Section 118.700  General Description

 

This Subpart implements Section 12-4.35(a-5) of the Code that authorizes the Department to administer in Illinois the Health Benefits for Immigrant Seniors Program to noncitizens 65 years of age or older who are not eligible for medical assistance receiving federal financial participation due to immigration status. Eligible individuals are not eligible for medical assistance under Article V of the Public Aid Code.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.705  Definitions

 

For the purposes of this Subpart, the following terms have the meanings ascribed in this Section:

 

"Code" means the Public Aid Code [305 ILCS 5].

 

"Department" means the Department of Healthcare and Family Services and any successor agencies.

 

"FPL" means the federal poverty income guidelines established by the federal Department of Health and Human Services and published in the Federal Register.

 

"Health Benefits for Immigrant Seniors" or "Program" means the Program authorized by Section 12-4.35(a-5) of the Code and created by this Subpart.

 

"Resident" means an individual who has an Illinois residence, as established in Section 5-3 of the Code.

 

"Medical assistance receiving federal financial participation" does not include emergency medical for certain non-citizens.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.710  Eligibility

 

An individual may be eligible for Health Benefits for Immigrant Seniors provided that all of the following eligibility criteria are met:

 

a)         The individual is not eligible for medical assistance receiving federal financial participation other than emergency medical for certain non-citizens;

 

b)         The individual is not:

 

1)         A U.S. citizen; or

 

2)         A person:

 

A)        Lawfully admitted for permanent residence under the Immigration and Nationality Act (INA); and

 

B)        Who has lawfully resided in the United States for five years or more;

 

c)         The individual is a resident of the State of Illinois;

 

d)         The individual is 65 years of age or over;

 

e)         The individual's income is at or below 100% FPL without, or after deducting, the costs of medical or remedial care as determined in accordance with 89 Ill. Adm. Code 120.60(c);

 

f)         The individual has nonexempt resources at or below the AABD MANG resource disregard level (see 89 Ill. Adm. Code 120.382). Certain resources shall be exempt from consideration in determining eligibility (see 89 Ill. Adm. Code 120.381). The resource test established in this Section will not apply any time the AABD MANG resource test is suspended;

 

g)         The individual's resources are at or below the appropriate limit for their household size, without, or after deducting, the costs of medical or remedial care as determined in accordance with 89 Ill. Adm. Code 120.60(c);

 

h)         The individual cooperates in establishing eligibility (see 89 Ill. Adm. Code 120.308); and

 

i)          The individual assigns rights to medical support and collection of payment (see 89 Ill. Adm. Code 120.319).

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.715  Eligibility Exclusions and Terminations

 

a)         An individual shall not be determined eligible for Health Benefits for Immigrant Seniors if the individual is an inmate of a public institution.

 

b)         An individual's coverage under the Program shall be terminated if the individual:

 

1)         No longer qualifies as an Illinois resident; 

 

2)         Becomes eligible for medical assistance under the Public Aid Code that receives federal financial participation;

 

3)         Fails to report to the Department changes that affect eligibility for the Program;

 

4)         Asks the Department to terminate the coverage;

 

5)         Is no longer eligible based on any other applicable State or federal law or regulation;

 

6)         Failed to provide eligibility information that was truthful and accurate to the best of the individual's knowledge and belief and that affected the individual's eligibility;

 

7)         Was incorrectly determined eligible;

 

8)         Fails to complete the redetermination of eligibility within the required timeframes or provide proof of on-going eligibility; or

 

9)         Becomes an inmate of a public institution.

 

c)         Following termination of an individual's coverage under the Program, the following action is required before the individual can be re-enrolled:

 

1)         A new application is completed and submitted, or an existing application or case is reopened, and the individual is determined otherwise eligible; and

 

2)         The individual cooperates with the Department to meet the prescribed timeframes regarding a determination of eligibility found in 305 ILCS 5/11-5.1(a)(2) and 89 Ill. Adm. Code 120.308(h).

