Get Illinois Medicaid Redetermination Form

Get Illinois Medicaid Redetermination Form

The Illinois Medicaid Redetermination form is a crucial document that individuals must complete to renew their medical coverage under the state's Medicaid program. This form, also referred to as "redetermination," requires applicants to provide updated information about their household, income, and any changes in health insurance. To ensure continued benefits, it is essential to fill out the form accurately and submit it by the specified due date.

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Renewing your medical coverage in Illinois is an important task that requires attention to detail. The Illinois Medicaid Redetermination form is your key to maintaining your benefits. When you receive this form, it will include your personal information, such as your name, address, and case ID, along with a notification that it's time for renewal, often referred to as "redetermination." To successfully complete the process, you must answer all questions accurately, sign the form, and provide necessary documentation like proof of income and expenses. Be mindful of the due date for submission, as failing to send in your completed form and supporting documents on time could result in the loss of your medical benefits. You can submit your form via fax, mail, or email, depending on what works best for you. If you have any questions or need assistance, there are resources available to help you navigate this process. Make sure to keep your information organized and respond promptly to ensure your coverage continues without interruption.

Document Breakdown

Fact Name Description
Purpose of the Form The Illinois Medicaid Redetermination form is used to renew medical coverage for eligible individuals and families.
Submission Methods Individuals can submit the completed form via fax, mail, or email. Specific contact details are provided for each method.
Deadline for Submission All forms and required proofs must be submitted by the specified due date to avoid termination of medical benefits.
Proof Requirements Applicants must attach proof of income, expenses, and other requested documentation to their form submission.
Contact Information A helpline is available for questions, providing assistance Monday to Friday and Saturday, with TTY services for the hearing impaired.
Dependents and Income The form requires information about dependents and various income sources, including salaries, unemployment, and social security.
Legal Consequences Providing false information on the form can result in criminal prosecution under both federal and state laws.
Governing Laws The Illinois Medicaid program operates under state laws and regulations, ensuring compliance with federal guidelines.
Language Assistance Spanish language support and free interpreter services are available for individuals needing assistance with the form.

Common PDF Forms

Misconceptions

Understanding the Illinois Medicaid Redetermination form is crucial for maintaining medical coverage. However, several misconceptions can lead to confusion. Below is a list of common misunderstandings regarding this form.

  • Misconception 1: The redetermination form is optional.
  • In reality, completing the redetermination form is mandatory to continue receiving Medicaid benefits. Failure to submit the form may result in the termination of coverage.

  • Misconception 2: You can submit the form without supporting documents.
  • Supporting documents, such as proof of income and expenses, must accompany the redetermination form. Incomplete submissions may delay processing or lead to denial of benefits.

  • Misconception 3: The form can be submitted at any time.
  • There is a specific due date for submitting the redetermination form. Late submissions can jeopardize medical coverage.

  • Misconception 4: Only the primary applicant needs to sign the form.
  • All adult members living in the household must provide information and sign the form if applicable. This ensures that all relevant data is accurately reported.

  • Misconception 5: You do not need to report changes in household income.
  • Any changes in income or household composition must be reported on the redetermination form. This information is essential for determining eligibility and benefits.

  • Misconception 6: The process is the same every year.
  • The requirements and processes for redetermination can change. It is important to review the instructions carefully each year to ensure compliance with current guidelines.

  • Misconception 7: You cannot get help with the form.
  • Assistance is available for completing the redetermination form. Individuals can call the provided helpline for guidance and support.

  • Misconception 8: Faxing is not a secure method for submitting the form.
  • Faxing is an accepted method for submitting the redetermination form and supporting documents. Ensure that the correct fax number is used for submission.

  • Misconception 9: You will be notified before your benefits are terminated.
  • Individuals may not receive prior notification if they fail to submit the redetermination form on time. It is essential to adhere to deadlines to avoid any lapse in coverage.

Example - Illinois Medicaid Redetermination Form

State of Illinois

Department of Healthcare and Family Services

Department of Human Services

ILLINOIS MEDICAID REDETERMINATION

<Name>

<Address><Barcode> <City, State ZIP>

<Letter Date>

Case ID: <Case ID>

Dear <Name>,

It is time to renew your medical coverage!

It’s time for renewal, also known as “redetermination” or “re-de.”

<Special Message Text>

Here’s what to do

1.Answer all questions on this form.

2.Sign this form at the bottom of page <3>.

3.Attach all proofs of income and expenses and other proofs we ask for.

4.Send your signed form and all proofs by <Due Date>.

Send your form and proofs to us one of these ways:

¨Fax your form and proofs to 1-855-394-8066

¨Mail your form and proofs in the envelope that we sent you

¨E-mail your form and proofs to HFS.medredes@illinois.gov

Your medical benefits may end if you do not send your proofs by <Due Date>.

