12/11/13
Summary
- Family Health Spenddown for non-pregnant parents and caretaker relatives ends January 1, 2014 due to a state law change.
- There is no change for persons who have a spenddown case in Aid to the Aged, Blind and Disabled (AABD) or children and pregnant women in Family Health Spenddown.
- A special form 157SP/S Notice of Change will be mailed to all Family Health Plans households containing a non-pregnant adult in spenddown.
- Special procedures are in place for active category 94/96 cases containing a non-pregnant adult in spenddown.
- Encourage parents and caretaker relatives affected by this change to apply for medical coverage through the Illinois Marketplace.
To pave the way for new medical coverage options through the Affordable Care Act (ACA), P.A. 98-0104 eliminates Family Health Spenddown for non-pregnant adults as of 12/31/13. This change does not affect a child's or a pregnant woman's eligibility for Family Health Spenddown, nor does it affect AABD spenddown.
Applications
Family Health Spenddown for non-pregnant adults may be authorized through December 31, 2013. Do not approve a non-pregnant adult in Family Health Spenddown for any month after December 2013.
If a non-pregnant adult can meet spenddown for a month prior to January, split the adult off and process the application in AIS with a Type Action 10 as an approve & cancel.
Special Notices
Client Notice 13.29 Important News About Your Family Health Spenddown Medical Benefit
CN/S 13.29 (pdf) will be sent the week of 11/25/13 to all Family Health Spenddown households containing a non-pregnant adult in spenddown.
Cancelation Notice Form 157SP/S
To ensure the Family Health Spenddown program ends for all non-pregnant adults effective January 2014, a central cancelation notice 157SP(pdf) and 157SPS Notice of Change (pdf) will be sent to all active Family Health Spenddown households on or about 12/16/13. Households selected to receive the notice will include transactions in the Client Database processed on or before 12/12/13.
Women age 19 and older who are in spenddown and have an expired estimated date of delivery (EDD) will also receive the central cancelation notice 157SP/S.
Do not send a cancelation notice if terminating Family Health Spenddown coverage for non-pregnant adults on 12/13/13 or later. Refer to the section below on Deletions or Cancelations. Even if spenddown is not terminated on the system until after terminal entry in December, Form 157SP/S is the only notification the adult will receive.
Active Cases
Unmet Spenddown
Most non-pregnant adults in Family Health Spenddown are in unmet spenddown. Many have not had medical coverage for more than three months because there are active children on their cases. If customers contact staff regarding CN/S 13.29, assure them that the coverage for their children remains the same and remind them to pursue other health coverage options at the Illinois Marketplace.
Spenddown may be met in ASDS for an adult for whom medical expenses are submitted as long as the target month is no later than December 2013.
Delete non-pregnant adults in unmet spenddown as soon as practical. If terminating medical on or before 12/12/13, use TAR 39 to generate the central notice.
Met Spenddown
Some non-pregnant adults may have met spenddown for future months beginning January 2014 or later. Because of the law change, they are not eligible for medical coverage after December 2013.
Important: Cancel or delete non-pregnant adults who are in spenddown met status effective January 2014. If the non-pregnant adult is eligible for AABD, the spenddown amount in January may decrease because of the difference in determining spenddown between Family Health Plans and AABD.
HFS medical policy will contact the FCRCs to help identify the small number of met spenddown cases that require follow up by terminal entry.
Eligibility for AABD
Some non-pregnant adults who are active in Family Health Spenddown have a disability. Many are already receiving SSI or SSDI from the Social Security Administration. Determine eligibility for AABD spenddown as soon as possible to avoid delays in coverage.
If a determination of disability is pending with the Client Assessment Unit (CAU), the adult may remain active in unmet spenddown in the category 94/96 case until a decision on the disability is received. Do not meet spenddown after December 2013 for an adult whose disability adjudication is pending.
Deletions
Non-pregnant adults in category 94/96 cases with spenddown should either be deleted or changed to RPY status effective January 2014. Use Type Action Reason (TAR) 43. No central notice is generated with this TAR. The centrally generated form 157SP/S is sufficient notification even if the transaction to terminate the adult from spenddown is taken after January 2014.
Cancelations
Category 94/96 cases containing only non-pregnant adults in spenddown should be canceled effective January 2014. Use TAR 28. No central notice is generated with this TAR. The centrally generated form 157SP/S is sufficient notification even if the transaction to terminate the adult from spenddown is taken after January 2014.
| Date |
Deletion TAR |
Cancelation TAR |
Notice |
| On or before 12/12/13 |
39 |
29 |
System sends notice as described in WAG 27-33-01-k or the revised message for either the FCRC or the All Kids unit:
Your income is over the allowable level. PM 06-08, 06-09.
Su ingreso es más que el nivel permitido. PM 06-08, 06-09.
|
| On or After 12/13/13 |
43 |
28 |
No central notice is generated. The one-time mailing of Form 157SP is sent on 12/16/13. |
System
Changes to AIS, ACM, ASDS and IPACS will be made as soon as possible to stop authorization of spenddown for a non-pregnant adult in a category 94/96 case.
If taking an action on a Family Health Plans case generates a system edit error that requires removal of the adult in spenddown, terminate medical eligibility for the non-pregnant adult on Family Health Spenddown.
MMIS Central Update
Regardless of the case status in the CDB, a system change in MMIS will centrally close out spenddown eligibility for non-pregnant adults in category 94/96 effective 12/31/13. This action is necessary to stop the MEDI system telling providers inaccurate information about spenddown eligibility and avoid paying any claims after December 2013. For this reason, it is important to avoid authorizing spenddown for a non-pregnant adult after December 2013.
During the next several months, information in the Client Data Base (CDB) may not match data in MMIS.
Appeals
Appeal rights do not apply if the reason for the appeal is that the client disagrees with the law change. However, the client has the right to appeal and be given a fair hearing if they believe that they remain eligible for medical benefits due to an error in the eligibility determination regarding their income or family size, or that they are eligible due to having a disability. In those situations, follow policy contained in PM 01-07.
[Signed]
Michelle R. B. Saddler, Secretary
Illinois Department of Human Services
Julie Hamos, Director
Illinois Department of Healthcare and Family Services
Forms Referenced:
Form 157SP/S
CN/S 13.29
