The Department on Aging (DoA) Community Care Program (CCP) offers crucial support to seniors, and understanding how to apply and utilize its benefits is essential. This guide explains how the DoA/CCP can assist with medical expenses, particularly in meeting spenddown requirements for medical assistance in Illinois, effective from September 1, 2010.
Understanding the DoA/CCP Application Process
Applying for the Department on Aging Community Care Program is a significant step towards accessing vital services. Individuals seeking DoA services are required to apply for medical benefits as part of the application process. This ensures that eligible individuals receive the full spectrum of support available to them. Care Coordination Units (CCUs) play a key role in assisting applicants through this process. They provide guidance and support in completing the necessary paperwork for medical benefits applications.
When you request DoA services, the CCU will provide you with HFS 2378H, the Mail-In Application for Medical Benefits, along with HFS 2538B (pdf), the IDoA Notification form. This notification is sent to the Family Community Resource Center (FCRC) to initiate the medical benefits application. It is important for applicants to cooperate fully and provide any necessary documentation to determine eligibility for medical benefits. This collaborative approach ensures a smoother and more efficient application experience.
Utilizing DoA/CCP Services to Meet Medical Spenddown
A key advantage of the DoA/CCP is that the costs of its services are recognized as allowable medical expenses for meeting spenddown requirements. Spenddown is the process by which individuals whose income exceeds the limit for Medicaid eligibility can still qualify for medical assistance by incurring medical expenses equal to the excess income. By utilizing DoA/CCP services, individuals can effectively reduce their countable income for Medicaid eligibility purposes.
It’s important to note that DoA/CCP service costs can only be applied to the spenddown obligation of the person receiving the services. In cases where a couple has a one-person standard for eligibility, DoA/CCP services for one spouse cannot be used to meet the spenddown obligation of the other spouse. Furthermore, if one spouse begins receiving DoA services, it may be necessary to separate companion spenddown cases to ensure accurate accounting of medical expenses.
How FCRCs Process DoA/CCP Expenses for Spenddown
Family Community Resource Centers (FCRCs) play a crucial role in processing DoA/CCP expenses for spenddown purposes. When determining spenddown status, FCRCs consider the estimated cost of DoA/CCP services as incurred on the first day of the month, regardless of when the services are actually delivered. These service costs are prioritized and applied to spenddown before any other medical bills or receipts.
If the DoA/CCP service costs are not sufficient to meet the spenddown amount in the month they are incurred, these costs can be carried over and used to meet spenddown in subsequent months. There is no time limit on using these service costs for spenddown. However, once the DoA/CCP service costs for a particular month have been used to meet spenddown, any remaining amount from that month cannot be carried over further.
To verify the costs of DoA/CCP services when spenddown is not met automatically, the CCU will provide Form 2538B. FCRCs use the verified amount on Form 2538B to calculate spenddown, starting from the first month of DoA service approval. This verified amount is used consistently until any changes are officially notified. When entering DoA/CCP service costs into the ASDS system, it is essential to use expense Type ‘A’ (Agency In Home Care) for accurate categorization and processing.
Central System for Meeting Spenddown with DoA/CCP
The Illinois system is designed to automatically identify individuals whose monthly DoA/CCP service costs meet or exceed their monthly spenddown amount. This automated process significantly streamlines the spenddown process for many DoA/CCP recipients. The system centrally takes action to update the case status to “met” when this condition is fulfilled. This automated matching occurs monthly during the schedule 08 cut-off.
To monitor these automated spenddown adjustments, Mobius Report #R8450469-03 is generated daily. This report identifies cases that have received either a Notice of Determination of Spenddown Met (Form 458SP-2) or a Notice of End of Eligibility for Medical Assistance (Form 3358A). These notices are automatically generated and sent when a case’s spenddown status changes due to the central system processing. This report serves as verification that these notices have been issued.
Another important report, Mobius Report #R83003741, is produced monthly. This report lists cases that have been terminated or where the monthly service costs are no longer sufficient to meet spenddown through the central system. This report helps to track cases that may require manual intervention or adjustments.
System Actions When DoA Services Meet Spenddown:
When DoA services are sufficient to meet spenddown, the system automatically makes several key updates:
- Item 80 code 390 (met/unmet indicator) is changed to ‘4’.
- Item 80 code 396 is deleted.
- Item 80 code 392 amount is reduced to zero, if necessary.
- Item 20 code ’16’ is changed to ’18’ (unless it is already ’20’, in which case it remains unchanged).
- Transaction Authorization (TA) 31/Transaction Authorization Request (TAR) A4 is generated.
- Form 458SP-2 (Notice of Determination of Spenddown Met) is sent to the client.
System Actions When DoA Services Are Terminated or Costs Are Insufficient:
Conversely, when DoA services are terminated or the costs are no longer adequate to meet spenddown, the system takes the following actions:
- Item 80 code 390 (met/unmet indicator) is changed to ‘2’.
- Form 3358A (Notice of End of Eligibility for Medical Assistance) is sent to the customer.
- Item 20 code ’18’ is changed back to ’16’.
- TA 31/TAR A5 is generated.
In situations where DoA/CCP monthly service costs are not enough to meet spenddown through the central system, these costs can still be manually applied towards spenddown using the ASDS system, utilizing expense Type A (Agency In Home Care).
Medical Backdating and Pay-in Spenddown Options
DoA/CCP service costs can be used to backdate medical assistance eligibility for up to 3 months prior to September 1, 2010. The system will automatically backdate eligibility if an individual was receiving DoA/CCP services during those months and the monthly cost was sufficient to meet or exceed their spenddown amount. If medical backdating is not processed centrally, FCRCs can manually apply DoA/CCP service costs for backdating upon receiving Form HFS 2538B from the CCU verifying the costs.
Furthermore, individuals receiving DoA/CCP services have the option to enroll in Pay-in Spenddown. This allows individuals to proactively pay the difference between their income and the Medicaid income limit to meet their spenddown obligation. To enroll in Pay-in Spenddown and obtain the necessary enrollment form (Form HFS 458SP-4), individuals can contact the Healthcare and Family Services (HFS) Hotline at 1-800-226-0768 (TTY: 1-877-204-1012) and request the Pay-In Spenddown Unit.
Conclusion
The Department on Aging Community Care Program plays a vital role in supporting seniors in Illinois. Understanding how to apply for the program and how its services interact with medical spenddown requirements is crucial for accessing these valuable benefits. By leveraging DoA/CCP services, eligible individuals can effectively manage their medical expenses and gain access to necessary medical assistance.
Forms Referenced:
- HFS 458SP2
- HFS 3358A
- HFS 2378H
- HFS 2538B
- HFS 2538C