Call us at 1-855-458-4945 (TTY: 1-855-694-5458) if you cannot send everything on time or if you have questions. We may be able to help you get the proofs you need.

Thank you,

Illinois Medicaid Redetermination

Questions? Call 1-855-458-4945 (TTY: 1-855-694-5458). The call is free!

Monday to Friday from 7 a.m. to 9 p.m. and Saturday from 8 a.m. to 1 p.m.

E-mail us at HFS.medredes@illinois.gov or send a fax to 1-855-394-8066.

Tenemos información en español. ¡Servicio de intérpretes gratis!

[MODE1]12/13 - [LT] - [LN] - [PM] - [NC]

Llame al 1-855-458-4945.[FILENAME] - [LETTERID]

[MAILINGNAME] - [BIFILEID]

Policy number: _____________________________________________

State of Illinois

Department of Healthcare and Family Services<Barcode>

Department of Human Services

ILLINOIS MEDICAID REDETERMINATION

Medical Renewal Form

1.Do these people still live with you?

Case ID: <Case ID>

 

<MemberName>

<MemberDOB>

Yes

No

 

 

 

 

 

 

<MemberName>

<MemberDOB>

Yes

No

 

 

 

 

 

 

<MemberName>

<MemberDOB>

Yes

No

 

 

 

 

 

 

<MemberName>

<MemberDOB>

Yes

No

 

 

 

 

 

 

 

 

 

 

2.Tell us about anyone else who lives with you:

 

Name

Date of birth

Relationship to you

 

First, Middle, Last, Suffix (Jr., Sr., II or III)

(month/day/year)

(for example: spouse, child, parent)

 

 

 

 

 

Name:

Date of birth:

Relationship:

 

 

 

 

 

Name:

Date of birth:

Relationship:

 

 

 

 

 

Name:

Date of birth:

Relationship:

 

 

 

 

 

Name:

Date of birth:

Relationship:

 

 

 

 

 

 

 

 

3.Is anyone who lives with you pregnant?

If yes, name: ______________________________________________________ Due date: ____________________________ Expected number of babies: __________

4. Did you or anyone living with you get new health insurance in the last year? Yes No

If yes, name of insurance plan:__________________________________________________________

Who is covered by this health insurance? ___________________________________________________________________________________________________________________

5.Will you or anyone who lives with you file a federal income tax return next year to report

income earned this year? Yes No

If yes, name of person filing tax return: ______________________________________________________________________________________________________________________

If this person will file jointly with a spouse, write name of spouse: ________________________________________________________________________

If this person will claim dependents on the tax return, write name(s) of dependents:

________________________________________________________________________________________ ________________________________________________________________________________________

________________________________________________________________________________________ ________________________________________________________________________________________

Questions? Call 1-855-458-4945 (TTY: 1-855-694-5458). The call is free!

 

Page 1

Monday to Friday from 7 a.m. to 9 p.m. and Saturday from 8 a.m. to 1 p.m.

 

 

E-mail us at HFS.medredes@illinois.gov or send a fax to 1-855-394-8066.

 

 

Tenemos información en español. ¡Servicio de intérpretes gratis!

[MODE1]

12/13 - [LT] - [LN] - [PM] - [NC]

Llame al 1-855-458-4945.

 

[FILENAME] - [LETTERID]

 

 

[MAILINGNAME] - [BIFILEID]

6. Can you be claimed as a dependent on anyone’s tax return?

Yes No

If yes, name of person: _____________________________________________________________________

Relationship to you:______________________________________

7.Do you and everyone living with you still get this income from these sources?

Salary, wages, and tips for everyone

Total per month: $ <amount>

(total before taxes are taken out)

Is this correct?

Yes

No

 

 

Self-employment income for everyone

Total per month: $ <amount>

(profit once business expenses are paid)

Is this correct?

Yes

No

 

 

Unemployment for everyone

Total per month: $ <amount>

 

Is this correct?

Yes

No

 

 

Social Security for everyone

Total per month: $ <amount>

 

Is this correct?

Yes

No

 

 

Pension or retirement income for everyone

Total per month: $ <amount>

 

Is this correct?

Yes

No

 

 

Spousal support received by everyone

Total per month: $ <amount>

 

Is this correct?

Yes

No

 

 

Interest or investment income for everyone

Total per month: $ <amount>

 

Is this correct?

Yes

No

 

 

Rental fees or royalties for everyone

Total per month: $ <amount>

 

Is this correct?

Yes

No

¨¨If you checked no for any income, write the correct amount in the next section.

8.Do you or anyone living with you get other income? Check all that apply.

Salary, wages, and tips

How much?

How often?

 

 

 

Self-employment

How much?

How often?

 

 

 

Unemployment

How much?

How often?

 

 

 

Social Security

How much?

How often?

 

 

 

Pension or retirement income

How much?

How often?

 

 

 

Interest or investment income

How much?

How often?

 

 

 

Rental fees or royalties

How much?

