Instructions for All Kids Application Agents (AKAAs) December 2012 This manual explains the All Kids Application Agent process, defines the role of the All Kids Application Agent, and gives detailed instructions for accurate completion of the All Kids, FamilyCare and Moms & Babies Application (Form 2378MC), hereafter called the 2378MC application. It complements the All Kids Application Agent Training.
Table of Contents All Kids Application Agent Manual 2012 Introduction... Page 6 Welcome!... 6 AKAAs... 6 AKAA Duties... 7 Identifying potentially eligible families... 7 Assisting in completion of the 2378MC application... 8 AKAA fraudulent conduct... 8 Submitting a completed application to the All Kids Unit... 9 Complying with confidentiality provisions... 9 Posting application assistance hours... 9 Notifying HFS of changes... 9 Part 1. Overview of All Kids up to 200% FPL, FamilyCare and Moms & Babies Plans... Page 11 All Kids and FamilyCare Assist... 11 All Kids Share... 12 All Kids Premium Level 1... 12 All Kids Premium Level 2... 13 Moms & Babies... 14 Paying Monthly Premiums... 15 Co-payments... 15 All Kids Rebate... 16 Table 1: Summary of co-pays and premiums... 17 Informed Choice... 19 Part 2. Covered Benefits and Service Delivery... Page 20 Covered Benefits: All Kids, FamilyCare and Moms & Babies Plans... 21 Covered Benefits: Rebate Plan... 21 Medical Providers... 21 Primary Care Case Management (PCCM)... 22 Illinois Health Connect (IHC)... 22 2
Voluntary Managed Care (VMC) and non-vmc Counties... 24 Time frame for choosing a Primary Care Provider (PCP)... 26 Excluded populations... 27 Role of the AKAA in PCCM... 27 Part 3. Eligibility Financial and Non-Financial Factors... Page 28 Financial Eligibility... 28 Monthly Total Countable Family Income... 28 Earned Income Credit... 29 Family Size... 29 Income Standards... 31 Do You Qualify For All Kids/FamilyCare/Moms & Babies? Worksheet... 31 Non-Financial Eligibility... 31 Period of Time Uninsured... 32 All Kids, FamilyCare and Moms & Babies Basic Non-Financial Eligibility Factors-Table 4... 34 Coverage Start Date... 35 Earlier Start Date... 36 Backdating: All Kids and FamilyCare Assist, Moms & Babies, FamilyCare Share & Premium and Newborns approved for Premium Levels 2... 36 Prior Coverage: All Kids Share and Premium Level 1... 37 Bills paid by a family during a covered period... 37 Eligibility Period and Change Reporting Requirements... 38 Children... 38 Adults... 38 Pregnant Women... 39 Caseworkers... 40 All Kids and FamilyCare Assist, Moms & Babies... 40 All Kids Share, Premium Levels 1-2 and Rebate and FamilyCare Share, Premium and Rebate... 40 3
Part 4. The All Kids Application Agent Assistance Process... Page 41 Step 1: Ask Questions... 41 Step 2: Explain All Kids, FamilyCare and Moms & Babies... 43 Step 3: Complete the Application with the Applicant... 44 Step 4: Explain the Documentation Requirements... 44 Step 5: Have Applicant Sign and Date... 46 Step 6: After the Application is Completed and Signed... 47 AKAA Transmittal Sheet... 47 Online Application Transmittal Sheet... 47 Priority Processing Transmittal Sheet... 47 The Renewal Process... 48 All FamilyCare or All Kids Reporting Changes... 48 Part 5. Documentation That Must Be Included with the Application. Page 49 Proof of Income... 49 Pay Stubs... 50 Tips... 50 Employer Statement... 50 Self-Employment... 52 Medical Backdating Requests... 53 Proof of Child Support or Spousal Support Paid... 53 Proof of Pregnancy... 54 Proof of Citizenship and Identity for U.S. Citizens... 54 Proof of Immigration Status for Non-Citizens... 56 Proof of Application for a Social Security Number... 58 Part 6. Temporary All Kids Medical Benefits... Page 59 Eligibility requirements... 60 Important points to know about Presumptive Eligibility... 60 4
Part 7. Remittance Advice.... Page 61 Remittance Advice... 61 Part 8. Resources....... Page 61 All Kids and FamilyCare Hotline... 61 Provider Hotline... 62 All Kids and FamilyCare Customer Service... 62 Department of Healthcare and Family Services (HFS) Websites... 63 Department of Human Services (DHS) Local DHS Family Community Resource Centers... 63 DentaQuest... 64 First Transit... 64 Illinois Client Enrollment Broker... 64 Illinois Health Connect... 64 Other Resources... 65 AKAA Liaisons for those located North of I-80... 65 AKAA Liaisons for those located South of I-80... 65 Provider Participation Unit... 65 Part 9. Ordering All Kids and FamilyCare Outreach Materials... Page 68 Outreach Materials... 68 Provider Forms... 68 AKAA Forms Available in the Warehouse... 69 AKAA Forms Not Available in the Warehouse... 70 Part 10. The 2378MC Online Application....... Page 71 Accessing the Online Application... 71 Using the Online Application... 72 5
Appendix of Forms, Brochures and Other Documents... Page 73 Portrait AKAA Forms... 73 Landscape AKAA Forms... 73 AKAA Forms Not Available in the Warehouse... 74 6
