WAG 06-25-04 Reviewing Changes

PM 06-25-04

Case Changes

Review eligibility for FHP or AABD when a person in an ACA Adult case reports one of the following:

  • a newborn is reported and the newborn lives with the parent or caretaker relative; or
  • children move into the home with the parent or caretaker relative; or
  • the person turns age 65; or
  • the person begins receiving Medicare.

Note: For pregnant women, the ACA Adult case may remain active until the birth of the newborn.

Do not require a new application when customer reports a change. To add a spouse to an ACA Adult case the customer must complete Form 243C, Request for Medical Benefits for Another Family Member(s) . Take the following actions:

  • ask tax status/relationship questions; and
  • verify income to determine eligibility under MAGI methodology;
  • process request if eligible; and
  • complete a case write-up regarding the request.

Change Case from ACA Adult to FHP

Who is eligible for the Family Health Plan (FHP)?

In addition to meeting Illinois residency, social security number requirement and U.S. citizenship, immigration status and income standards a person must be:

  • pregnant women;
  • children (age 18 or younger); or
  • parents or caretaker relative of children under the age of 18 with minor children living in the home.

Answer the following questions when changing an ACA Adult to FHP.

Question: Is this person a parent or caretaker relative with minor children in the home and receiving ACA Adult? 

If yes, review for FHP. Parents and caretaker relatives with minor children in the home are not eligible for ACA Adult.

When the ACA Adult case needs to be changed to Family Health Plans, cancel the ACA Adult case, suppress the notice in Item 39 and open the Family Health Plans case reusing the same basic ID number. Using TA 34 to change the ACA Adult case to FHP is no longer functional.

If a change in income is reported enter the case in IES as if it were a new application and run eligibility. Send Form 1721, if additional information is needed.

If the person is determined ineligible for FHP, consider AABD eligibility. Refer to the section below on "Reviewing Eligibility for AABD ".

When reviewing eligibility for FHP refer to Manual Release #15.19, Modified Adjusted Gross Income (MAGI) Budgeting for Medical, dated 07/29/15 (updated 08/18/15) and policy memo, Renewal Processing & MAGI Calculator, dated 03/21/14.

Example 1: Mary, age 67, has two grandchildren living in the home. Since Mary is over the age of 64 she not eligible for ACA Adult. Due to minor children living in the home she may be eligible for FHP. If Mary is not eligible for FHP, review for AABD. See section on "Reviewing Eligibility for AABD".

Example 2: Sue, age 35, is currently in the ACA Adult eligibility group.  She reported that her minor child moved into the home. Sue is no longer eligible for ACA Adult. Review eligibility for FHP. If Sue is not eligible for FHP, review for AABD. See section on "Reviewing Eligibility for AABD".

Example 3:An ACA Adult reports a newborn. The newborn is potentially eligible for Moms and Babies because the mother was receiving Medicaid under ACA Adult. Review PM 06-09-01. If they are eligible for FHP, change the case level coding as described above.

Change Case from FHP to ACA Adult

There are times when a parent or caretaker relative is no longer eligible for medical under FHP. This occurs when:

  • the only eligible child(ren) moves out of the home; or
  • the only eligible child turns 18.

The parent or caretaker relative may be eligible for ACA Adult when the only eligible child turns age 18. The 18 year old remains eligible until he/she turns age 19 due to continuous eligibility.  Determine eligibility for ACA Adult for the parent or caretaker relative.  If the parent or caretaker relative is eligible for ACA Adult, open the case in IES using the date of discovery as the application date. 

  • Enter TA 34 in item 3
  • Process the deletion. Refer to WAG 18-03-11-d.
  • Enter "W" in item 28
  • Enter "K" in item 25

Actions can only be processed in IPACS.

Illinois Medicaid Redetermination Project (IMRP) -Medical Only

The Illinois Medicaid Redetermination Project (IMRP) sends redetermination forms to ACA Adults turning age 65, 18 year olds on FHPs turning 19 years old, and ACA Adults who will begin receiving Medicare. The redetermination form must be completed and signed.  The central unit will review the returned redetermination form and determine eligibility for a new case. Refer to Policy Memo, Changes to the Illinois Medicaid Redetermination Project (IMRP) revised, dated 02/06/2014.

For AABD, use regular AABD budgeting. Request verification of resources for AABD, if required. Review PM 02-07-03-i regarding simplified processing. MAGI budgeting does not apply to AABD cases. MAGI budgeting does apply to an 18 year old in FHP who is turning 19 years old and being considered for the ACA Adult group.

Cancel the current case after eligibility has been determined for a different eligibility group. Prior to Phase II implementation, staff must register the redetermination in order to establish a new case in IES. Approve if determined eligible for medical in a different program and suppress the notice.