 

d)         If the Department determines the individual's exclusion or termination was in error, the individual can be re-enrolled.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.720  Application Process

 

a)         Individuals apply for the Program by submitting an application through any available method (see 89 Ill. Adm. Code 110.5), including on-line at ABE.illinois.gov (Illinois Application for Benefits Eligibility), by mail, in person, by phone, or another method. The Department may designate entities that may assist individuals to submit applications.

 

b)         The application shall meet all requirements of 89 Ill. Adm. Code 110.10 (Application for Medical Assistance), including provisions regarding who may apply on behalf of the individual.

 

c)         Applicants are obligated to provide truthful and accurate information for determining eligibility and to promptly report any change in information provided on the application.

 

d)         The Department may cease enrollment and deny applications that meet the eligibility requirements of this Subpart if the Department determines this action is necessary to maintain the cost of the Program within the available funding.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.725  Determination of Monthly Countable Income

 

a)         The earned and unearned income of the following persons, when included in the applicable standard under 89 Ill. Adm. Code 120.10, shall be counted when determining eligibility under Section 118.710, except as specified in subsections (b) and (c):

 

1)         Income of the individual;

 

2)         Income of the individual's spouse; and

 

3)         Unearned income of a dependent child under the age of 18 years who is included in the income standard as set forth at 89 Ill. Adm. Code 120.20 because it is to the advantage of the individual.

 

b)         Monthly unearned income shall be counted as described at 89 Ill. Adm. Code 120.330 through 120.347, 120.350, 120.355, 120.371 and 120.376. 

 

c)         Monthly earned income shall be considered as described at 89 Ill. Adm. Code 120.360, 120.361 and 120.371 through 120.375.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.730  Eligibility Determination and Enrollment Process

 

a)         The applicant's eligibility for medical assistance receiving federal financial participation will be considered as a part of the eligibility determination process for this Program.

 

b)         If the monthly countable income is at or below 100% FPL without, or after deducting, the costs of medical or remedial care as determined in accordance with 89 Ill. Adm. Code 120.60(c), the application will be approved if all other factors of eligibility under Section 118.710, including resource limits, are met. The Health Benefits for Immigrant Seniors Program income standard is 100% FPL.

 

c)         Applicants will be notified, in writing, regarding the outcome of their eligibility determination.

 

d)         Eligibility will be redetermined at least annually.

 

e)         Individuals may obtain backdated medical coverage for up to three months prior to the month of application unless the individual does not meet all eligibility requirements for one or more backdated months.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.735  Appeals

 

a)         Any person who applies for or receives benefits under the Program shall have the right to appeal any of the following actions:

 

1)         Refusal to accept, or failure to act on, an application or reapplication;

 

2)         Denial of an application or cancellation at the redetermination of eligibility, including denial based on failure to meet one or more of the eligibility requirements specified in this Subpart.

 

A)        No eligibility exists during the appeal process.

 

B)        If the appeal is upheld, the individual will have the opportunity to receive coverage back to the original application date, including possible backdated months or the cancellation month;

 

3)         Termination of coverage based on failure to continue to meet one or more of the eligibility requirements specified in this Subpart. 

 

A)        If the termination is not upheld on appeal, coverage under the Program shall be reinstated retroactive to the termination date.

 

B)        The individual may choose coverage for all or some of the months during the appeal process as long as the retroactive months are consecutive to the new initial month of regular eligibility; and

 

4)         Individuals or their representatives do not have the right to appeal Department decisions necessary to keep the cost of the Program within the annual appropriations, such as a Department decision to:

 

A)        Deny an application due to closing of enrollment for the Program;

 

B)        Make a change to the Program pursuant to Section 118.760; and

 

C)        Require more frequent redeterminations of eligibility.

 

b)         In addition to the actions that are appealable under subsection (a), individuals shall have the right to appeal any of the following actions:

 

1)         Denial of payment for a medical service or item that requires prior approval; or

 

2)         Decision granting prior approval for a lesser or different medical service or item than was originally requested.