Introduction All Kids Application Agent Manual 2012 Welcome! All Kids, FamilyCare and Moms & Babies are State of Illinois healthcare programs for families. These programs provide comprehensive health insurance benefits for children age 18 and younger, their custodial parents or caretaker relatives, as well as pregnant women and newborn children. The Department of Healthcare and Family Services (HFS) and the Illinois Department of Human Services (DHS) administer these programs in Illinois. All Kids, FamilyCare and Moms & Babies enrollment continues to grow. All Kids Application Agents have contributed to the success of these programs. Thank you to all of you! AKAAs All Kids Application Agents (AKAAs) help families apply for All Kids, FamilyCare and Moms & Babies. AKAAs are community-based organizations, including faith-based organizations, day care centers, local governments, unions, medical providers and licensed insurance agents. To become an AKAA, a community-based organization or licensed insurance agent must submit a letter on business letterhead that explains the business and how staff will be in contact with families likely to be eligible for All Kids, FamilyCare and Moms & Babies. Letters from prospective AKAAs should be faxed to 217-557-4274. 7
If you do not have access to a fax machine, you can also mail your letter to: Illinois Department of Healthcare and Family Services Bureau of All Kids PO Box 19122 Springfield, Illinois 62794-9122 Before AKAA services may be offered, the community-based organization or licensed insurance agent must ensure that: Executive staff and the Director of the Illinois Department of Healthcare and Family Services have signed an AKAA agreement, and, Employees who will perform AKAA duties have received training in the completion of the 2378MC application. AKAA Duties Identifying Potentially Eligible Families AKAAs find families who may have eligible members through knowledge of other programs with similar eligibility requirements, such as: Women, Infants and Children (WIC), Free and Reduced School Lunch, Subsidized Child Care, and Supplemental Nutrition Assistance Program (SNAP). AKAAs can use the Do You Qualify for All Kids/FamilyCare /Moms & Babies? worksheet (Appendix Page 111) to help families estimate what they may qualify for. AKAAs should use this worksheet only as a guide and not determine eligibility. Families who wish to apply should never be discouraged from applying. 8
Assisting in Completion of the 2378MC Application AKAAs help families to apply for All Kids, FamilyCare and Moms & Babies by: Getting all proofs required from the person applying (the family member completing the application is usually a parent) Ensuring all questions are answered Making sure the applicant signed and dated the completed application. Note: An application is not complete until all required documentation is attached. AKAA Fraudulent Conduct AKAA fraudulent conduct is a violation of the AKAA agreement and may result in termination of an AKAA s agreement. Examples of fraudulent conduct include: The deliberate failure to list a spouse or any family member. The deliberate failure to list income from a spouse or other family member. The intentional falsification of family information. Charging families for services related to All Kids and FamilyCare, including charging for translating any All Kids and FamilyCare information into another language. Fraudulent conduct should be reported to the Illinois Department of Human Services Fraud Hotline: 1-800-252-8903. 9
Submitting a Completed 2378MC Application AKAAs should submit completed applications to the All Kids Unit. To be complete, an application must: Be signed and dated by the applicant, Have all questions answered completely, Have all required documentation attached and Include a completed checklist (cover page of the application). AKAAs should submit online applications whenever possible. The 2378MC on-line application can be accessed at <www.myhfs.illinois.gov>. AKAAs need to sign up for access to the Medical Electronic Data Interchange (MEDI), HFS s online eligibility verification system, in order to file the 2378MC. For more information on how to use the online application, please see Part 10 of this manual. AKAAs can also mail applications to the All Kids Unit at: All Kids Unit P.O. Box 19122 Springfield, IL 62794-9122 Applications may be faxed in emergency situations only and must include a statement of medical need on the fax coversheet. See Page 51 for this priority processing. Complying with Confidentiality Provisions 10 AKAAs must comply with all confidentiality requirements described in the AKAA agreement. The federal Health Insurance Portability and Accountability Act (HIPAA) does not permit the release of confidential family information that AKAAs acquire as a result of performing AKAA duties to any person or organization other than to the Illinois Departments of Healthcare and Family Services or Human Services for the purposes of determining eligibility for state-sponsored health benefits coverage.
