination for the rest of the household is processed the 19+ year old's medical benefit will close. A 643A must be processed as a new application for the 19+ year old.

If the 19+ year old is the spouse of the head of household, or is claimed as a tax dependent, the individual may remain eligible on the case and eligibility will be determined using the redetermination form for the rest of the household.

Examples:

Example 1 The case contains mother and son. The son is now 19. The mother claims her son as a dependent on her taxes. A redetermination is sent to the household. The form is returned by the parent who indicates that she will file taxes and continue to claim the 19 year old as her tax dependent. Use the REDE form that is signed by the parent.

Example 2 The case contains mother and son. The son is now 19. The mother does not claim her son as a dependent on her taxes. A 643A will be sent for the son to complete, and a separate redetermination form will be sent to the mother. The son will no longer be eligible to receive coverage on his mother's case and must return the 643A.

NOTE: A signature is only required from the 19+ year old if they are not the spouse of the HoH or when they are not being claimed as tax dependent by the HOH

Case Merge

Initially, staff were instructed to not merge cases due to the potential loss of benefits during the PHE. Case merge may now be completed as needed.

Some examples of when this is necessary:

• When an individual has a separate case for MSP and medical - having two separate cases results in customers not having access to their medical benefits. MSP and Medical must be received on the same case.

IMPORTANT: The Case Merge MUST be completed the day the action is started. The source case is immediately closed when the action starts. If the full merge is not completed coverage will be lost. It's very important for the caseworker to search for associated pending applications or active cases prior to completing the redetermination. This includes both medical cases and MSP.

• This is best done by performing an individual inquiry search, searching by name and date of birth. Identifying existing cases before processing an application will prevent unnecessary additional cases and reduce the need for case merges.
• If an active case or application is found, a program add action should be completed on the older case and the new application disposed.
• This will prevent an individual having multiple cases.

Please refer to the IES Wizard Perform a Case Merge and Medical Morsel! Medical Savings Plan and Medical Case Merge Reminders for further instructions.

Spenddown - Processing AABD Income and Resource Spenddown at Redetermination

During the continuous coverage requirement once a person met spenddown their spenddown remained met ongoing. Due to the end of the continuous coverage requirement, once a redetermination is completed customers with a spenddown will have to meet that spenddown again. Meeting one month will no longer result in met status for future months.

After redetermination, cases will no longer remain in met status ongoing. There may be medical expenses (receipts and bills) that have been submitted and are in the ECR that have not been added to the case. Review the ECR and verifications for submitted medical expenses that have not been used and enter them as appropriate. Review the redetermination and verifications for any information about expenses that may be used. If no medical expenses were found, the case may be approved in unmet spenddown.

Important Reminders

• A medical expense can only be used once to meet spenddown. When a bill for a medical expense has been used to meet spenddown, a receipt for the same expense cannot be used unless the full amount of the bill was not used.
• In order to use a medical bill or receipt to meet spenddown, the bill or receipt must be dated within 6 calendar months of the month that the customer wants to use the bill. When the customer has a receipt and a bill for the same service always use the receipt to meet spenddown, unless the bill is from an earlier month and the customer wants to use it for that month.
  • When a customer submits a bill, determine if the bill is a "current bill" or an "old bill." A "current bill" is a bill with a billing date (month and year) that is within 6 months of the month that the customer wants to use the bill. An "old bill" is a bill with a billing date that is more than 6 calendar months from the month that the customer wants to use the bill. The 6-month timeframe is the difference between the month of billing and the month the customer wants to use the bill.
• Refer to PM 15-08-00: Spenddown for more detailed information.

NOTE: For LTC cases when determining the post eligibility treatment of income, only allow expenses that incurred no earlier than three months preceding the month of current application and the expense is a current and unpaid customer liability for a service that will not be paid for by Medicaid.

Entering Bills and Receipts in IES

• Bills and receipts received are entered on the Medical Expenses Details page in IES.
• The Medical Expenses Summary page displays the individual medical expenses and spenddown history for each bill.
• The CSCD entered determines the month spenddown is met. Spenddown status indicators will display on the Eligibility Summary page under the Benefits/SPD column.
• Staff may utilize the Eligibility Monthly Spenddown Bypass to stop IES from automatically meeting a spenddown for a targeted month if requested by the customer.
• IES allows the caseworker to target future months for up to 6 months beginning with the current month.
• Add a case comment explaining the bill or expense entered.

AABD spenddown customers have the option of paying the amount of their monthly income and asset spenddown to HFS to receive a medical card. This is known as the Pay-In Spenddown program. Refer to PM 15-08-15: Pay-In Spenddown for more information.

Please review PM 15-08-05: Allowable Medical Expenses for additional information on medical expenses.

Long Term Care Cases - Asset Discovery Investigation (ADI) Referrals

Continue to follow the same referral criteria for LTC-ADI. The LTC MFOs are required to refer applications and redeterminations to LTC-ADI that meet the referral criteria.