 

c)         Individuals may initiate the appeal process by submitting a request for appeal to the Department's Bureau of Administrative Hearings.

 

d)         The request for a hearing may be filed by the individual affected by the action or by the individual's authorized representative.

 

e)         For purposes of initiating the appeal process, a copy of a written, signed request for a hearing is considered the same as the original written, signed request.

 

f)         The request for a hearing must be filed no later than 60 days after notice of the appealable action has been given.

 

g)         The provisions of 89 Ill. Adm. Code 104.Subpart A (Practice in Administrative Hearings) shall govern the handling of appeals and the conduct of hearings under the Program.

 

h)         An individual can, prior to a decision being rendered on the appeal, reapply for the Program.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.740  Renewals of Eligibility

 

a)         Prior to the eligibility period ending, and in sufficient time for the individual to respond to the Department's request for information, the Department or its designee will send an annual renewal notice to the individual. Failure to respond to the renewal notice when required may result in termination.

 

b)         Renewals shall be subject to all eligibility requirements and exclusions set forth in this Subpart, including Sections 118.710, 118.715, 118.725 and 118.730.

 

c)         The Department may require renewal of eligibility more frequently than annually if necessary to keep spending within available funding.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.745  Covered Services

 

Covered health care services shall be the same as covered services for adults described in Article V of the Code, including kidney transplants, except as provided in Section 118.750. The Department may also cover certain services, including, but not limited to, select Department of Human Services Home Services Program (HSP) services and select Department on Aging Community Care Program (CCP) services, to the extent the individual is otherwise determined eligible for those services.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.750  Service Exclusions

 

The following health care services shall not be covered under this Subpart:

 

a)         Nursing facility services;

 

b)         Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD) services;

 

c)         Specialized Mental Health Rehabilitation facility (SMHRF) services;

 

d)         Medically Complex for the Developmentally Disabled facility (MC/DD) services; and

 

e)         Funeral and burial expenses.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.755  Provider Reimbursement

 

a)         Provider participation under this Subpart shall be subject to enrollment with, and approval by, the Department. 

 

b)         Providers shall be reimbursed in accordance with the established rates of the Department or other appropriate State agency.

 

c)         Providers under this Subpart shall be prohibited from billing individuals covered under this Program for any difference between the charge amount and the amount paid by the Department.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

 

Section 118.760  Program Limitations

 

There is no entitlement to medical services under this Subpart and those services are available only to the extent that payments made for individuals eligible under this Subpart do not exceed the funding available for this Program. The Department may take any action it deems necessary to assure payments for this Program do not exceed available funding, including but not limited to: ceasing or limiting enrollment, changing standards of eligibility that are not statutorily required, changing enrollment practices, changing eligibility time periods, and reducing available medical services.

 

(Source:  Added at 44 Ill. Reg. 19684, effective December 11, 2020)

SUBPART H: KIDNEY TRANSPLANTATION AND RELATED SERVICES FOR NONCITIZENS

 

Section 118.780  Kidney Transplantation for Noncitizens with End-Stage Renal Disease

 

Pursuant to Public Act 98-0651, which amended Section 5-5 of the Public Aid Code, effective for dates of outpatient services and inpatient discharges on and after October 1, 2014, notwithstanding Section 1-11 of the Code and any citizenship or immigration requirements under Title 89, any noncitizen is eligible for kidney transplantation when each of the following criteria are met:

 

a)         The noncitizen:

 

1)         has end-stage renal disease;

 

2)         is enrolled with the Department with coverage limited to renal dialysis services;

 

3)         is not eligible for comprehensive medical benefits under any government funded or private insurance plan;

 

4)         otherwise meets the income, asset, and categorical requirements of the medical assistance program; and

 

5)         meets the residency requirements of Section 5-3 of the Code.

 

b)         Providers, including transplant centers, providing kidney transplantation services under this Subpart shall be pre-certified by the Department and meet all provider requirements consistent with 89 Ill. Adm. Code 148.82. Only providers, including transplant centers, enrolled in the medical assistance program, and located in the State of Illinois and St. Louis, MO shall be allowed to perform the kidney transplantation and conduct the medically necessary care identified in subsection (c).