Posting Application Assistance Hours Illinois uses federal Medicaid and Children s Health Insurance Program (CHIP) funds to help finance these healthcare programs. The federal Centers for Medicare and Medicaid Services (CMS), a part of the U.S. Department of Health and Human Services, oversees Medicaid and CHIP in each state and territory. CMS requires that sites assisting families in applying for Medicaid and CHIP must post the hours that such assistance is available. If application assistance services are not available at your site during all regular business hours, then you must post the times when families may get assistance completing applications. Notifying HFS of Changes AKAAs are required to notify HFS of any changes in corporate address, corporate name, site name, site address, names of contacts at each site, and any other information. Fax or mail changes to: Provider Participation Unit Illinois Department of Healthcare and Family Services PO Box 19114 Springfield, Illinois 62794-9114 Phone: 217-782-0538 Fax: 217-557-8800 Reporting updated information to HFS will help us keep our online and phone referral database current so that we are able to communicate with you when there are important policy changes and program updates. You can also sign up to receive e-mail updates at: http://www.allkids.com/akaa/notify.html For more information on All Kids Application Agents visit: www.allkids.com/akaa 11
Part 1. Overview of All Kids, FamilyCare and Moms & Babies All Kids and FamilyCare Assist All Kids and FamilyCare Assist pay healthcare costs for eligible children age 18 or younger and their parents who live with them in Illinois. Certain relatives who are raising children in place of their parents may also be eligible. These relatives must be related to a child by blood or adoption within a 5 th degree of kinship and are referred to as caretaker relatives. A person who is or was married to a relative within the 5th degree of kinship can also be a caretaker relative. Some examples of caretaker relatives are grandparent, great grandparent, aunt, first cousin and stepparent. To be eligible for Assist, a child or parent/caretaker relative must have countable family income at or below 133% of the Federal Poverty Level (FPL). All Kids and FamilyCare Assist pay for medically necessary healthcare. Children and parents have no premiums. Children do not have co-payments, except, $3.65 for emergency room visit in a non-emergency situation. Parents/caretaker relatives have co-payments of: $3.65 a day for hospital inpatient stays, $3.65 for each visit to a doctor or other medical practitioner, including dentists, $3.65 for each brand name prescription, $2 for each generic prescription. $3.65 for emergency room visit for non-emergency service. Table 1 on Page 17 shows parent/caretaker relative co-pay amounts under Adults. 12
All Kids Share All Kids Share pays for healthcare costs for eligible children age 18 or younger who live in Illinois. To be financially eligible, a family must have countable family income above 133% and at or below 150% of the FPL. All Kids Share pays for medically necessary healthcare services with no premiums. Children have the following co-payments: $3.65 for each hospital inpatient stay $3.65 for a visit to the emergency room $10 for each emergency room visit for a non-emergency condition $3.65 for each visit to a doctor or other medical practitioner $2.00 for each generic prescription $3.65 for each brand name prescription $100 maximum annual copayment per family All Kids Premium Level 1 All Kids Premium Level 1 pays healthcare costs for eligible children 18 or younger who live in Illinois. To be financially eligible, a child must have countable family income above 150% and at or below 200% of the FPL. All Kids Premium Level 1 pays for medically necessary healthcare services and recipients pay low premiums and co-pays. Children s services have the following copayments: $5.00 for each hospital inpatient stay $5.00 for a visit to the emergency room $25.00 for each emergency room visit for a non-emergency condition $5.00 for each visit to a doctor or other medical practitioner $5.00 for each brand name prescription $3.00 for each generic prescription Monthly premiums are based on the number of children covered: 13
$15 for one person $25 for two people $30 for three people $35 for four people $40 for five or more people There is a $100 maximum annual copayment per family. All Kids Premium Level 2 All Kids Premium Level 2 pays healthcare costs for eligible children age 18 or younger who live in Illinois. To be financially eligible, a child must have countable family income above 200% and at or below 300% of the FPL All Kids Premium Level 2 offers the same benefits as All Kids Share and Premium Level 1 for children except that non-emergency medical transportation will not be covered for children in families with income over 200% of the FPL. Services include doctor visits, hospital visits, dental care, vision care, prescription drugs, medical equipment, mental health services and much more. All Kids was expanded for families who do not have access to health insurance. It was not intended to encourage families who have insurance to change plans or to cause employers to stop offering coverage to their employees. Children must be uninsured for at least 12 months before they can be eligible for All Kids Premium Level 2. However, a child may be eligible for All Kids Premium Level 2, if the child meets one of the following health insurance exceptions: The child lost health insurance as a result of a parent s loss of employment; or The child has COBRA insurance now or in the last 12 months; or The child reached the insurance plan s maximum lifetime benefit limit (proof is required); or The child is a newborn that is not covered by another insurance policy; or The child has an insurance policy that is limited to a disease specific illness such as cancer treatment or only covers accidents or hospitalization; or The child s non-custodial parent provides the child s health insurance and the child s custodial parent is unable to access benefits for the child, or 14
