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“Failure to Evaluate” Claims – Ensuring Illinoisans Get All Benefits to which They are Entitled

Author: Trey Daly, Public Benefits Practice Group Director, Legal Aid Chicago


What is an FTE claim?

A Failure to Evaluate claim (FTE) is just that – a claim that an Illinois Department of Human Services (IDHS) application was not reviewed and evaluated for all eligible benefits. Illinois Administrative Code and IDHS policy manuals spell out a requirement to evaluate an application fully.


An application for public benefits should be deemed an application for all such benefits to which a person may be entitled unless the applicant expressly declines, in writing, to apply for any particular benefit. When an applicant’s file is not reviewed for benefits to which they are eligible, there is a potential Failure to Evaluate claim (FTE). See 305 ILCS 5/11-4 and 89 Ill. Admin. Code Section 10.415. The Illinois Department of Human Services (IDHS) policy manual states that all applications are to be considered a request for all programs with three specific exceptions. PM 02-05-00. The exceptions here are 1) when applicant declines to apply in writing; 2) the application is on a form for medical benefits only; and 3) the application is on a form for SNAP only.


Short of these circumstances, an application for benefits is deemed an application for all benefits. Not surprisingly, applications are frequently reviewed for some, or even one, benefit program rather than all that might apply.


Why is this a problem?

When applicants are not considered for the full complement of benefits, they are prevented from receiving the benefits going forward. Failure to evaluate drastically reduces the level of aid applicants may receive and can perpetuate an already difficult situation.


In addition to reducing the amount of benefits awarded, Failure to Evaluate creates a situation of owed back pay which must then be requested via a claim. These claims often require record retrieval, extensive calculations, and detailed arguments. The good news is that the financial rewards can be quite tangible and have a very real impact on client's lives. Successful FTE claims include:

$8,621 in reimbursed Medicare part B premiums $14,873 in child only TANF (covering a 9 year span) $27,185 in AABD cash for 19 years’ worth of unpaid benefits



Potential Solutions

There are two main steps towards a client recovering the months, sometimes years, of back-pay for failure to evaluate claims. First, the client, with assistance by a MLP attorney, should apply for the benefits program the IDHS never evaluated them for, and submit all information and documentation necessary to prove they were categorically eligible at the time of their original public benefits application. If the client is currently in the redetermination process for their other benefits, they can also express their interest about the excluded benefits program directly to IDHS during that process.


Then, after that application or redetermination is processed and the client is approved for and receiving MSP/AABD Cash/TANF, the client along with their attorney can file an appeal on ABE (ABE.Illinois.gov, the IDHS portal) for FTE. This appeal should be flagged for the type of benefit now being received but not dated to their most recent application, but instead left undated so as to be backdated to the time of their original application or a redetermination for other benefits when they were categorically eligible but never enrolled.


How to Spot a Potential FTE Claim

While a medical practitioner may not know the specifics about which benefits a patient has ever applied for, there are some red flags to be aware of that a client might have an FTE claim.

If a client is receiving Medicare due to age or disability status, is receiving other public benefits such as SNAP, and has repeatedly expressed difficulty in affording their Part A or Part B premiums, that is a flag that one should look into if they were ever evaluated for a Medicare Savings Program.


In regards to AABD Cash: If a client's main or only source of income is SSI, and while on SSI they have also been on Medicaid or another public benefits program such as SNAP, one should look into the possibility that they were never enrolled in AABD Cash.


When you suspect a client might have a FTE claim, ask the client if they have ever heard of a MSP/AABD Cash, if they would be interested in such a program, and if they recall ever expressly denying interest at the time of their initial application.


FTE is a fairly common occurrence and the benefits to the client can be great when they are discovered, which is why it is crucial for MLP partnerships to know the signs and steps to take in pursuit of these claims. Hopefully recent changes in the ABE application process which requires applicants to either say yes or no to the four categories of benefits covered by the application will reduce failure to evaluate from happening in the future.

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