PM 20-02-03 Automated Medical Benefit Restriction for Incarcerated Individuals

WAG 20-02-03

Central MMIS Updates

When an individual who is receiving medical benefits is identified as being incarcerated in an Illinois Department of Corrections (IDOC) facility, the medical benefit is restricted in MMIS to inpatient hospitalization and related professional medical services rendered as part of the hospital stay. 

Individuals in a federal prison are not eligible for HFS medical benefits.

Restriction of Medical Benefits

An automated process restricts medical benefits by updating MMIS on a weekly basis using an electronic file from IDOC. The automated restriction also ends payment for managed care, long term care coverage and primary case management fees to physicians and clinics during the period of incarceration.

An OBRA code CI restricts medical eligibility for incarcerated individuals in MMIS to inpatient hospitalization and professional medical services related to the hospital stay. 

Restricted medical benefits start on the date after the individual is admitted to the correctional facility.  The individual must comply with all required activity to maintain medical eligibility.

Restoration of Medical Benefits

IDOC releases the individual from the correctional facility with a two week supply of their maintenance medications.  The automated data update ends the medical restriction and authorizes full medical benefits within a week after the individual's release.  The last day of the restriction is the day before the release date.

In the instance where the individual has been released from the correctional facility and is in need of immediate medical coverage within the first week, send an email to and include the individual's name, case number, and RIN.  HFS central office will review the IDOC records to verify the individual has been released and will manually end the restriction restoring full medical coverage.