- Applications that are transfered from the Health Insurance Marketplace include an Electronic Attestation page that has language about HFS Medical Program cooperation requirements.
- If the Electronic Attestation page does not contain a 'yes' response for medical related requirements, the applicant must sign a Rights and Responsibilities page to qualify for medical benefits.
A person who applies for medical benefits must agree to assign to HFS their rights to medical support or other third party medical payments. A parent or caretaker must also agree to cooperate in establishing paternity and obtaining medical support on behalf of dependent children for whom they are applying. Applicants who do not agree can be denied Medicaid. This does not apply to children and pregnant women.
See PM 03-19-00 and PM 24-02-00 for more information.
Marketplace Application Electronic Attestation Page
Applications that are transfered from the Health Insurance Marketplace include an Electronic Attestation page that contains language about cooperation requirements. The following information appears on the Electronic Attestation page. The second column in this table shows what must be marked 'yes' for medical eligibility.
|lines that must have 'Y' for medical
|Applicant attests to not being incarcerated
|Applicant is currently awaiting disposition
|Applicant agrees to inform FFM of changes to application
|Applicant is aware of Medicaid obligations
|Applicant attests that the information provided is truthful
|Applicant agrees to cooperate with agencies that collect medical support information from absent parents
|Applicant agrees to the terms of signature
|Applicant agrees to allow FFM access to his or her tax return
|Applicant agrees to provide tax return information for next 4 years
When a 'Y' does not appear in one of the required rows, the applicant must sign an agreement to cooperate as a condition of eligibility. Send the applicant the 'Cash/Medical-Clients Rights and Responsibilities', pages 16 to 18 of Form 2378B, with Form 267-Instructions to Customer, to request that they sign and return the signature page.
Use Denial TAR 40 Until TAR 79 is Available in IES
If the applicant does not sign and return the signature page, deny medical benefits for the adult applicant. Do not deny a child or pregnant woman for this reason.
If available in IES for the medical program that is being denied, use TAR 79, "Refused to cooperate with medical support policy". If TAR 79 is not yet available, use TAR 40, "Did not give nonfinancial information" and document in case notes that the person did not cooperate with medical support rights. IES will be updated to allow denial TAR 79 to be used in IES for all medical programs at a later date.
[signed copy on file]
Michelle R. B. Saddler
Secretary, Illinois Department of Human Services
Director, Healthcare and Family Services