Individuals applying for waiver services must first qualify for and be enrolled in the Illinois Medicaid program. This section provides information on how providers can confirm an individual's Medicaid eligibility and then provides information about participant enrollment in the waiver programs.
Enrolled service providers and PAS/ISSA agencies may call the HFS Provider hotline during state working hours to verify an individual's Medicaid enrollment. Providers may make up to six inquiries per call. The toll-free number is 1-800-842-1461. When using the automated system, callers must:
(e.g., 123456789100 (FEIN/SSN + 100)).
Callers who do not know the individual's RIN may talk with a Provider hotline staff member. To confirm eligibility when speaking with a staff member, callers must provide the individual's name, birth date and SSN.
HFS maintains a website, Medical Electronic Data Interchange (MEDI), on which registered users (service providers) may verify an individual's Medicaid eligibility status. The website contains information on how to use the system. First time users should:
After this one-time registration, users may use MEDI to verify individual Medicaid enrollment. Waiver providers cannot use the MEDI system to submit claims or to access remittance advices.
Note: The message "Eligible for DHS social services," means the individual is not enrolled in Medicaid. Some individuals have been assigned a Recipient ID Number (RIN) without being enrolled in Medicaid. PAS/ISSA staff, case managers, and Service Facilitators should make every effort to enroll these people in Medicaid.
A DHS-designated Pre-Admission Screening/Individual Service and Support Advocacy (PAS/ISSA) agency screens applicants for Medicaid HCBS waiver-funded services clinical eligibility and offers an informed choice of services. Please see the Pre-Admission Screening Agency (PAS) Manual. This manual contains guidance for PAS agencies on clinical eligibility determinations.
Clinical eligibility criteria, also known as level of care or level of service criteria, for Medicaid HCBS Waiver funding are presented in Table 1. As part of the waiver eligibility determination process, individuals must be evaluated to determine level of service needs.
Persons within the PAS agencies completing initial level of service evaluations and re-evaluations must be Qualified Intellectual Disabiilty Professionals (QIDP) as defined in Federal ICF/MR Regulations. The QIDPs:
Children who are determined clinically eligible for either of the Children's Waivers who are under the age of 19 can apply for Medicaid under special eligibility rules that can waive family income for families who would not otherwise qualify for Medicaid benefits for their child, based on the parent's income.
The PAS agency that determines clinical eligibility for the Children's Waivers can assist families to apply for Medicaid for their child. For children found clinically eligible for the waivers and for whom funding is authorized, PAS agencies will follow special procedures to help the family apply for Medicaid benefits. This will ensure that the child's Medicaid application is given special handling. Please contact the PAS agency in your area for more information about the Children's Waiver Medicaid application process.
For young adults determined eligible for the Children's Waiver, the PAS agency will assist the individual to apply for Medicaid benefits as an adult through the local DHS office. Please contact PAS for more information about the Medicaid application for young adults.
Individuals must be assessed as eligible for Intermediate Care Facility for people with Mental Retardation (ICF/MR) level of care/level of service:
See the Pre-Admission Screening (PAS) Manual for more complete information regarding these definitions and level of service requirements.
This includes the Division of Rehabilitation Services Home Services Program, the Department on Aging Community Care Program, the University of Illinois Division of Specialized Care for Children Technology-Dependent/Medically-Fragile Children's Waiver Program, and the Supportive Living Facility Program (SLF).
If receiving other waiver services, the participant must terminate the other waiver services and choose the Adult Waiver prior to, and as a condition of, receiving DD waiver services.
See the PAS Manual for detailed information about level of care/level of service requirements.
If receiving other waiver services, the participant must terminate the other waiver services and choose the Children's Support Waiver prior to and as a condition of receiving developmental disabilities waiver services.
The number of individuals served each year will be based on available appropriations. New enrollees will be selected from the Prioritization of Urgency of Need For Services (PUNS) database, a database maintained by the Division of Developmental Disabilities of individuals potentially in need of state-funded developmental disability services within the next five years. The selection criteria will provide for selection of individuals on several bases, including urgency of need, length of time on the database, and randomness.
If receiving other waiver services, the participant must terminate the other waiver services and choose the Children's Residential Waiver prior to and as a condition of receiving DD waiver services.
The number of individuals served each year will be based on available appropriations. New enrollees will be selected from the Prioritization of Urgency of Need For Services (PUNS) database, a database maintained by the Division of Developmental Disabilities of individuals potentially in need of state-funded DD services within the next five years. The selection criteria will provide for selection of individuals on several bases, including urgency of need, length of time on the database and randomness.
For residential services, the State gives priority within available waiver capacity to eligible persons according to the following priority population criteria, in priority order, beginning with the most critical need:
For support services, the Division gives priority within available waiver capacity to eligible persons who have been identified as individuals who are not receiving any support services from the Division or the Division of Rehabilitation Services (except vocational rehabilitation services). Within this population, if requests exceed available capacity, the Division will prioritize:
Sharing of assessment information is essential to the development of a timely and appropriate individual service plan. Sharing of other documentation of PAS actions and determinations is necessary to ensure that participants are made aware of their rights and that all providers are informed about each participant's status. The PAS/ISSA agency must send the following information to the responsible case manager or Service Facilitator when the Waiver Program clinical eligibility determination process is complete and services are being initiated:
Provider requests for service termination of waiver services to an individual can be recommended by the provider only if there is documentation that the basis for termination is in accordance with program rules.
In such situations, termination of services can be recommended only after consultation with the individual, individual's guardian, and other persons from the individual's support network as the individual or the guardian chooses and in compliance with appeal rights requirements specified in the waiver rule (59 Ill. Adm. Code 120).
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
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