 

c)         The kidney transplantation procedure shall be medically necessary, and providers shall be prior approved and certified by the Department to perform kidney transplantation and services under this section. Only medically necessary services associated with kidney transplantation shall be covered, including but not limited to donor and recipient transplant surgeries (including facility, surgical, and anesthesia services), recommended, to the extent covered under the medical assistance program, pre-op evaluation and screening, assessment for evaluation of recipient's ability to comply with medical and follow-up instructions, acquisition and harvesting of kidney to be transplanted, hospitalization, medical follow-up and testing, rehabilitative and home nursing services, pharmacy costs, including anti-rejection and anti-infective medicines, and incidental costs for care of complications in the peri-operative period.

 

d)         Requests for repeat kidney transplantation shall be considered in exceptional circumstances and shall require prior approval by the Department.

 

e)         Transplantation of organs other than kidneys shall not be a covered service under this Subpart.

 

f)         Clinical trials shall not be a covered service under this Subpart.

 

g)         Experimental procedures shall not be a covered service under this Subpart.

 

h)         Reports, including patient's progress, kidney function tests, complications, if any, and a list of current medications shall be submitted to the Department from the transplant center and transplant surgeon at three months after surgery and at the anniversary date of transplantation annually for five years.

 

i)          Payment for services rendered under this Subpart shall be at a single bundled rate, which shall be payment in full for all medically necessary services associated with the transplantation under this Subpart, with the exception of immunosuppressant drugs. The bundled rate shall have two components. First, the inpatient stay during which the transplant takes place will be priced using the Department's hospital rate methodology (see 89 Ill. Adm. Code 149.100) and, second, the Department will add $15,000 to this price to cover all ancillary services covered in subsection (c) except drugs covered through pharmacy as appropriate and related to the transplant. These two components will comprise the single bundled rate for transplant for the first year (12 months) from the date of kidney transplant.

 

j)          Drugs paid for under this Subpart shall be subject to all the Department's pharmaceutical protocols and procedures, including but not limited to placement on the prior approval list, preferred drug list, genetic drug preference, and utilization controls, except:

 

1)         drugs may not be shipped to any address outside the State of Illinois; and

 

2)         immunosuppressant drugs shall be paid for at the Department's prevailing rates under 89 Ill. Adm. Code 140 to a pharmacy provider approved specifically for this program. Immunosuppressant drugs paid for under this Subpart shall be covered by the Department if medically necessary and as long as the noncitizen remains eligible under this Subpart.

 

(Source:  Added at 46 Ill. Reg. 14541, effective August 8, 2022)

 

Section 118.790  Post Kidney Transplantation Services for Noncitizens

 

Pursuant to Public Act 102-0043, which amended Section 5/12-4.35 of the Public Aid Code, any noncitizen is eligible for post-transplant drugs and related services after 12 months from the date of kidney transplant, when each of the following criteria are met:

 

a)         The noncitizen:

 

1)         provides proof that they received a kidney transplant, at least 12 months prior, at a certified transplant center in Illinois, and now require medically necessary post-transplant drugs and related services. Acceptable proof shall include medical records and operative report confirming the date of and location where the transplant occurred;

 

2)         is not eligible for comprehensive medical benefits under any government funded or private insurance plan;

 

3)         otherwise meets the income, asset, and categorical requirements of the medical assistance program; and,

 

4)         meets the residency requirements of Section 5-3 of the Code.

 

b)         Requests for post kidney transplant services for noncitizens shall be reviewed for eligibility and prior authorized by the Department for medical necessity initially and annually thereafter.

 

c)         Covered benefits shall include, to the extent covered under the medical assistance program, immunosuppressant drugs; other drugs as necessary for treatment of condition(s) resulting from a kidney transplant, or those pre-existing condition(s) which necessitated a kidney transplant; an annual evaluation by patient’s primary care physician, a nephrologist, and a transplant surgeon in Illinois; and a standard battery of diagnostic tests for post-transplant patients, including blood tests, urine tests, kidney ultrasound, and kidney biopsy.