How often?

 

 

 

Spousal support received

How much?

How often?

 

 

 

Other: ________________________________________________

How much?

How often?

¨¨Attach proof of the amount for any income received in the last 30 days.

Page 2

State of Illinois

Department of Healthcare and Family Services<Barcode>

Department of Human Services

ILLINOIS MEDICAID REDETERMINATION

Case ID: <Case ID>

9.Do you or anyone living with you pay any of these expenses? Check all that apply.

Spousal support paid to someone else

How much?

How often?

 

 

 

Student loan interest paid

How much?

How often?

 

 

 

Other: ________________________________________________

How much?

How often?

¨¨Attach proof of all expenses paid in the last 30 days.

10.We also need these proofs from you:

Copy of a Social Security card for <MemberName>

Other: _____________________________________________________________________________________________________________________________________________________________________

11.Read and sign below:

ƒ I understand that officials in charge of my health benefits may check all information on this form.

ƒ I understand they may check my information electronically. If they ask for my help checking information, I must cooperate.

ƒ I understand that anyone who knowingly lies or provides untrue information, or arranges for someone to knowingly lie or provide untrue information, or intentionally misuses the health benefits card issued by the State of Illinois, may be committing a crime which can be prosecuted or punished under federal law, state law, or both.

ƒ If the Illinois Department of Healthcare and Family Services pays medical bills for me, the State of Illinois may collect my medical support payments instead of me.

ƒ I am signing this form under the penalty of perjury. That means the information I have provided on this renewal form is true to the best of my knowledge, and I may be punished under law if I provide false or untrue information.

_______________________________________________

_________________________________

Your signature

Today’s date

12.Remember! Make sure you answered all questions and signed the form.

¨¨Send this form to us with all proofs by <Due Date>.

Questions? Call 1-855-458-4945 (TTY: 1-855-694-5458). The call is free!

 

Page 3

Monday to Friday from 7 a.m. to 9 p.m. and Saturday from 8 a.m. to 1 p.m.

 

 

E-mail us at HFS.medredes@illinois.gov or send a fax to 1-855-394-8066.

 

 

Tenemos información en español. ¡Servicio de intérpretes gratis!

[MODE1]

12/13 - [LT] - [LN] - [PM] - [NC]

Llame al 1-855-458-4945.

 

[FILENAME] - [LETTERID]

 

 

[MAILINGNAME] - [BIFILEID]

Dos and Don'ts

When filling out the Illinois Medicaid Redetermination form, there are important steps to follow. Here’s a list of things you should and shouldn’t do:

  • Do answer all questions completely and accurately.
  • Do sign the form at the designated area.
  • Do attach all required proofs of income and expenses.
  • Do submit your signed form and proofs by the due date.
  • Do reach out for help if you have questions or need assistance.
  • Don’t leave any questions blank; this could delay your application.
  • Don’t forget to keep copies of everything you send for your records.

Following these guidelines will help ensure a smooth renewal process for your medical coverage.

Illinois Medicaid Redetermination: Usage Instruction

Completing the Illinois Medicaid Redetermination form is essential for maintaining your medical coverage. Follow these steps carefully to ensure that you provide all necessary information and documentation. Missing details could lead to delays or loss of benefits.

  1. Begin by filling in your name and address at the top of the form.
  2. Locate your Case ID and write it down in the designated space.
  3. Answer all questions on the form. Make sure to check the appropriate boxes and provide any required details.
  4. For each member of your household, indicate if they still live with you and provide their date of birth.
  5. List anyone else living with you, including their name, date of birth, and relationship to you.
  6. If applicable, note if anyone in your household is pregnant and provide the due date and expected number of babies.
  7. Indicate whether you or anyone in your household received new health insurance in the past year. If yes, provide the name of the insurance plan and policy number.
  8. Answer whether you or anyone in your household will file a federal income tax return next year. If yes, include the name of the person filing and any dependents they will claim.
  9. State if you can be claimed as a dependent on someone else's tax return and provide their name and relationship to you.
  10. List all sources of income for you and everyone living with you. Confirm if the amounts are correct and provide any necessary corrections.
  11. Indicate if you or anyone living with you receives any other types of income. Attach proof of income received in the last 30 days.
  12. Check if you or anyone living with you pays any expenses, such as spousal support or student loan interest. Attach proof of these expenses as well.
  13. Provide any additional required documents, such as a copy of a Social Security card for any household member.
  14. Read the statements at the end of the form. Sign and date the form to confirm that all information is true and complete.
  15. Before submitting, double-check that you have answered all questions and signed the form.
  16. Send the completed form and all supporting documents by the due date. You can fax, mail, or email them using the provided contact information.

After you submit your form, the Illinois Medicaid office will review your information. They may contact you for further details if needed. It’s important to keep a copy of everything you send for your records. If you have questions during the process, don't hesitate to reach out to the provided contact numbers for assistance.