MR #16.17: Medical Extension Process in IES

Illinois Department of Healthcare and Family Services Illinois Department of Human Services

10/5/16

Summary:

In IES Phase 2, the Medical Extension (ME) program will be managed by FCRCs rather than a central Medical Extension Unit (MEU).
Medical Extension EDGs that are the result of increased earned income require a quarterly review in the 4th and 7th month of the certification period.
Policy regarding the required quarterly reviews and case maintenance requirements is added to the manual.
A TANF or FHP EDG will no longer progress to Medical Extension when the client does not respond to a request for information based on a New Hire report, or when an employed client requests cancellation of TANF.
This release also updates policy about determining financial eligibility for the Moms & Babies program, and eliminates references to the 30 & 1/3 Earned Income Exemption.

Extended Medical Determination in IES
1. Medical Extension (ME) Certification Period
2. Families that Don't Qualify for Medical Extension
Maintaining Medical Extension
Initial eligibility for Moms & Babies Program
MANUAL REVISIONS
Forms referenced

Under IES Phase 2, the Extended Medical program will be managed by FCRCs rather than a central Medical Extension Unit.

Extended Medical Determination in IES

When the worker reruns eligibility and the family is financially ineligible for TANF, or a parent or caretaker relative who received FamilyCare has income that increases above the Family Assist standard, the system will determine if the family qualifies for extended medical per PM 18-05-06.

This applies to cases where:

TANF or, FamilyCare with income at or below the Family Assist level, was received for 3 of the last 6 months before income increased above the TANF or Family Assist level,
the increased income is due to new or increased earned income or spousal support, and
the person who has increased earned income or spousal support is in the TANF benefit unit or receives FamilyCare.

Example 1: Ms. Zee received TANF and medical benefits with her 2 children since December 2016. On 06/07/17, Ms. Zee reports that she has a new job. Due to her increased earned income she no longer qualifies for TANF. When her income is entered into Data Collection and her eligibility is rerun, the system determines that the family qualifies for extended medical.

Example 2: Ms. Aye receives FamilyCare and All Kids Assist with her 2 children. Countable monthly income is $1,800. The last month of their certification period is 06/2017. On 01/07/17, Ms. Aye reports that she has a new job and countable income is now $2,900, which is above the All Kids Assist, and the FamilyCare Assist Standard for 3. The updated income is entered into IES.

The family does not qualify for extended medical because income was not at or below the Family Assist level for 3 of the last 6 months. Since the current certification period is not ending, the children continue to receive All Kids Assist until the end of the certification period. Medical benefits are canceled for Ms. Aye and she is referred to the Marketplace.

Example 3: Mr. Bee and his child receives FamilyCare and All Kids Assist. Countable income is $1,200. The last month of their certification period is 06/2017. On 06/01/17 in response to the REDE, Mr. Bee reports that he has a new job and countable income is now $2,500, which is above the Assist standard for 2.

The family does not qualify for extended medical because income was not at or below the Family Assist level for 3 of the last 6 months. Since the certification period is ending, when the REDE is certified in IES with the updated income amount, the child is determined eligible for All Kids Premium Level 1. And, Mr. Bee's medical benefits are canceled and he is referred to the Marketplace.

Example 4: Mrs. Ivy, who is in a TANF unit with her grandchildren for at least 3 of the last 6 months, goes to work. She earns enough to make herself ineligible for TANF cash, but her grandchildren stay eligible. The grandmother qualifies for extended medical.

Example 5: Mr. Flores received FamilyCare since May and his income fell below the Family Assist standard for the first time in August. He starts a new job on September 1st and his earnings exceed the Family Assist and FamilyCare standard effective October. Mr. Flores does not qualify for extended medical because his income has not been at or below the Family Assist level for at least 3 of the last 6 months. His medical benefits are canceled and he is referred to the Marketplace.

Medical Extension (ME) Certification Period

Medical Extensions certification periods are:

4 months if due to spousal support, or
12 months if due to earned income with quarterly reports due in the 4th and 7th months

The ME certification period starts with the first month the family should have stopped receiving TANF or Family Assist. This is the month action could have been taken had the earnings or spousal support been reported timely and a notice of change provided.

Example 6: Ms. Rose has received TANF since January, and starts working in early June. Due to the earned income, she will no longer qualify for TANF effective July. The potential 12-month extension starts with July and ends the following June. This period applies even if the income was not reported in June.

