Section 120.60  Cases Other Than Long Term Care, Pregnant Women and Certain Children

The following subsections apply to all cases other than those receiving care in licensed intermediate care facilities, licensed skilled nursing facilities, Department of Human Services (DHS) facilities, or DHS approved community based residential settings under  89 Ill. Adm. Code 140.643, or pregnant women and children under age 19 who do not qualify as mandatory categorically needy.

a)         The eligibility period shall begin with:

1)         the first day of the month of application;

2)         the first day of any month, prior to the month of application, in which the client meets non-financial eligibility requirements up to three months prior to the month of application, if the client so desires; or

3)         the first day of a month, after the month of application, in which the client meets non-financial eligibility requirements.

b)         Eligibility Without Spenddown for MANG

1)         For AABD MANG, if the client's nonexempt income available during the eligibility period is equal to or below the applicable MANG standard (Sections 120.20 and 120.30) and nonexempt assets are not in excess of the applicable asset disregard  (Section 120.382), the client is eligible for medical assistance from the first day of the eligibility period.  The Department will pay for covered services received during the entire eligibility period.

2)         For TANF MANG, if the client's nonexempt income available during the eligibility period is equal to or below the applicable MANG standard (Sections 120.20 and 120.30), the client is eligible for medical assistance from the first day of the eligibility period.  The Department will pay for covered services received during the entire eligibility period.

3)         The client is responsible for reporting any changes that occur during the eligibility period which might affect eligibility for medical assistance.  If changes occur, appropriate action shall be taken by the Department, including termination of eligibility for medical assistance.  If changes in income, assets or family composition occur which would make the client a spenddown case, a spenddown obligation will be determined and subsection (c) of this Section will apply.

4)         A redetermination of eligibility will be made at least every 12 months.

c)         Eligibility with Spenddown for MANG

1)         For AABD MANG, if the client's nonexempt income available during the applicable eligibility period is greater than the applicable MANG standard and/or nonexempt assets are over the applicable asset disregard, the client must meet the spenddown obligation determined for the eligibility period before becoming eligible to receive medical assistance.  The spenddown obligation is the sum of the amount by which the client's nonexempt income exceeds the MANG standard and the amount of nonexempt assets in excess of the applicable asset disregard.

2)         For TANF MANG, if the client's nonexempt income available during the applicable eligibility period is greater than the applicable MANG standard, the client must meet the spenddown obligation determined for the eligibility period before becoming eligible to receive medical assistance.  The spenddown obligation is the amount by which the client's nonexempt income exceeds the MANG standard.

3)         The client meets the spenddown obligation by incurring or paying for medical expenses in an amount equal to the spenddown obligation.

A)        Medical expenses shall be applied to the spenddown obligation in the following order:

i)          Expenses for necessary medical or remedial services, as funded by DHS from sources other than federal funds.  Such expenses shall be based on the service provider's usual and customary charges to the public.  Such expenses shall not be based on any nominal amount the provider may assess the client.  These charges are considered incurred the first day of the month, regardless of the day the services are actually provided.

ii)         Payments made for medical expenses within the previous six months. Payments are considered incurred the first day of the month of payment.

iii)         Unpaid medical expenses.  These are considered as of the date of service and are applied in chronological order.

B)        If multiple medical expenses are incurred on the same day, the expenses shall be applied in the following order:

i)          Health insurance deductibles (including Medicare and other co-insurance charges).

ii)         All copayment charges incurred or paid on spenddown met day.

iii)         Expenses for medical services and/or items not covered by the Department's Medical Assistance Program.

iv)        Cost share amounts incurred for in-home care services by individuals receiving services through the Department on Aging (DonA).

v)         Expenses incurred for in-home care services by individuals receiving or purchasing services from private providers.

vi)        Expenses incurred for medical services or items covered by the Department's Medical Assistance Program.  If more than one covered service is received on the day, the charges will be considered in order of amount.  The bill for the smallest amount will be considered first.

C)        If a service is provided during the eligibility period but payment may be made by a third party, such as an insurance company, the medical expense will not be considered towards spenddown until the bill is adjudicated.  When adjudicated, that part determined to be the responsibility of the client shall be considered as incurred on the date of service.

