Medicaid Redetermination Problems – FAQs (October 19, 2015)

A “Redetermination” is a review of eligibility for Medicaid, All Kids, SNAP or cash assistance. Eligibility for Medicaid and All Kids must be reviewed at least once a year. The state must decide whether a client meets the rules to keep getting benefits.

We have consulted with HFS and the Illinois Medicaid Redetermination Project (IMRP) based on the questions you have been posting on HelpHub and have drafted these FAQs to give assisters the best practical advice for helping clients who are experiencing problems with Medicaid redeterminations. For other questions about the IMRP process, please see this HFS Fact sheet.

#1 Client has a notice of termination from Medicaid and you believe they are still eligible for Medicaid.

File an appeal using this form if your client is within 10 days of the date they received a notice of termination or within 10 days of the date they are supposed to be terminated. Request continuing benefits and your client will not have a break in their Medicaid coverage while you follow the instructions below to help them process their redetermination.

#2 Client has lost Medicaid coverage but does not know how long ago they were terminated.

If a client tells you that they were told by a provider that they no longer have Medicaid, you will first need to determine if they were terminated within the last 90 days. If the client has their medical card, call (855) 828-4995, which is an HFS automated system that allows you to check if a Medicaid case was active on a particular date. Follow the instructions and enter the client's RIN number from their medical card and check to see when their case was terminated and if their case was active within the past 90 days. Another option is to email and ask when the case was canceled. As a last resort, call the DHS hotline at (800) 843-6154 and wait on hold to speak to a representative.

If the client was terminated within the last 10 days, see #8 below.

#3 Client has the original or a copy of the Redetermination Form but has not submitted it to IMRP or has no proof that it has been submitted to IMRP and it is within 90 days of the date of termination of their Medicaid benefits.

If a client comes to you with the original or a copy of the redetermination form within 90 days of the date of termination of Medicaid benefits, have them complete the form and submit verification (i.e., paystubs), if necessary. If it is a Medicaid only case, they should fax it in to IMRP; if it is a Medicaid/SNAP case, they should fax it into the client’s local DHS Family Community Resource Center (FCRC). To look up the client’s local DHS FCRC office, use the DHS Office Locator.
After faxing in the form, call IMRP to confirm receipt of the form. IMRP call center may not be able to locate the form until it is processed in 24-72 hours; however, if you call right after faxing the form in, the call center should be able to confirm the receipt if you can provide the time and the phone number that the fax was sent from. They do not recommend emailing in the form because the federal requirements mandate that the email is not kept after 5 business days; while they may still have it in their files, it is not as reliable as a fax. For all fax transmissions, keep the fax printout to prove transmission.

#4 Client no longer has the original or a copy of the Redetermination Form or never received a form, and it is within 90 days of the date of the termination of their Medicaid benefits.

Call IMRP with client on the phone or have client call IMRP if case is Medicaid only (and DHS if it is a Medicaid/SNAP case) and request a replacement form. The form must be sent by mail and can only very rarely be faxed to the client or to the case manager due to HIPAA concerns. Tell the client to watch their mail and make sure their address is correct (and correct it with IMRP while on the phone and DHS after the call if it is not correct). When the client receives the replacement form which should arrive in two business days, they should immediately confirm the information in it and/or provide any requested information and then fax it to IMRP and call to check it is received using the same method as described above.

Historically it is very difficult to reach anyone at a DHS office over the phone. Medicaid/SNAP clients should go to their local DHS office in person to request a replacement redetermination form if you cannot reach the office by phone.

If it is very close to the end of the 90 day period and client has previously tried to fax the form in multiple times or has not received any forms in the mail, the case manager may ask the IMRP call center to expedite the case to a supervisor to request that a form be faxed to the client or the case manager while they are on the phone. This practice cannot be authorized by the call center staff due to HIPAA concerns and is not the preferable manner for handling a request for a duplicate form. It should only be used if the client may lose their right to reinstatement due the running out of the 90 days. The case manager should tell the supervisor that the case is urgent, close to the 90 day termination period, and that the client will lose their opportunity for reinstatement if the form is mailed.

#5 Client has no proof of submission of Redetermination Form and 90 days has passed since Medicaid was terminated.

Client must reapply for Medicaid but should do so as soon as possible and request backdating for 3 months if client has past medical bills.

#6 Client has proof of submission of Redetermination Form (such as a fax transmission or email confirmation) and 90 days has not passed since the Medicaid was terminated.

Follow the process in #1 to appeal and resubmit form to IMRP or if the case is medically urgent, or close to the 90 day limit, send the information by email to either Stephani Becker () or Stephanie Altman () and we will submit it to HFS and request reinstatement of the case.

#7 Free health services during a coverage gap

Clients will often first find out they lack insurance when attempting to receive treatment during a crisis. While you are working with the State to reinstate their benefits, it's a good idea to also refer them somewhere where they can attempt to receive services right away. Some providers will continue seeing an existing patient when there is a temporary gap in their coverage if they know the patient is working to reinstate their benefits. Attempt to contact the client's provider and explain to them why the client is temporarily uninsured and what you are doing to fix the problem. If that does not work, federally qualified health centers (FQHC) and some other clinics will treat patients regardless of their ability to pay.
Find the closest FQHC, free and charitable clinic or Cook County Health & Hospitals System outpatient clinic and encourage the client to seek treatment there (or go to an Emergency Room, if it’s an emergency) and then they can resume seeing their regular doctor once their benefits are reinstated.

#8 When to file an appeal

File an appeal using this form if (1) your client is within 10 days of the date they received a notice of termination or within 10 days of the date they are supposed to be/were terminated. On the form, the client can indicate that they want their benefits to continue until a hearing decision is made and therefore, they will not have a break in their Medicaid coverage while their redetermination is processed; or (2) your client's issue is not fixed by one of the above options, you feel your client's situation is complicated or unfair, or their case has gone unaddressed by the individuals you've contacted.

Your client will receive a letter with a hearing date within a few weeks of filing the appeal. Your client will be given an informal hearing with their DHS office where they will be able to explain what went wrong with their case. Usually, the DHS office will be eager to resolve the issue and reinstate the client if they are eligible. It is ideal for clients to have legal representation in these situations. If your client is reinstated before the hearing date you may simply withdraw the hearing request by contacting the Bureau of Hearings. Contact CARPLS for help finding free legal assistance for your client.

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