 

d)         Providers may request exceptions for additional medically necessary post kidney transplant related services, which will be reviewed by the Department on a case-by-case basis.

 

e)         As in case of other partial benefits programs for special populations covered by the Department, the programs of Kidney Transplantation for Noncitizens with End-Stage Renal Disease, and Post Kidney Transplantation Services for Noncitizens will be managed directly by the Department.

 

(Source:  Added at 46 Ill. Reg. 14541, effective August 8, 2022)

SUBPART I: HEALTH BENEFITS FOR IMMIGRANT ADULTS

 

Section 118.800  General Description

 

This Subpart implements Section 12-4.35(a-6) of the Code that authorizes the Department to administer in Illinois the Health Benefits for Immigrant Adults Program to certain non-citizens who are not eligible for medical assistance receiving federal financial participation due to immigration status.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.805  Definitions

 

For the purposes of this Subpart, the following terms have the meanings ascribed in this Section:

 

"Code" means the Public Aid Code [305 ILCS 5].

 

"Department" means the Department of Healthcare and Family Services and any successor agencies.

 

"FPL" means the federal poverty income guidelines established by the federal Department of Health and Human Services and published in the Federal Register.

 

"Health Benefits for Immigrant Adults" or "Program" means the Program authorized by Section 12-4.35(a-6) of the Code and created by this Subpart.

 

"Resident" means an individual who has an Illinois residence, as established in Section 5-3 of the Code.

 

"Medical assistance receiving federal financial participation" does not include emergency medical services for certain non-citizens.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.810  Eligibility

 

An individual may be eligible for Health Benefits for Immigrant Adults provided that all of the following eligibility criteria are met:

 

a)         The individual is not eligible for medical assistance receiving federal financial participation other than emergency medical for certain non-citizens;

 

b)         The individual is not:

 

1)         A U.S. citizen; or

 

2)         A person:

 

A)        Lawfully admitted for permanent residence under the Immigration and Nationality Act (INA); and

 

B)        Who has lawfully resided in the United States for five years or more;

 

c)         The individual is a resident of the State of Illinois;

 

d)         The individual is 42-64 years of age;

 

e)         The individual's income is at or below 138% FPL as determined in accordance with 89 Ill. Adm. Code 120.64;

 

f)         The individual cooperates in establishing eligibility (see 89 Ill. Adm. Code 120.308); and

 

g)         The individual assigns rights to medical support and collection of payment (see 89 Ill. Adm. Code 120.319).

 

(Source:  Amended at 46 Ill. Reg. 16734, effective September 21, 2022)

 

Section 118.815  Eligibility Exclusions and Terminations

 

a)         Coverage of medical services under this Subpart for inmates of public institutions shall be consistent with 89 Ill. Adm. Code 120.318 and other applicable law.

 

b)         An individual's coverage under the Program shall be terminated if the individual:

 

1)         No longer qualifies as an Illinois resident; 

 

2)         Becomes eligible for medical assistance under the Public Aid Code that receives federal financial participation;

 

3)         Fails to report to the Department changes that affect eligibility for the Program;

 

4)         Asks the Department to terminate the coverage;

 

5)         Is no longer eligible based on any other applicable State or federal law or regulation;

 

6)         Failed to provide eligibility information that was truthful and accurate to the best of the individual's knowledge and belief and that affected the individual's eligibility;

 

7)         Was incorrectly determined eligible; or

 

8)         Fails to complete the redetermination of eligibility within the required timeframes or provide proof of on-going eligibility.

 

c)         Following termination of an individual's coverage under the Program, the following action is required before the individual can be re-enrolled:

 

1)         A new application is completed and submitted, or an existing application or case is reopened, and the individual is determined otherwise eligible; and

 

2)         The individual cooperates with the Department to meet the prescribed timeframes regarding a determination of eligibility found in 305 ILCS 5/11-5.1(a)(2) and 89 Ill. Adm. Code 120.308(h).