The child lost medical benefits under one of the Family Health Plans at or below 200% FPL in the 12 months prior to application Note: AKAAs should accept the family s statement regarding COBRA coverage and end date of insurance due to job loss. Families with children in All Kids Premium Level 2 must make co-payments and pay premiums. Children s services have the following copayments: $100 for each inpatient hospital stay, $30 for each emergency room visit, $30 for each emergency room visit for a non-emergency condition, $10 for each visit to a doctor or other medical practitioner, $7 for each brand-name prescription, and $3 for each generic prescription. 5% of HFS rate for hospital and outpatient services $500 annual maximum copayment per child Co-payments are never required for children s preventative health services, which include immunizations and well-child check-ups. This also includes preventive dental services such as routine examinations, cleanings, fluoride treatments, and sealants. Monthly premiums are based on the number of children covered. $40 for 1 child $80 for 2 or more children Moms & Babies Moms & Babies is a program for pregnant women and their babies. Moms & Babies pays for both outpatient and inpatient hospital services for women while they are pregnant, and for at least 60 days after the baby is born. 15
It also pays for healthcare services to babies for the first year of the baby's life, if the mother is covered by Moms & Babies when the baby is born. There are no co-payments or premiums for enrollees in Moms & Babies. Paying Monthly Premiums Personal check, money order or Visa or MasterCard may be used to pay premiums. Payments can be mailed, made by phone to 1-877-828-2375 or submitted online at: www.allkids.com/epay/ Families falling 60 or more days behind in premium payments will result in cancellation of All Kids Premium Level 1 coverage. Past due premium amounts and the first new premium must be paid in advance before coverage can begin again. Individuals enrolled in All Kids Share or Premium Level 1 who are Native American Indians or Alaska Natives do not pay co-payments or premiums. Co-payments Medical providers are responsible for collecting co-payments and giving receipts to families. Medical providers may also choose not to charge a co-payment. AKAAs should make sure that families understand the difference between copayments and premiums and the family s responsibility to pay them. If a family does not want to pay a monthly premium, they must call us to cancel their coverage immediately upon receiving an approval notice. The family must pay the required monthly premium even if a medical card is not used. All Kids Share and All Kids Premium Level 1 families receive an envelope to keep track of co-payment receipts. The maximum family co-payment cost is $100 per 16
year. When co-payments reach the $100 limit, the family should mail the envelope and all co-payment receipts to the All Kids Unit address at: All Kids and FamilyCare Illinois Department of Healthcare and Family Services P.O. Box 19122 Springfield, IL 62794-9122 Upon receipt of the co-payment envelope, All Kids staff will verify that the copayment limit has been reached and will notify the family that they do not need to pay co-payments until the beginning of their next year of coverage. There are no co-payments for children enrolled in All Kids Assist. Co-payments are never required for children s preventive health services, which include immunizations and well-child check-ups. This also includes preventive dental services such as routine examinations, cleanings, fluoride treatments and sealants. All Kids Rebate The All Kids Rebate plan provides a health insurance policyholder with a monthly rebate if children, age 18 or younger, are covered by their private or employer sponsored health insurance. The policyholder may be a custodial parent, a non-custodial parent, caretaker relative or other individual with employer-sponsored or individual insurance. To be eligible, the insured children must have countable monthly income above 133% and at or below 200% of the FPL. The private or employer-sponsored health insurance must cover physician and hospital inpatient services. Rebate payments reimburse a policyholder for some or all of the premium 17
costs of their private or employer sponsored health insurance coverage. The monthly rebate amount is based on the current premium paid by the policyholder, up to a maximum of $75 per child each month. All Kids Rebate participants receive the services and use the provider network available to them through their private or employer sponsored health insurance. Co-payments, deductibles and premiums are determined by the private or employer sponsored health insurance plan. Note: Federal policy does not currently allow for certain Medicaid-eligible (All Kids Assist, Moms & Babies) children to receive All Kids Rebate. Some families with countable family income at or below 133% of FPL may have private health insurance and wish to receive Rebate. They will not receive Rebate but will be enrolled in All Kids or FamilyCare Assist instead. Table 1: Summary of co-pays and premiums for All Kids and FamilyCare Assist, Share, Premium Level 1, Rebate and Moms & Babies plans FPL = Federal Poverty Level - FamilyCare Assist All Kids Assist All Kids Share All Kids Premium Level 1 All Kids Premium Level 2 All Kids Rebate Moms & Babies Eligible Perçons Insurance Status Adults Insured or Uninsured Children Insured or Uninsured Children Insured or Uninsured Children Children Children Pregnant Women Insured or Uninsured Insured or Uninsured Insured Uninsured Monthly Countable Family Income 0-133% of FPL 0-133% of FPL 133-150% of FPL 150-200% of FPL 200-300% of FPL 133-200% of FPL 0-200% of FPL Well-Child Check-Up 18 $0 $0 $0 $0 $0 N/A $0
Doctor & other Medical Visit $3.65 per hospital day and for each doctor visit $0 $3.65 $5 $10 N/A $0 Prescription drug $2 generic $3.65 brand name $0 $2 generic $3.65 brand name $3 generic $5 brand name $3 generic $7 brand name N/A $0 Emergency room use in nonemergency situation $3.65 $3.65 $10 $25 $30 N/A $0 Emergency Room visit in an emergency situation 0 0 $3.65 $5.00 $30 N/A -- 0 Monthly Premiums $0 $0 $0 $15 for 1 child$25 for 2 children $30 for 3 children $35 for 4 children $40 for 5 or more children $40 for 1 child $80 for 2 or more children N/A $0 Note: As of July 1, 2006, undocumented, non-citizen children are eligible for All Kids at any income level. 19
Informed Choice Children covered by private or employer sponsored health insurance with countable family income above 133% and at or below 200% can elect to enroll in either: Share or Premium Level 1, or Rebate premium assistance coverage. When families with private or employer sponsored health insurance choose Share or Premium Level 1, they cannot also receive Rebate premium assistance. Rebate payments reimburse policyholders for some or all of the premium costs of their private or employer sponsored health insurance coverage. The monthly rebate amount is based on the current premium paid by the family, up to a maximum of $75 per child each month. Share or Premium Level 1 may cover services not covered by private insurance or employer sponsored health insurance. It is the families choice as to which option they decide to take. Families should be sure their current medical providers accept All Kids before deciding. They may also ask if a primary provider is enrolled as a Primary Care Provider with the Illinois Health Connect program. See Form KC 3800 Health Care Programs for Illinois Families on Appendix Pages 103 & 104 and Pages 105 and 106 in Spanish. 20
