Affidavit Concerning Payments for the Family Case Management Program
[print on agency letterhead]
AFFIDAVIT
[Date]
I, [Name], work as [Title]of the [Agency Name]. We serve low income children and adults in [Jurisdiction], including outreach and case management for the Family Case Management program.
While we have received some payments for some clinical services provided to our Medicaid clients, we are still in financial jeopardy. In fact, the State of Illinois owes us $[Total Amout] for services provided for the Family Case Management grant program since July 2015.
The following table shows the amounts for services that would be paid prospectively for services through the Family Case Management grant, the amount we have received, and the amount we are still owed for each month:
Amount Expended, Amount Received, and Amount Owed for Services Provided for the Family Case Management Program Grant, by Month, SFY’16Month / Amount Expected / Amount Received / Amount Owed
July 2015
August 2015
September 2015
October 2015
November 2015
December 2015
TOTAL
[NOTE: IF YOUR HEALTH DEPARTMENT DOES NOT PROVIDE MEDICAL CASE MANAGEMENT FOR HEALTHWORKS, PLEASE DELETE THE FOLLOWING STATEMENT]These funds also support Medical Case Management of pre-school aged children in foster care pursuant to the B.H. Consent Decree.
[NOTE: DELETE THIS PARAGRAPH AND THE FOLLOWING TABLE IF IT DOES NOT APPLY] Local health departments, as units of local government, may also receive matching funds from the Department of Healthcare and Family Services for expenditure of local resources above and beyond the amount provided by the Family Case Management grant, if they have entered into an agreement with the Illinois Department of Healthcare and Family Services for this purpose. [Agency Name] has such an agreement, and we have expended the following amounts in excess of payments expected from the Family Case Management grant, but have received only the following amounts in reimbursement of these expenses in support of Illinois’ Medicaid program:
Amount Expended, Amount Received, and Amount Owed for Services Provided for the Family Case Management Program with Local Funds, by Month, SFY’16Month / Amount Expended / Amount Received / Amount Owed
July 2015
August 2015
September 2015
October 2015
November 2015
December 2015
TOTAL
We cannot continue provide outreach and case management services to Medicaid-eligible families with a pregnant woman or young child without reimbursement. We will soon exhaust our reserves and will have borrowed all of the money that any source will lend us.
If we discontinue these services [number] of low-income families in [Jurisdiction] will no longer receive care.
Respectfully submitted,
[Administrator Name]
[Administrator Title]
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