• OIG referrals could occur at initial processing of an application or after the case has been approved.
• Refer to the Medical Morsel - Changes to Criteria for Referrals to Long Term Care-Asset Discovery Investigation (LTC-ADI) unit for more information.

Undeliverable Mail

Federal regulations require a different process for the handling of mail returned as undeliverable. Updates have been made to the Undeliverable Mail Task instructions to reflect the changes. New federal guidelines come in three categories:

1.  PRIOR to a case's month of redetermination, mail returned to the state as undeliverable does not count as a valid reason to terminate medical coverage, and caseworkers do not need to send a Verification Checklist if the state receives returned mail without a forwarding address.

Prior to a case being redetermined, coverage may only be terminated because of returned mail in the following two instances:

  2. DURING a case's medical redetermination, if a redetermination form (643, 1893, etc.) is returned to the state as undeliverable,  caseworkers must attempt to contact the customer for  a valid address.

REMINDER: Only redetermination forms received as undeliverable mail or undeliverable VCLs sent during the redetermination process require additional customer contact.

  3.  AFTER a medical case has been redetermined, or for cases with applications approved on or after April 1, 2023, the state will return to normal processing of undeliverable mail for that case. Follow standard procedures reflected in the Undeliverable Mail Task instructions.

Processing Late Redeterminations and Reinstating Medical Cases Canceled at Redetermination

Cases closed because of failure to respond to a redetermination or verifications required for redetermination may be reinstated if redetermination or verifications are received within 90 days of the coverage loss. Review eligibility for a medical case when the customer cooperates with the redetermination by submitting all required documents prior to end of the third month (or 90 days if longer) following the last day of coverage. A new application is not required to reinstate benefits.

• If the customer cooperates timely and all other factors of eligibility for medical benefits are met, reinstate the case and process the redetermination. Depending on the results of the redetermination, the customer may be approved for ongoing coverage in a new type of assistance other than the one they were reinstated into initially.
• If the case is eligible for reinstatement, the effective date of reinstatement is retroactive to the first day for which coverage had been canceled. Therefore, the case is reopened with no loss in benefits.
• Do not reinstate a case if the customer cooperates more than three months (or 90 days if longer) after the effective date of cancelation. The customer must submit a new application.
• Review further instructions in the IES resource center for how to process a late redetermination and medical restatement.

IDHS OneNet: Late Medical Rede Processing - Case Closed (illinois.gov)

IDHS OneNet: Medical Reinstatement/Program Request (illinois.gov)

Referrals to the Marketplace

Closure notices will include a message for customers when their account is referred to the Marketplace. The customer must visit GetCoveredIllinois.com to create an account and apply. There will be a special enrollment period of 30-60 days for the customer to enroll when losing Medicaid.

Managed Care Organizations may perform outreach to assist in the transition when their customers lose Medicaid benefits.

Appeals - Advance Notice and Fair Hearing Rights

A customer has the right to file an appeal and request a fair hearing to contest a Medicaid eligibility determination. A reasonable time period to file an appeal must not exceed 90 days from the date of notice.

A minimum of 10 days advance notice and fair hearing rights must be provided prior to terminating or reducing Medicaid eligibility.

During the unwinding period, customers also have the right to continue to receive benefits pending the fair hearing decision when the customer requests the fair hearing within a reasonable timeframe. If a customer requests a fair hearing after the date of the case action and within the allowable timeframe, benefits must be reinstated back to the date of action.

Applications Processed after March 31, 2023

Overrides will no longer be applied to new medical benefits approved on or after April 1, 2023. The continuous coverage requirement expires March 31, 2023. The continuous coverage requirement will not be applicable to any applications, including backdated months, processed on or after April 1, 2023.

Caseworkers may otherwise resume normal office procedures after the application has been completed. This includes performing case maintenance changes such as updating income, entering a bill or expense, or removing a member from a household.

Note: These changes are contingent to the date the application has been processed NOT the date of application

References

* Renewal Refresher Training

* PM 19-02-04, WAG 19-02-04, PM 19-02-04-c, WAG 19-02-04-c

* IES Wizards

Obsoleted COVID-19 Policy Memos

• COVID-19 Pandemic Response - Update Ensuring Access to Care - Release Date 04/14/2020
•  COVID-19 Pandemic Response - Delay of Medical Redeterminations - Release Date 04/07/2020

Updated COVID-19 Policy Memos

• COVID-19 Pandemic Response - Updated Verification Requirements for Medical Applications - Release Date 04/02/2020
• COVID-19 Pandemic Response - Updated Verification Requirements for Medical Applications and Active Cases - Release Date 01/13/2021

Ongoing COVID-19 Policy Memos

• COVID 19 Suspension of the Collection of Premiums and Copayments for Medical Programs - Release Date 07/28/2020
• COVID-19 Pandemic Response - Reasonable Compatibility Threshold Increased - Release Date 07/13/2020
• COVID-19 Adult Presumptive Eligibility - Release Date 04/18/2020

[signed copy on file]

Grace B. Hou

Secretary, Illinois Department of Human Services

Theresa Eagleson

Director, Healthcare and Family Services