Illinois Medicaid Redetermination Form PDF Details

Navigating the journey of healthcare coverage within the Illinois Medicaid program, particularly during the redetermination process, is paramount for ensuring the continuation of vital medical benefits. The Illinois Medicaid Redetermination form stands as the cornerstone of this process, serving as a comprehensive pathway for recipients to reaffirm their eligibility for medical coverage. With a due date looming over, the importance of accurately completing and timely submitting this form cannot be overstated. It implores recipients to verify household composition, income levels, and other changes that could influence their eligibility status. Crucially, the form not only seeks information on basic demographics but delves into specifics, such as changes in income, insurance coverage adjustments, and any applicable household modifications. Additionally, the form is a testament to transparency and compliance with state and federal regulations, emphasizing the necessity for honesty and accuracy in the details provided. This procedural step ensures that benefits align correctly with current circumstances, thereby enabling the Department of Healthcare and Family Services to continue supporting the health needs of families across Illinois. As such, understanding the nuances of the Illinois Medicaid Redetermination form is essential for all beneficiaries looking to seamlessly renew their coverage and secure peace of mind concerning their healthcare services.

QuestionAnswer
Form NameIllinois Medicaid Redetermination Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesillinois medicaid redetermination form 2021, illinois renewal medicaid form, illinois medical cannabis renewal form, illinois medical renewal online

Form Preview Example

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]

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:__________________________________________________________ Policy number: _____________________________________________

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]