Part 2. Covered Benefits and Service Delivery Covered Benefits: All Kids, FamilyCare and Moms & Babies Plans Inpatient and outpatient hospital services, including emergency room care Physician services Inpatient and outpatient surgical services Clinic services Prescription drugs (limit four per month*) Laboratory and X-ray services Inpatient and outpatient mental health services Inpatient and outpatient substance abuse treatment services Dental services (for children only **) Medical supplies, equipment, prosthesis and orthoses Nursing care services Physical therapy, occupational therapy and speech therapy Hospice care Transportation to get medical care (Not available for All Kids Premium Level 2) Home healthcare services Audiology (hearing) services Optometric (eye) services and supplies*** Optometrist (eye) services Family planning services and supplies Podiatry (feet) services Chiropractor services (for children) Intermediate care facility for persons with developmental disabilities services Skilled pediatric nursing facility services Early intervention services, including case management Pregnancy care including delivery Special program for pregnancy women and their infants (Family Case Management) Nursing home services Children s check-ups, immunizations (shots), screenings and 21
treatment Renal dialysis services Respiratory equipment and supplies *Children and adults who need more than four prescriptions per month must get prior approval. Some medications are not affected by this policy. People should discuss their concerns with their physician to find out whether or not the limit will affect them. **Adults are only covered for dental emergencies defined as: Services for the relief of pain and infection. These services include exams, X-ray s and necessary sedation for removal of a tooth. ***Adult are eligible for only one pair of glasses every two years. Call the toll-free All Kids Hotline for more information about covered benefits. The All Kids Hotline phone number is 1-866- ALL-KIDS (1-866-255-5437) or TTY: 1-877-204-1012. Covered Benefits: Rebate Plan All Kids Rebate participants receive the services and use the provider network available to them through their private or employer sponsored health insurance. Rebate participants do not receive an All Kids or FamilyCare medical card. Medical Providers Most HFS Medical Program enrollees, including most children enrolled in All Kids and adults enrolled in FamilyCare, are required to participate in Illinois Health Connect or the voluntary Medicaid Managed Care Program, both of which require the enrollee to receive care through their Primary Care Provider (PCP). The next sections have more information about these requirements and selecting a PCP. Enrollees that have a Primary Care Provider (PCP) in Illinois Health Connect, the 22
Department s Primary Care Case Management Program, or Medicaid Managed Care (also called HMOs or MCOs) should call their PCP or health plan first to make an appointment for their preventive and primary healthcare services, such as check-ups or immunizations (shots). All Kids and Family Care participants that are not enrolled in Illinois Health Connect or Medicaid Managed Care can seek services from any medical provider enrolled with the Illinois Department of Healthcare and Family Services Medical Assistance Program. When scheduling appointments with doctors or other medical providers, enrollees should ask the provider s office if they accept All Kids and FamilyCare patients (sometimes referred to as Medicaid patients). If the provider will not accept this coverage, All Kids and FamilyCare enrollees should find another provider in order to avoid paying all medical costs themselves. Providers may be in Illinois or out-of-state. Primary Care Case Management (PCCM)/Illinois Health Connect Illinois Health Connect is a program that connects enrollees with a medical home to make sure that preventive and primary healthcare is provided in the best setting. Participants who are enrolled in Illinois Health Connect have a medical home through a PCP. PCPs in Illinois Health Connect serve as an enrollee s medical home by providing, coordinating and managing the clients primary and preventive services, including well child visits, immunizations, screenings and follow-up care as needed. The PCP will also make referrals to specialist for additional care or tests as needed. Having a single PCP ensures that enrollees have access to quality care from a provider that understands their unique healthcare needs. 23
Enrollees should contact their PCP first when they need nonemergency preventive and primary medical care. Other health care providers can refuse to treat the enrollee without a referral from their PCP. To continue the ongoing efforts to connect enrollees with their medical home and support continuity of care, Illinois Health Connect implemented Phase I of its Referral System. Under this system, enrollees are required to see their own PCP, or a provider or clinic affiliated with their PCP for most of their primary and preventive healthcare needs. PCPs seeing Illinois Health Connect enrollees who are NOT enrolled on their panel or on an affiliated PCP's panel on the date of service, must obtain a referral from the enrollee's PCP in order to be reimbursed by HFS for services provided. PCPs can submit referrals for their enrollees to see other PCPs through the Illinois Health Connect Provider Portal via the secure HFS MEDI system and directly with Illinois Health Connect via fax or by calling Illinois Health Connect. Specialists and non-pcps do not require a referral for services under Phase I. Enrollees can call Illinois Health Connect at 1-877-912-1999 (TTY: 1-866-565-8577) to find out who their PCP is, or go online at www.illinoishealthconnect.com and click on Who s My PCP. HFS contracted with Automated Health Systems (AHS) to administer the day-to-day operations of the PCCM program, including outreach, education and enrollment of enrollees and connecting the enrollee to a best fit PCP, provider education, provider recruitment and enrollment, referral assistance and tracking, quality assurance efforts, including a Bonus for High Performance program, operation of a nurse consultation line and a provider and client call center. 24
