01/19/16
Summary:
- Effective with IES Phase 2 implementation, a prior coverage determination will be made for a child who is certified for All Kids Share and Premium Level 1 when the applicant requested at least one month back date coverage for that child.
- This release provides temporary procedures to approve Family Health Spenddown rather than prior coverage for a month in which a child meets spenddown and the spenddown met date is before the date that prior coverage would begin.
- This release also corrects MAGI budgeting policy to clarify that only the interest portion of mortgage payments on rental property is allowed as a self-employment expense.
- Removes obsolete policy reference to FamilyCare Share or Premium backdating.
- Prior Coverage for All Kids Share and Premium
- Related IES Screen Change (Phase 2)
- Prior Coverage or Spenddown?
- Miscellaneous Changes
- MANUAL REVISIONS
- Forms referenced
Prior Coverage for All Kids Share and Premium
Prior coverage is available only the first time a child is approved for All Kids Share or Premium Level 1. After IES Phase 2 implementation, prior coverage can be requested in one of two ways:
- Post Phase 2, IES will determine eligibility for prior coverage when a child is certified for All Kids Share or Premium Level 1 and the applicant requested at least one month medical backdate coverage on the application for that child, or
- if the family did not request backdate coverage at application, they may submit a prior coverage request to the HFS All Kids Unit within 6 months of the initial date of All Kids Share or Premium Level 1 coverage for the child for whom prior coverage is requested. This option will continue to be available after IES Phase 2 implementation.
When prior coverage is authorized at initial application or when a child is added to an IES case, details about the prior coverage approval will appear in the 360C Notice of Decision as eligibility in the 'Earlier Months' coverage table. When it is authorized as a result of a request received after a child is already certified for Share or Premium coverage, the customer will be notified via Form 243KCA as before.
Authorization of prior coverage does not change the 12-month eligibility period that was set up when the case was approved.
Related IES Screen Change (Phase 2)
Prior coverage can be authorized only at initial application or within 6 months of certification the first time a child receives Share or Premium coverage. For this reason the question: "Has the individual received Share or Premium previously?" is being added to the Individual page in Data Collection for Phase 2. A response to this question will be mandatory for children.
A 'Yes' response to the above question will in turn require a response to the nest question on this page: "Has the individual received CHIP Prior Coverage?" The reason for this question is that if there is a break in All Kids Share or Premium coverage after a family has received prior coverage, and the family is later eligible for All Kids Premium, the family must pay their first month's premium before receiving All Kids Premium coverage again.
- NOTE: Since IES will only pick up inactive cases that have been canceled in the 6 months prior to conversion, the worker must review the MMIS screen (PF8 in IPACS/BlueZone) to answer these questions correctly.
- In MMIS, All Kids Share or Premium benefits are identified by SHR, PR1 or PR2 under the 'MANG P' column. Prior coverage is identified by a MANG P code of 4 or 4B.
Prior Coverage or Spenddown?
Prior coverage should not be authorized for a month in which spenddown is met, if the spenddown met date is before the date that prior coverage would begin. However, IES is not yet programmed to determine eligibility for Family Health Spenddown before authorizing prior coverage.
Until IES is programmed to consider spenddown before prior coverage, to approve spenddown coverage for a child who has medical expenses that would meet spenddown before the prior coverage start date, send HFS 2958, Request for Correction/Addition to MMIS Eligibility File, to the Exception Processing Unit (EPU).
- Example: On December 14th Mr. Big applies for medical benefits for his 10 year old daughter, Joy, and requests one month backdated coverage. His monthly income is $2,000 and Joy's EDG size is 2. On December 30th she is determined eligible for All Kids Share effective February. IES determines that she qualifies for prior coverage from Nov 30th through Jan 31st.
- Since medical expenses were submitted, determine whether spenddown would have been met prior to the prior coverage start date.
Countable Income = $2,000
- Spenddown Standard for EDG size of 2 = $375
= Spenddown amount = $1,625
Medical Expense incurred 11/20 = $2,000
- Since the medical expense would have met spenddown on November 20th, before the prior coverage start date, complete Form 2958 to provide spenddown met coverage from Nov 20th through Nov 30th. Update the prior coverage eligibility period to Dec 1st through Jan 31st.
Miscellaneous Changes
- Under MAGI budgeting, allowable self employment expenses are based on IRS rules. This release corrects PM 08-03-01-b to clarify that only the interest portion of mortgage payments on rental property is allowed as a self-employment expense.
- References to FamilyCare Share or premium backdating are removed from the manual. For more information refer to the 6/06/12 policy memo, FamilyCare Share, Premium and Rebate Ends for Adults.
MANUAL REVISIONS
[signed copy on file]
James T. Dimas
Secretary-designate, Illinois Department of Human Services
Felicia F. Norwood
Director, Illinois Department of Healthcare and Family Services
Forms referenced
- Form 360C
- Form 243KCA
- Form 2958