Example 7: Mr. Laurel received FamilyCare since February and his income has been below the Family Assist standard since May. He starts a new job on September 1st and his earnings exceed the Family Assist Standard beginning in October. He does not report his increased earnings until January. Since October would have been the first month that his income exceeded the Family Assist standard had it been reported timely, his potential 12 month extension starts with October and ends the following September.

Families that Don't Qualify for Medical Extension

Prior to IES Phase 2, a TANF or FHP EDG progressed to ME when the client did not respond to a request for information based on a New Hire report, or when an employed client requested cancellation of TANF. Under Phase 2, TANF and FHP EDGs will no longer qualify for ME for those reasons.

If the family is not eligible for extended medical, for children under age 19:

If the certification period has not ended, the child receives All Kids Assist for the remainder of the 12 month certification period.
If the certification period has ended, IES will determine eligibility for All Kids Share or Premium. Medical benefits are canceled if income is more than the All Kids Premium Level 2 standard (318% of the FPL), and the child does not qualify for another program.

For adults age 19 and over, IES will determine eligibility for other medical programs. Medical benefits are canceled if income exceeds the FamilyCare Assist Standard and the adult does not qualify for another program.

Maintaining Medical Extension

Under IES Phase 2, cases with Medical Extension are maintained by the Family Community Resource Centers (FCRC). Prior to Phase 2, ME was maintained by the central Medical Extension Unit (MEU).

A family no longer qualifies for extended medical if they no longer have a dependent child under age 18 in the home. If the extended medical ends during the 12-month period, any person under age 19 remains eligible due to continuous eligibility policy (see PM 18-05-01).

A family can receive extended medical up to 12 months when the reason they qualify is due to new or increased earnings. They qualify for the first 6 months without an income limit. Then they can receive an additional 6 months if they:

complete and return all required review forms,
still have a child under age 18 at home who was included in the first 6-month extension,
have earnings that are less than 185% of the federal poverty level using MAGI budgeting policy, and
have not quit work without good cause.

Medical Extension Quarterly Reviews (HFS 3361)

Federal regulations require that persons who receive ME due to new or increased earned income must complete and return the medical extension reviews to ensure that they continue to qualify for ME after the initial 6 months.

In addition to all other case maintenance activities, FCRCs process quarterly review forms (HFS 3361) for Medical Extension EDGs.

First Quarterly Review

IES generates the first HFS 3361 at cut off in the 3rd month of the 12 month medical extension certification period, which is due back by the 15th of the following month (the 4th month in the cert period). The 3361 instructs the client to return the form to the Central Scan Unit.
The client returns the form to Central Scan Unit or FCRC.
1. When Form 3361 is received at the Central Scan Unit or FCRC, a worker must enter the date in the "4 Month Quarterly Report Date" received date field on the "REDE Received - Details" page. This lets IES know that the 3361 form has been received and prevents auto-cancellation.
2. The FCRC worker must review the form and enter any updated information into Data Collection as a case change. If the client continues to qualify for extended medical, no further action is taken.
3. If the reported income is over 185% of the FPL, or the client has quit their job without good cause, the adults no longer qualify for extended medical. If the persons is not eligible under another medical program, the system cancels medical benefits effective the 7th month of the cert period.
If the client does not return the form, IES automatically cancels the adults' medical benefits effective the 7th month of the cert period.

Second Quarterly Review

IES generates the first HFS 3361 at cut off in the 6th month of the 12 month medical extension certification period, which is due back by the 15th of the following month (the 7th month in the cert period). HFS 3361 instructs client to return form to the Central Scan Unit.
The client returns the form to Central Scan Unit or FCRC.
1. When Form 3361 is received at the Central Scan Unit or FCRC, a worker must enter the date in the "8 Month Quarterly Report Date" received date field on the "REDE Received - Details" page.
  Note: The title of this field will be corrected to "7 Month Quarterly Report Date" after Phase 2 implementation.
2. The FCRC worker must review the form and enter updated information if any, into Data Collection as a case change. If the client continues to qualify for extended medical, no further action is taken.
3. If the reported income is over 185% of the FPL, or the client has quit their job without good cause, the adults no longer qualify for extended medical. IES determines eligibility for another program, and cancels medical benefits if not eligible effective the 8th month of the cert period.
If the 2nd quarterly review form is not returned, IES will not automatically cancel the adults' medical benefits. The worker must take an action to close the extended medical EDG. If another action is processed on the case after the due date, IES will close the medical extension EDG if a received date has not yet been entered.