When an HFS Medical Programs application is approved, a notice is mailed to the applicant explaining the medical coverage approved for each person that requested health benefits. Most newly approved enrollees then receive an enrollment packet notifying them that they must choose a PCP for their medical home. These packets provide information on their healthcare choices and remind them of the importance of their medical home. Voluntary Managed Care (VMC) and Non-VMC Counties VMC Counties In the VMC counties, most participants who must pick a PCP may choose a PCP in Illinois Health Connect or a Managed Care Organization for their medical home. VMC counties include: Adams, Brown, Cook, Henry, Jackson, Kane, Madison, Mercer, Perry, Pike, Randolph, Rock Island, Scott, St. Clair, Washington and Williamson. In the VMC counties, HFS has contracted with AHS to be the Illinois Client Enrollment Broker. As the Illinois Client Enrollment Broker, AHS provides the Potential Enrollee with unbiased education about all health plans available to them and assists in enrolling them with a health plan and a PCP. Potential Enrollees in the VMC counties receive their education and enrollment packets from the Illinois Client Enrollment Broker. Potential Enrollees may make their health plan and PCP choices and enroll by: Calling the Illinois Client Enrollment Broker Help Line at 1-877-912-8880 (TTY: 1-866-565-8576). The call is free. or; Completing the enrollment form in the enrollment packet and mailing it to the Illinois Client Enrollment Broker (See Page 72); or Going online at www.illinoisceb.com and click on Enroll. 25
Health Plan options available to most Potential Enrollees in the VMC Counties are as follows: Cook County Family Health Network (An MCO that is like an HMO) Harmony Health Plan (An HMO) Meridian Health Plan (An HMO) Illinois Health Connect (A PCCM program) Jackson, Kane, Madison, Perry, Randolph, St. Clair, Washington or Williamson County Harmony Health Plan (An HMO) Illinois Health Connect (A PCCM Program) Adams, Brown, Henry, Mercer, Pike, Rock Island or Scott County Meridian Health Plan (An HMO) Illinois Health Connect (A PCCM Program) Non-VMC Counties Potential Enrollees in the non-vmc counties (all other counties not listed above) must choose a PCP who is part of Illinois Health Connect for their medical home. Potential Enrollees in these counties receive their enrollment packets and additional information from Illinois Health Connect. Potential Enrollees may make their PCP choice and enroll by: Calling the Illinois Health Connect Client Help Line at 1-877-912-1999 (TTY: 1-866-565-8577). The call is free. or; Completing the enrollment form in the enrollment packet and mailing it to Illinois Health Connect; (See Page 73); or Going online at: <www.illinoishealthconnect.com> and click on Enroll. 26
Time frame for choosing a PCP (for all Illinois counties) Eligible All Kids and FamilyCare participants receive enrollment packets from either Illinois Health Connect or the Illinois Client Enrollment Broker based on their county of residence. These enrollment packets provide education and information on their healthcare choices and instructions for how to pick a PCP and how to enroll. Potential Enrollees are required to select a PCP, and health plan if applicable, within 60 days of receiving an initial enrollment packet. If the Potential Enrollee does not respond to the initial enrollment packet within the first 15 days, they will be sent a reminder notice. If the Potential Enrollee does not respond within the first 30 days to the initial enrollment packet, a second enrollment packet will be mailed. The second enrollment packet will remind the Potential Enrollee that they have 30 more days to make a choice or they will be assigned a PCP, and health plan if applicable. The second enrollment packet will also tell the Potential Enrollee the PCP and health plan they will be assigned to if no choice is made. If the Potential Enrollee has not made a choice after 60 days of the initial enrollment packet, they will be assigned to a best fit PCP, in Illinois Health Connect based on an auto-assignment algorithm. The auto-assignment algorithm takes into consideration existing Provider-Enrollee relationships based on claims data; geographic location of the Enrollee and the PCP; family members PCP assignments; provider specialty; and capacity limits. Excluded Populations Most All Kids, FamilyCare and Moms & Babies enrollees are required to participate in Illinois Health Connect. However, the 27
following are a few of the populations not required to choose a PCP: Native American Indian and Alaskan Natives Children under age 21 who received SSI Children under age 21 who are managed by the Division of Specialized Care for Children (DSCC) Children in foster care Children who get Subsidized Guardianship or Adoption Assistance from the Department of Children and Family Services (DCFS) A complete list of excluded populations is found at: http://www.hfs.illinois.gov/assets/pccm fs.pdf Role of the AKAA in Illinois Health Connect AKAAs who work with families that are required to pick a PCP should encourage these families to carefully read the information provided in the enrollment packets and follow the instructions to select a PCP. Families are also encouraged to contact the Illinois Health Connect Help Line or the Illinois Client Enrollment Broker Help Line or visit the program Web sites for more information. Operators on the client help lines will answer questions, provide additional information to further educate the potential enrollee about their healthcare choices and enroll them with the PCP, and health plan if applicable, of their choice. Samples of Client enrollment materials and instructions on selecting a PCP, and health plan if applicable, are posted on the program Web sites. Illinois Health Connect http://www.illinoishealthconnect.co m 1-877-912-1999 TTY: 1-866-565-8577 28
Illinois Client Enrollment Broker http://www.illinoisceb.com 1-877-912-8880 TTY : 1-866-565-8576 For additional information on PCCM, the list of excluded populations not required to participate in PCCM, and other helpful information, visit: www.hfs.illinois.gov/managedcare/ Part 3. Eligibility Financial and Non-Financial Factors To be enrolled in All Kids, FamilyCare or Moms & Babies, children, parents/caretaker relatives and pregnant women must be eligible. There are two parts to eligibility: Financial criteria Non-financial criteria Financial Eligibility Financial eligibility for All Kids, FamilyCare and Moms & Babies is based on a family s total countable monthly income and family size. Monthly Total Countable Family Income Monthly total countable family income is income from all family members and from all sources including, but not limited to: Employment Self-employment Social Security, except Supplemental Security Income (SSI) Retirement Rental property Home day care providers Babysitting or other jobs Child or spousal support 29