4)         After application for medical assistance for cases eligible with a spenddown obligation who do not have a QMB or MANG(P) member, an additional eligibility determination will be made.

A)        For TANF MANG, if countable income is greater than the income standard (Section 120.30), and for AABD MANG, if countable income is greater than the income standard or countable assets are greater than the asset disregard (Section 120.382(d)), a person will not be enrolled in spenddown unless:

i)          the person does not have a spenddown obligation for any month of the 12-month enrollment period;

ii)         medical expenses equal the spenddown obligation for at least one month of the 12-month enrollment period; or

iii)         the person is on a waiting list or would be on a waiting list to receive a transplant if he or she had a source of payment.

B)        Cases which meet any of these conditions will be notified, in writing, of the spenddown obligation.  The client will also be notified that his or her case will be reviewed beginning in the sixth month of the 12-month enrollment period.  If the client has not had medical eligibility in one of the last three months at the time of review (including the month of review), the case will terminate unless the case contains a person who is on a waiting list or who would be on a waiting list to receive a transplant if he or she had a source of payment.  A new application will be required if the client wishes continued medical assistance.

C)        When proof of incurred medical expenses equal to the spenddown obligation is provided to the local office, eligibility for medical assistance shall begin effective the first day that the spenddown obligation is met.  The Department will pay for covered services received from that date until the end of the eligibility period.  The client shall be responsible, directly to the provider, for payment for services provided prior to the time the client meets the spenddown obligation.

5)         Cases with a spenddown obligation which do not have a QMB, a MANG(P) member or a person on a waiting list or who would be on a waiting list to receive a transplant if he or she had a source of payment, will be reviewed beginning in the sixth month of enrollment to determine if they have had medical eligibility within the last three months, including the month of review.  If so, enrollment will continue.  If not, enrollment will be terminated and the client will be advised that if he or she wishes continued medical assistance, a reapplication must be filed.  Upon reapplication, a new 12-month enrollment period will be established (assuming non-financial factors of eligibility are met).  If appropriate, a new spenddown obligation will be created.

A)        If the client files a reapplication prior to four months after the end of the period of enrollment, the client will be sent through a special abbreviated intake procedure making use of current case record material to verify factors of eligibility not subject to change.

B)        Cases that remain eligible in the tenth month of the enrollment period or which have a QMB, a  MANG(P) member or a person on a waiting list or who would be on a waiting list to receive a transplant if he or she had a source of payment, will remain enrolled and will be redetermined once every 12 months.

6)         The client is responsible for reporting any changes that occur during the enrollment period which might affect eligibility for medical assistance.  If changes occur, appropriate action shall be taken by the Department, including termination of eligibility for medical assistance.

7)         For AABD MANG, if changes in income, assets or family composition occur, appropriate adjustments to the spenddown obligation and date of eligibility for medical assistance shall be made by the Department.  The client will be notified, in writing, of the new spenddown obligation.

A)        If income decreases, or assets fall below the applicable asset disregard and, as a result, the client has already met the new spenddown obligation, eligibility for medical assistance shall be back-dated to the appropriate date.

B)        If income or assets increase and, as a result, the client has not produced proof of incurred medical expenses equal to the new spenddown obligation, the written notification of the new spenddown amount will also inform the client that eligibility for medical assistance will be interrupted until proof of medical expenses equal to the new spenddown obligation is produced.

8)         For TANF MANG, if changes in income or family composition occur, appropriate adjustments to the spenddown obligation and date of eligibility for medical assistance shall be made by the Department.  The client will be notified, in writing, of the new spenddown obligation.

A)        If income decreases and, as a result, the client has already met the new spenddown obligation, eligibility for medical assistance shall be back-dated to the appropriate date.

B)        If income increases and, as a result, the client has not produced proof of incurred medical expenses equal to the new spenddown obligation, the written notification of the new spenddown amount will also inform the client that eligibility for medical assistance will be interrupted until proof of medical expenses equal to the new spenddown obligation is produced.

(Source:  Amended at 29 Ill. Reg. 14939, effective September 30, 2005)