The Illinois Department on Aging (DoA) Community Care Program (CCP) is a vital resource for seniors in Illinois, offering services designed to help them remain independent in their homes and communities. A significant update to this program, effective September 1, 2010, made DoA/CCP service costs allowable medical expenses for meeting spenddown requirements for medical assistance. This change streamlines access to care for many eligible individuals.
Key Changes to the Community Care Program and Spenddown
This policy update introduced several important changes to how the Community Care Program interacts with medical spenddown requirements in Illinois:
- Allowable Medical Expense: Costs associated with DoA/CCP services are now recognized as valid medical expenses when calculating spenddown. This means that these costs can help individuals meet their spenddown obligations faster, enabling quicker access to medical benefits.
- System Automation for Spenddown: The Illinois Department of Human Services (DHS) implemented a system to automatically identify individuals whose DoA/CCP service costs meet or exceed their monthly spenddown amount. This system centrally updates cases to “met status,” reducing administrative burden and ensuring timely processing.
- Retroactive Eligibility: The system is designed to backdate medical eligibility by up to three months if an individual was receiving DoA/CCP services during those months and their service costs were sufficient to meet the spenddown. This retroactive component provides crucial support for individuals who may have incurred medical expenses prior to formal spenddown approval.
- Pay-In Spenddown Enrollment: Individuals receiving DoA/CCP services are also eligible to enroll in the Pay-in Spenddown program, offering another avenue to manage their medical expenses and maintain eligibility for medical assistance.
- Revised and New Notices: To reflect these changes, the Illinois Department of Healthcare and Family Services (HFS) revised the HFS 2538B, Illinois Department on Aging (IDoA) Notification. Additionally, a new notice, HFS 2538C, Using Department on Aging (DoA) Community Care Program (CCP) Services to Meet Spenddown, was introduced to inform individuals enrolled in spenddown about these updates.
Application Process and Requirements for DoA/CCP Services
Individuals interested in accessing DoA/CCP services must apply for medical benefits as part of the application process. Care Coordination Units (CCUs) play a crucial role in assisting applicants with this requirement.
Application Assistance: CCUs are responsible for guiding applicants through the medical benefits application process. They provide necessary forms, such as the HFS 2378H, Mail In Application for Medical Benefits, and HFS 2538B, IDoA Notification, to the Family Community Resource Center (FCRC).
Applicant Cooperation: Applicants are required to cooperate with the verification process to determine their eligibility for medical benefits. This ensures that all necessary information is provided to facilitate a smooth and efficient application review.
Utilizing DoA/CCP Service Costs for Spenddown
A core component of this policy update is the ability to use the costs of DoA/CCP services to meet medical spenddown requirements.
Prioritizing DoA/CCP Costs: When determining spenddown status, the estimated cost of DoA/CCP services is considered incurred on the first day of the month, regardless of when services are actually delivered. These costs are applied to spenddown calculations before any other medical bills or receipts.
Carry-Over Policy: If DoA/CCP service costs are not sufficient to meet the spenddown in the month they are incurred, these costs can be carried over and applied to meet spenddown in subsequent months. There is no time limit on using these carried-over costs. However, any unused portion of DoA/CCP service costs from a given month, after meeting spenddown for that month, cannot be carried over further.
Verification and Application of Costs: The CCU provides Form 2538B to verify the costs of DoA/CCP services when spenddown is not met automatically. FCRCs use the verified amount on Form 2538B to meet spenddown, starting from the first month of DoA service approval. This verified amount is used until any changes are officially notified. It’s important to remember that these expenses are considered incurred on the first day of the month. When entering DoA/CCP service costs in the ASDS system, expense Type ‘A’ (Agency In Home Care) should be used.
Central System for Meeting Spenddown with DoA/CCP Services
The automated system plays a key role in streamlining spenddown management for individuals utilizing DoA/CCP services.
Automated Identification and Status Updates: The system identifies individuals whose monthly DoA/CCP service costs equal or exceed their monthly spenddown amount. It then automatically updates the case status to “met.” This process occurs monthly during the schedule 08 cut-off.
Reporting and Notifications: Mobius reports are generated to track and verify system actions. Report #R8450469-03 is produced daily, identifying cases that 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 centrally generated and sent when cases transition between met and unmet status. Report #R83003741 is produced monthly, listing cases that have been terminated or no longer meet spenddown requirements through the central process.
System Actions When Spenddown is Met: When DoA services are sufficient to meet spenddown, the system automatically makes several updates:
- Changes Item 80 code 390 met/unmet indicator to ‘4’.
- Deletes Item 80 code 396.
- Reduces the amount following Item 80 code 392 to zero, if necessary.
- Changes Item 20 code ’16’ to ’18’ (unless Item 20 is already coded ’20’).
- Generates TA 31/TAR A4.
- Sends Form 458SP-2 to the client.
System Actions When Services Change or are Terminated: When DoA services are terminated or costs no longer meet spenddown centrally, the system takes the following actions:
- Changes Item 80 code 390 met/unmet indicator to ‘2’.
- Sends Form 3358A to the customer.
- Changes Item 20 code ’18’ back to ’16’.
- Generates TA 31/TAR A5.
For cases where DoA/CCP monthly service costs are not enough to meet spenddown through the central system, costs can still be manually applied toward spenddown using the ASDS system and expense Type A (Agency In Home Care).
Medical Backdating with DoA/CCP Services
The policy also allows for medical backdating, leveraging DoA/CCP service costs.
Retroactive Eligibility: DoA/CCP service costs can be used to backdate medical eligibility for up to 3 months prior to September 1, 2010. The system automatically backdates eligibility if an individual was receiving DoA/CCP services and their monthly costs were sufficient to meet their spenddown amount.
Manual Backdating: In situations where medical backdating was not processed centrally, FCRCs can manually apply DoA/CCP service costs to backdate medical eligibility. This requires verification of costs via Form HFS 2538B from the CCU.
Pay-in Spenddown Option for DoA/CCP Recipients
Individuals receiving DoA/CCP services have the option to enroll in the Pay-in Spenddown program. This provides an alternative method for managing spenddown obligations.
Enrollment Information: To enroll in Pay-in Spenddown, individuals can request a Pay-In Spenddown Enrollment Form (Form HFS 458SP-4) by contacting the Healthcare and Family Services (HFS) Hotline at 1-800-226-0768 (TTY: 1-877-204-1012) and specifically asking for the Pay-In Spenddown Unit.
New Transaction Authorization Request (TAR) Codes
Two new TAR codes were introduced in conjunction with these policy changes:
| Code | Message |
|---|---|
| A4 | Spenddown obligation met with DHS-DRS/DDD or DoA/CCP service costs. Central Use Only |
| A5 | Spenddown obligation not met with DHS-DRS/DDD or DoA/CCP service costs. Central Use Only |
Forms Referenced
- HFS 458SP2
- HFS 3358A
- HFS 2378H
- HFS 2538B
- HFS 2538C
This updated policy significantly impacts how individuals can utilize the Illinois Department Of Aging Community Care Program in conjunction with medical assistance spenddown requirements, offering a more streamlined and supportive system for seniors in need of care.