Allowable deductions from total income are: $90 for each adult with income from a job, Monthly day care expenses paid, up to a maximum of $200 for children under 2 and $175 for children 2 and over, $50 of child support received and Total child support paid An employed pregnant woman receives a $30 and 1/3 deduction from her earned income at application. Note: In calculating total countable family income, All Kids and FamilyCare do not include employment income of a child 18 and younger who is not a parent or spouse. Earned Income Credit Family Size The portion of an employee s pay that is an Earned Income Tax Credit (EITC) is not considered countable income. Information on the EITC is available on the U.S. Internal Revenue Service Web site. Applicants may call the IRS at 1-800-829-1040 to use the services of a tax professional or get assistance in completing the EITC tax form. In determining family size for the All Kids, FamilyCare and Moms & Babies programs, count the following family members who live together: The applicant (parent, guardian, caretaker relative, pregnant woman or child living on his or her own) completing the application. The applicant s spouse. The applicant s children or stepchildren 17 and younger living in the home. (18 year olds are not counted in the family size.) The applicant s boyfriend or girlfriend if they have a child in common living in the house with them. Do not count the unborn child of pregnant women 30
in the family size. All Kids will automatically increase the household size to include the number of unborn babies based on proof of pregnancy. Note: 18 year olds reach the maximum age on the day before their 18th birthday and are considered a family size of one and can be enrolled in an All Kids case separate from the rest of the family if eligible. Example: An 18-year-old is eligible using the standard for one person (not considering the parents income) until the first full month at the age of 19. An 18-year-old turning 19 on January 1, 2010, would be eligible through December 2009, but an 18- year-old turning 19 on January 2, 2010 would be eligible through January 2010. Note: A parent who doesn t live with at least one of his/her children under age 19 is not eligible for coverage through All Kids. Note: The All Kids Unit doesn t determine household size in the same manner as the local DHS office. For this reason there are certain households that might be better off applying at the local DHS office. Those households include a stepparent with income, children receiving child support or Social Security as dependent, high medical bills, a disabled family member, or someone over 65 years old. Income Standards Once a family s total countable monthly income and family size are determined, these are compared to the Monthly Income Levels table to determine whether eligible family members are financially eligible, and if that is the case, for which All Kids and FamilyCare plan they are eligible. 31
Do You Qualify All Kids/FamilyCare Moms & Babies? (Worksheet) AKAAs can use the Do You Qualify for All Kids/ FamilyCare/Moms & Babies? worksheet (Appendix Page 111) with families to explain how income is counted and to estimate whether a family may be eligible for All Kids and FamilyCare. AKAAs should use this worksheet only as a guide. Only staff in the All Kids Unit or local DHS Family Community Resource Centers can determine eligibility. Families who wish to apply should never be discouraged from applying based solely on the results of this worksheet. Non-Financial Eligibility Several non-financial factors determine whether individuals are eligible for All Kids, FamilyCare and Moms & Babies. Some factors vary by plan. Non-financial eligibility factors are shown below. See Table 4, Basic Non-Financial Eligibility Factors on Page 38. Children must be 18 or younger, Only custodial parents or caretaker relatives may be eligible for coverage, Pregnant women of any age or citizenship/immigration status may be eligible, Non-pregnant adults must be U.S. citizens or qualified legal immigrants, Participants must be Illinois residents, Non-pregnant adults and most children who are citizens or documented immigrants must provide a Social Security number or proof of SSN application, Children in families with income over 200% FPL must be uninsured for 12 months with some exceptions 32
Period of Time Uninsured All Kids Premium Level 2 covers children without private health insurance. For this plan, children must meet additional nonfinancial criteria to discourage families who have insurance from dropping coverage or to cause employers to stop offering coverage to their employees. Children with family incomes that fall into All Kids Premium Level 2 (200 to 300 % FPL) must be uninsured for a period of at least 12 months to qualify for All Kids. However, children meeting one of the following exceptions are exempt from this requirement: The child lost health insurance as a result of a parent s loss of employment; or The child has COBRA insurance now or in the last 12 months; or The child lost eligibility under All Kids at or below 200% FPL within the past 12 months and doesn t owe unpaid premiums or Rebate overpayments; or The child reached the insurance plan s maximum lifetime benefit limit (proof is required); or The child is a newborn that is not covered by another insurance policy; or The child has an insurance policy that is limited to a disease specific illness such as cancer treatment or only covers accidents or hospitalization; or The child s non-custodial parent provides the child s health insurance and the child s custodial parent is unable to access benefits for the child. Note: AKAAs should accept the family s statement regarding COBRA coverage and end date of insurance due to job loss.the following table includes more information about non-financial eligibility factors. 33
