Section 4500.40  Presumptive Eligibility Criteria

a)         Each hospital shall develop and implement a Presumptive Eligibility Policy setting forth the presumptive eligibility criteria by which a patient's financial need is determined and used by the hospital to deem a patient eligible for hospital financial assistance without further scrutiny by the hospital. The presumptive eligibility criteria set forth in each hospital's Presumptive Eligibility Policy shall be applied to an uninsured patient as defined in Section 10 of the Act as soon as possible after receipt of health care services from a hospital by the patient and prior to the issuance of any bill for those health care services by the hospital.

b)         Patients in hospitals that are not Critical Access Hospitals or rural hospitals shall be deemed presumptively eligible for hospital financial assistance if the patient demonstrates one or more of the following, which shall be included in the presumptive eligibility criteria for those hospitals:

1)         Homelessness;

2)         Deceased with no estate;

3)         Mental incapacitation with no one to act on patient's behalf;

4)         Medicaid eligibility, but not on date of service or for non-covered service;

5)         Enrollment in the following assistance programs for low-income individuals having eligibility criteria at or below 200% of the federal poverty income guidelines:

A)        Women, Infants and Children Nutrition Program (WIC);

B)        Supplemental Nutrition Assistance Program (SNAP);

C)        Illinois Free Lunch and Breakfast Program;

D)        Low Income Home Energy Assistance Program (LIHEAP);

E)        Enrollment in an organized community-based program providing access to medical care that assesses and documents limited low-income financial status as a criterion for membership;

F)         Receipt of grant assistance for medical services.

c)         Hospitals that are not Critical Access Hospitals or rural hospitals may include additional presumptive eligibility criteria, provided that the additional criteria are used for or have the effect of expanding a patient's presumptive eligibility for hospital financial assistance, which shall be included in the presumptive eligibility criteria for the particular hospital.  These additional criteria may include, but are not limited to:

1)         Recent personal bankruptcy;

2)         Incarceration in a penal institution;

3)         Affiliation with a religious order and vow of poverty;

4)         Enrollment in the following assistance programs for low-income individuals:

A)        Temporary Assistance for Needy Families (TANF);

B)        IHDA's Rental Housing Support Program.

d)         Patients in hospitals that are Critical Access Hospitals or rural hospitals shall be deemed presumptively eligible for hospital financial assistance if the patient demonstrates one or more of the following, which shall be included in the presumptive eligibility criteria for those hospitals:

1)         Homelessness;

2)         Deceased with no estate;

3)         Mental incapacitation with no one to act on patient's behalf;

4)         Medicaid eligibility, but not on date of service or for non-covered service.

e)         Hospitals that are Critical Access Hospitals or rural hospitals may include additional presumptive eligibility criteria, provided that the additional criteria are used for or have the effect of expanding a patient's presumptive eligibility for hospital financial assistance, which shall be included in the presumptive eligibility criteria for those hospitals, such as:

1)         Recent personal bankruptcy;

2)         Incarceration in a penal institution;

3)         Affiliation with a religious order and vow of poverty;

4)         Patients who receive grant assistance for medical services;

5)         Women, Infants and Children Nutrition Program (WIC);

6)         Supplemental Nutrition Assistance Program (SNAP);

7)         Illinois Free Lunch and Breakfast Programs;

8)         IHDA's Rental Housing Support Program;

9)         Low Income Home Energy Assistance Program (LIHEAP);

10)         Temporary Assistance for Needy Families (TANF);

11)         Enrollment in an organized community-based program providing access to medical care that assesses and documents limited low-income financial status as a criterion for membership.

(Source:  Amended at 38 Ill. Reg. 20263, effective October 10, 2014)