Fill a Valid 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, often referred to as “redetermination” or “re-de,” ensures that the Illinois Department of Healthcare and Family Services has the most current information about your household's income and living situation. Filling out this form accurately and submitting it on time is essential to maintain your health benefits.

To get started on your renewal, please click the button below to fill out the form.

Open Illinois Medicaid Redetermination Editor

Fill a Valid Illinois Medicaid Redetermination Form

Table of Contents

The Illinois Medicaid Redetermination form is an essential document for individuals and families who rely on Medicaid for their healthcare coverage. This form serves as a renewal application, often referred to as "redetermination" or "re-de," and must be completed to ensure continued medical benefits. Recipients receive a letter notifying them of the need to renew, along with their unique case ID. The process involves answering various questions about household members, income sources, and expenses. Applicants must also provide proof of their financial situation, such as income statements and any relevant documentation. It is crucial to complete the form accurately and submit it by the specified due date to avoid a lapse in coverage. The Illinois Department of Healthcare and Family Services encourages individuals to reach out for assistance if they encounter challenges in gathering the necessary information. With clear instructions provided, including options for submission via fax, mail, or email, the form aims to streamline the renewal process while ensuring that all required information is collected efficiently.

Example - Illinois Medicaid Redetermination Form

State of Illinois

Department of Healthcare and Family Services

Department of Human Services

ILLINOIS MEDICAID REDETERMINATION

<Name>

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.”

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.	[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:

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 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.	[MODE1]	12/13 - [LT] - [LN] - [PM] - [NC]
Llame al 1-855-458-4945.		[FILENAME] - [LETTERID]
		[MAILINGNAME] - [BIFILEID]

▼ PDF

Document Breakdown

Fact Name	Description
Purpose of the Form	The Illinois Medicaid Redetermination form is used to renew medical coverage for individuals enrolled in Medicaid. It is essential for maintaining eligibility.
Submission Methods	Individuals can submit the completed form and required documents via fax, mail, or email. The fax number is 1-855-394-8066, and the email address is HFS.medredes@illinois.gov.
Deadline for Submission	All forms and supporting documents must be submitted by a specified due date to avoid a lapse in medical benefits.
Required Information	The form requests detailed information about household members, income sources, and expenses. Accurate and complete answers are necessary for proper evaluation.
Legal Framework	This form is governed by the Illinois Public Aid Code (305 ILCS 5/), which outlines the requirements for Medicaid eligibility and redetermination processes.
Contact Information	For assistance, individuals can call 1-855-458-4945 (TTY: 1-855-694-5458). Help is available 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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