Table 4 All Kids, FamilyCare, and Moms & Babies Basic Non- Financial Eligibility Factors Moms & Babies All Kids & Family Care Assist All Kids Share All Kids Premium Level 1 All Kids Rebate All Kids Premium Level 2 Insurance Status Insured or Uninsured Insured or Uninsured Insured or Uninsured Insured or Uninsured Must be Insured Uninsured Immigration Status Pregnant woman and newborn only need to be Illinois resident Children only need to be Illinois residents Adults must be U.S. citizen or qualified legal Immigrants and Illinois Residents Children only need to be Illinois residents Children only need to be Illinois residents Children only need to be Illinois residents Children only need to be Illinois residents Must provide a Social Security Number? No, However a pregnant woman with a SSN should provide it Undocumented or nonimmigrant children, and newborns No Children who meet citizen or immigrant requirements- Yes Adults Yes Undocumented or nonimmigrant children, and newborns No Children who meet citizen or immigrant requirements- Yes Undocumented or non-immigrant children, and newborns No Children who meet citizen or immigrant requirements- Yes Undocumented or nonimmigrant children, and newborns No Children who meet citizen or immigrant requirements- Yes Undocumented or nonimmigrant children No Children who meet citizen or immigrant requirements- Yes 34
Coverage Start Date In some situations, coverage will begin earlier. See Part 6, Temporary All Kids Medical Benefits, on Page 64. For applications submitted by an AKAA, the application date is either the date received at All Kids for online applications or the date the applicant signed the 2378MC for mailed applications. If the 2378MC has an invalid provider number or the application is not filed by an AKAA, the application date is the date received at All Kids. All Kids and FamilyCare Assist, and Moms & Babies If approved for All Kids and FamilyCare Assist or Moms & Babies, eligibility will begin on the first day of the month of application. All Kids Share, Premium Levels 1and 2, and All Kids Rebate If approved for All Kids Share, Premium Level 1 or 2 and All Kids Rebate, eligibility is prospective and will begin on the first day of the next processing month. The processing month is a calendar month and varies depending on when the All Kids Unit approves the application. If the application is approved by the 15 th of the month (or the next business day after the 15 th, if the 15 th is not a business day), coverage will begin on the first day of the next calendar month. Example: If the All Kids Unit approves the application for All Kids Share, Premiums Level 1 or 2, or All Kids Rebate, coverage on August 14 th, coverage will begin on September 1 st. 35
If the application is approved after the 15 th of the month or the next business day after the 15 th, if the 15 th is not a business day, coverage will begin on the first day of the month after the next calendar month. Example: If the All Kids Unit approves the application for All Kids Share, Premiums Levels 1 or 2, or All Kids Rebate, on Nov 18 th coverage begins January 1 st. Earlier Start Dates Backdating: All Kids and FamilyCare Assist and Moms & Babies, and Newborns approved for Premium Level 2 Families approved for All Kids and FamilyCare Assist and Moms & Babies may request that their eligibility be backdated up to three months prior to the application month. Children approved for Share or Premium Level 1 and 2 are not eligible for backdate. Newborns may receive medical coverage under All Kids Premium Level 2 effective with the month of birth if the child was born to parents who are Illinois residents at the time of birth and the signed request is made prior to the first day of the fourth month after the month of birth. Up to a 3 monthbackdate may be requested if the parents are willing to pay the child's premium from the earliest month of the backdate through the current processing month. Families can request backdating by answering Yes to question #7 on the application and indicating which months they are seeking coverage A health benefits card or notice may be issued for the backdate period. 36
Prior Coverage: All Kids Share and Premium Level 1 Children approved for All Kids Share and Premium Level 1 may request prior coverage for payment of medical bills up to two weeks before the application date. Prior coverage is permitted only once, when the child is first approved for All Kids Share or Premium Level 1. A health benefits card is not issued for the prior coverage period. A family receives a notice showing the prior coverage start date. To request prior coverage, participants must call the All Kids Hotline at 1-866-ALL-KIDS (1-866-255-5437) (TTY: 1-877-204-1012). The Hotline will send a Request for Prior Coverage form to the family. The family should complete the form and return it to the All Kids Unit in Springfield within the first six months of coverage. Note: Children found eligible for All Kids Premium Level 2 are not eligible for prior coverage or backdating, with the exception of newborns. Bills paid by a family during a covered period If a family pays for a covered medical service during a period that was later covered by All Kids and FamilyCare, the family can ask the medical provider to bill All Kids and FamilyCare. If the provider agrees, the provider must reimburse the family for services that All Kids and FamilyCare cover. 37 If the only family members covered are children, reporting changes in income or family size are not required. It may be advantageous to report income decreases that may make them eligible for a plan with lower co-pays or premium. Even if family income increases, children will remain financially eligible until the end of their 12-month continuous eligibility period.
Eligibility Period and Change Reporting Requirements Children Children remain financially eligible for All Kids for 12 months. Children s coverage under All Kids Assist, Share, Premium Levels 1 and 2 and Rebate continues for twelve months from the coverage start date, unless the child becomes ineligible due to a non-financial reason. Non-financial reasons that could cause a child to lose coverage include: The child turns 19. The child moves out of Illinois. A child on All Kids Rebate loses private health insurance. Application information is determined to have been inaccurate and the accurate information makes the child ineligible. If the only family members covered are children, reporting changes in income or family size are not required. It may be advantageous to report income decreases that may make them eligible until the end of their 12-month continuous eligibility period. Adults Adults may not remain financially eligible when family income increases. Families with adults covered by FamilyCare Assist must report the following changes within 10 days of the change: 38 Income Family size Address or phone number