Example 8: Ms. Rose and her 5 year old son, Joe, qualify for extended medical due to increased earnings. Their 12 month cert period is from July through the following June. Their first review form is mailed in mid-September with a due date of Oct 15th. If not received, Ms. Rose's ME eligibility will automatically end effective January (the 7th month of her ME cert period). Joe will continue to receive medical until the end of the cert period.

Her 2nd review form will be mailed in mid-December. If not received by the due date, the worker takes action to end her ME eligibility effective February, or the next month that can be affected.

Note: An adult who lost eligibility due to not returning the quarterly review form can be added back to extended medical when the signed 3361 is returned as long as they still meet the ME program criteria.

When Form 3361 is Not Generated

Form HFS 3361 is not generated in the 3rd and 6th months of the ME certification period in the following situations:

At conversion, when a Medical Extension case that is past the 3rd or 6th month of its certification period is converted from the CDB to IES at Phase 2 implementation.
Ongoing, when the Medical Extension is certified after the date that a 3361 review form should have been generated because an income change was not reported or budgeted timely.

When a Medical Extension EDG is certified in IES too late to issue the quarterly review form, IES will bypass the 1st (or 2nd) quarterly review. The missed review form will not be sent to the client and IES will exempt the person from that review by populating the received date. The worker is not required to generate the 3361 manually.

Example 9: Mr. Laurel is certified into ME effective February due to earnings that increased in September. Since his 12 month certification period should have started last October, it is too late to generate the first 3361 that should have been issued in December. IES automatically populates a receipt date in the "4 Month Quarterly Report Date" field to prevent an auto cancellation. The next quarterly review form will be generated in mid-March, which is the 6th month of the certification period.

Income Change on Medical Extension with SNAP

For Medical Extension, verification is not required when the client reports an income change on the 3361 form. Since verification is not required, when an income change is entered in IES, the worker must select 'other acceptable verification' to prevent generating a VCL for medical.

If the case contains SNAP, a VCL for SNAP only may be required when reported income is different than what was being budgeted on the SNAP EDG. See PM 18-04-09-a for income changes reported on cases not in MPR and for income changes reported during the approval period for those cases in MPR. For cases in MPR when the change is also reported on the report form see, PM 19-07-07 and WAG 19-07-07.

If the verified income is different from what the client reported on the 3361, it will affect the Medical Extension only if it's over 185% of FPL. If it's under 185%, the adult continues to qualify for ME.

Good Cause for Job Quit

When the client claims good cause for quitting a job, document the reason for leaving the job in the case record. Good cause for quitting a job includes situations beyond the client's control, such as but not limited to:

the client's illness or illness of another unit member that requires the client's presence,
a lack of transportation to the job site,
a household emergency,
lack of adequate child care for a child under age 13,
an employer discriminates based on age, race, sex, color, handicap, religious beliefs, national origin, or political beliefs,
a job has work demands or conditions that make it unreasonable to continue (for example, is working and not being paid on schedule),
a person must quit their current job in order to accept a new job,
another unit member accepted a job in another county that requires that the family to move
a person's leaving of a job is a normal pattern for that type of work. Examples of a pattern of employment where workers frequently move from one employer to another are, migrant farm labor or construction work, or
the job is "unsuitable employment". A job is unsuitable if:
- wages offered (including tips) are less than the state minimum wage,
- wages are on a piecework basis and the amount the person can reasonably expect to earn is less than the minimum wage,
- as a condition of employment, the person is required to: join, resign from, or refrain from joining any legal labor organization (this does not include being required to pay dues),
- the job offered is subject to a strike or lockout at the time of the offer,
- the job poses an unreasonable degree of risk to the person's health and safety,
- the person is physically and mentally unable to do the work, or
- Commuting time is more than 2 hours per day, not including travel to and from child care.

Initial eligibility for Moms & Babies Program

This release updates policy regarding how to determine countable income for the Moms & Babies program. To determine initial eligibility under Moms & Babies, use Modified Adjusted Gross Income (MAGI) budgeting methodology described in PM 15-04-02 and PM 15-06-01-f. Always count the number of babies expected toward any EDG in which the pregnant woman is counted.

If countable monthly income exceeds the Moms & Babies Income Standard, decide eligibility for Family Health Spenddown. A pregnant woman cannot spend down to the Moms & Babies standard.