ACA Adult Cases with SNAP-Age 65 or Receiving Medicare

A report will be generated that will identify existing ACA Adult cases that have persons who are age 65 or older and those who receive Medicare. This report will be issued to each FCRC. The caseworker must review eligibility and determine if a person on the list is eligible for other medical groups.

To prevent future errors, edits have been recently added in IPACS and ACM that will prevent entering "K" in item 25 when the case includes an individual who has Medicare and the Medicare coding is entered on the case by the worker. An error message, "Code K invalid for item 25. Individual has Medicare, review for AABD eligibility." will display. 

Caseworkers must review eligibility for ACA Adult when changes are made to the case.

Answer the following questions when changing an ACA Adult to AABD due to Medicare or age:

Question 1: Is the person on Medicare? 

If yes, review eligibility for FHP and AABD. If this person is on Medicare they are not eligible for ACA Adult.

Question 2: Is the person age 65 or older?

If yes, review eligibility for FHP and AABD. This person is not eligible for ACA Adult.

AABD Budgeting

AABD does not use MAGI budgeting when determining eligibility. Income that is exempt under MAGI budgeting is not exempt for AABD. Unlike FHP and ACA Adult cases resources are not exempt for AABD.  See PM 02-07-03-i and PM 07-02-00.

Reviewing Eligibility for AABD

Refer to PM-02-07-03-i for simplified processing when determining eligibility for AABD . When changing a case from ACA Adult to AABD, due to the person turning age 65 or receiving Medicare, review the income on the existing ACA Adult case.  Determine from the chart below the verifications required in order to determine AABD eligibility:

Type of Income What to send to the client Worker Action
Person receiving SSI Nothing Approve for AABD
Person receiving SSA only and income is at or below 100% FPL and income is verified

Form 1721

HFS 2378DR

 Allow the client 10 days to respond.
Person receiving income other than SSA and income is at or below 100% FPL

Form 1721

Income (Last 30 days)

HFS 2378DR

 Allow the client 10 days to respond.
Person receiving SSA only and SSA is over 100% FPL Form 1721HFS 2378VR Allow the client 10 days to respond.
Person receiving other income (not SSI or SSA) over 100% FPL

Form 1721

Income (Last 30 days)

HFS 683

 Allow the client 10 days to respond.

Send Form 1721 with appropriate form (listed above) requesting needed information. When the client returns the appropriate forms complete the following steps:

  1. Review returned documents. Determine eligibility for AABD.
  2. Review household composition to determine who to include in the standard. Refer to PM 15-06-02-c. Complete HFS 2382a, AABD MANG Computation Sheet-Community Case. Be sure to upload documentation.
  3. Cancel the ACA Adult case (suppress the cancellation notice if the person will be approved for another program).
  4. Set up an AABD case in IES, if eligible. Send the necessary approval notices.

If requested information is not received within 10 days, cancel the ACA Adult case. Send Form 360C, Notice of Decision.

Note: When a person who was receiving SSI income is placed in non-pay status, verification of income and resources is required. Simplified processing does not apply to these persons although they may still be eligible for AABD.

Consider HBWD (Health Benefits for Workers with Disabilities) when a person is determined eligible for AABD spenddown, and has earned income, pays FICA, and is aged 16-64. See PM 15-08-00 regarding AABD Spenddown.

Change Case from AABD to ACA Adult

Individuals enrolled in AABD Spenddown whose income is over 100% FPL but not more than 138% of the FPL may be eligible for ACA Adult. If a person is enrolled in AABD Spenddown, review the person's eligibility for the ACA Adult group. Take the following actions:

  • Ask tax status/relationship questions and verify income to determine eligibility under MAGI methodology.
  • Process the determination of ACA Adult eligibility in IES as a new application and complete a write-up in IES regarding the request to review for ACA Adult eligibility.
  • If a the person is determined eligible for as an ACA Adult, stop and cancel AABD spenddown in IPACS before approving the ACA Adult case in IES. Suppress the AABD cancellation notice. Send the central approval notice for the ACA Adult case.

Example: Mr. Smith is enrolled in the AABD Spenddown. His spenddown is $302 each month. Mr. Smith's income is below 138% of the FPL. Mr. Smith requested to be enrolled in the ACA Adult Program. A new application is not required. Follow the above steps to determine his eligibility for ACA Adult.

SNAP Benefits

When a medical case, with SNAP changes to a different medical case, add the remainder of the SNAP approval period to the new medical case. Issue a new Link Card.

If the case is determined no longer eligible for medical, cancel the medical case and open a SNAP only case for the remainder of the SNAP approval period.

If medical benefits are canceled due to failure to provide requested information, set up a separate SNAP case for the remainder of the SNAP approval period and issue a new Link Card.

A person in a Family Health Plan (FHP) case can be in a facility for up to 3 months and stay in the FHP case. If care is needed for more than 3 months, the client must be removed from the FHP case and eligibility determined separately for the person in the facility and the other persons on the case.