Are you an Illinois resident in need of a Medicaid redetermination form? Confused about the eligibility and reevaluation process for Medicaid benefits? Worry not – this blog post should serve as your guide! Here, we will provide insight on how to locate and submit a pre-printed renewal/redetermination form for households enrolled in the Illinois Department of Healthcare & Family Services. In addition, advice regarding applications that are incomplete or delayed will also be included to help ensure that your application is processed both quickly and effectively. So keep reading if you want to learn all you need to know about redetermining your Medicaid coverage!
| Question | Answer |
|---|---|
| Form Name | Illinois Medicaid Redetermination Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | illinois medicaid redetermination form 2021, illinois renewal medicaid form, illinois medical cannabis renewal form, illinois medical renewal online |
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
<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
¨Mail your form and proofs in the envelope that we sent you
¨
Your medical benefits may end if you do not send your proofs by <Due Date>.
Call us at
Thank you,
Illinois Medicaid Redetermination
Questions? Call
Monday to Friday from 7 a.m. to 9 p.m. and Saturday from 8 a.m. to 1 p.m.
Tenemos información en español. ¡Servicio de intérpretes gratis!
[MODE1]12/13 - [LT] - [LN] - [PM] - [NC]
Llame al
[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>
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<MemberName> |
<MemberDOB> |
Yes |
No |
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<MemberDOB> |
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2.Tell us about anyone else who lives with you:
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Name |
Date of birth |
Relationship to you |
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First, Middle, Last, Suffix (Jr., Sr., II or III) |
(month/day/year) |
(for example: spouse, child, parent) |
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Date of birth: |
Relationship: |
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Date of birth: |
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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 |
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Page 1 |
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Monday to Friday from 7 a.m. to 9 p.m. and Saturday from 8 a.m. to 1 p.m. |
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Tenemos información en español. ¡Servicio de intérpretes gratis! |
[MODE1] |
12/13 - [LT] - [LN] - [PM] - [NC] |
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Llame al |
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[FILENAME] - [LETTERID] |
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[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> |
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(total before taxes are taken out) |
Is this correct? |
Yes |
No |
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Total per month: $ <amount> |
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(profit once business expenses are paid) |
Is this correct? |
Yes |
No |
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Unemployment for everyone |
Total per month: $ <amount> |
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Is this correct? |
Yes |
No |
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Social Security for everyone |
Total per month: $ <amount> |
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Is this correct? |
Yes |
No |
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Pension or retirement income for everyone |
Total per month: $ <amount> |
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Is this correct? |
Yes |
No |
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Spousal support received by everyone |
Total per month: $ <amount> |
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Is this correct? |
Yes |
No |
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Interest or investment income for everyone |
Total per month: $ <amount> |
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Is this correct? |
Yes |
No |
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Rental fees or royalties for everyone |
Total per month: $ <amount> |
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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? |
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How much? |
How often? |
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Unemployment |
How much? |
How often? |
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Social Security |
How much? |
How often? |
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Pension or retirement income |
How much? |
How often? |
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Interest or investment income |
How much? |
How often? |
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Rental fees or royalties |
How much? |
How often? |
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Spousal support received |
How much? |
How often? |
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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? |
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Student loan interest paid |
How much? |
How often? |
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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:
I understand that officials in charge of my health benefits may check all information on this form.
I understand they may check my information electronically. If they ask for my help checking information, I must cooperate.
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.
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.
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 |
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Page 3 |
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Monday to Friday from 7 a.m. to 9 p.m. and Saturday from 8 a.m. to 1 p.m. |
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Tenemos información en español. ¡Servicio de intérpretes gratis! |
[MODE1] |
12/13 - [LT] - [LN] - [PM] - [NC] |
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Llame al |
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[FILENAME] - [LETTERID] |
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[MAILINGNAME] - [BIFILEID] |