 

d)         If the Department determines the individual's exclusion or termination was in error, the individual can be re-enrolled.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.820  Application Process

 

a)         Individuals apply for the Program by submitting an application through any available method (see 89 Ill. Adm. Code 110.5), including on-line at ABE.illinois.gov (Illinois Application for Benefits Eligibility), by mail, in person, by phone, or another method. The Department may designate entities that may assist individuals to submit applications.

 

b)         The application shall meet all requirements of 89 Ill. Adm. Code 110.10 (Application for Medical Assistance), including provisions regarding who may apply on behalf of the individual.

 

c)         Applicants are obligated to provide truthful and accurate information for determining eligibility and to promptly report any change in information provided on the application.

 

d)         The Department may cease enrollment and deny applications that meet the eligibility requirements of this Subpart if the Department determines this action is necessary to maintain the cost of the Program within the available funding.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.825  Determination of Monthly Countable Income

 

Income will be determined in the manner described in 89 Ill. Adm. 120.64(i) and other applicable provisions in 89 Ill. Adm. 120.64.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.830  Eligibility Determination and Enrollment Process

 

a)         The applicant's eligibility for medical assistance receiving federal financial participation will be considered as a part of the eligibility determination process for this Program.

 

b)         If the monthly countable income is at or below 138% FPL in accordance with 89 Ill. Adm. Code 120.64, the application will be approved if all other factors of eligibility under Section 118.810 are met.

 

c)         Applicants will be notified, in writing, regarding the outcome of their eligibility determination.

 

d)         Eligibility will be redetermined at least annually.

 

e)         Individuals may obtain backdated medical coverage for up to three months prior to the month of application unless the individual does not meet all eligibility requirements for one or more backdated months.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.835  Appeals

 

a)         Any person who applies for or receives benefits under the Program shall have the right to appeal any of the following actions:

 

1)         Refusal to accept, or failure to act on, an application or reapplication;

 

2)         Denial of an application or cancellation at the redetermination of eligibility, including denial based on failure to meet one or more of the eligibility requirements specified in this Subpart.

 

A)        No eligibility exists during the appeal process.

 

B)        If the appeal is decided in the individual's favor, the individual will have the opportunity to receive coverage back to the original application date, including possible backdated months or the cancellation month;

 

3)         Termination of coverage based on failure to continue to meet one or more of the eligibility requirements specified in this Subpart.

 

A)        If the termination is decided in the individual's favor on appeal, coverage under the Program shall be reinstated retroactive to the termination date.

 

B)        If coverage is reinstated pursuant to subsection (a)(3)(A), the individual may choose coverage for all or some of the months during the appeal process as long as the retroactive months are consecutive to the new initial month of regular eligibility.

 

4)         Individuals or their representatives do not have the right to appeal Department decisions necessary to keep the cost of the Program within the annual appropriations, such as a Department decision to:

 

A)        Deny an application due to closing of enrollment for the Program;

 

B)        Make a change to the Program pursuant to Section 118.860; and

 

C)        Require more frequent redeterminations of eligibility.

 

b)         In addition to the actions that are appealable under subsection (a), individuals shall have the right to appeal any of the following actions:

 

1)         Denial of payment for a medical service or item that requires prior approval; or

 

2)         Decision granting prior approval for a lesser or different medical service or item than was originally requested.

 

c)         Individuals may initiate the appeal process by submitting a request for appeal to the Department's Bureau of Administrative Hearings.

 

d)         The request for a hearing may be filed by the individual affected by the action or by the individual's authorized representative.

 

e)         For purposes of initiating the appeal process, a copy of a written, signed request for a hearing is considered the same as the original written, signed request.

 

f)         The request for a hearing must be filed no later than 60 days after notice of the appealable action was given.

 

g)         The provisions of 89 Ill. Adm. Code 104.Subpart A (Practice in Administrative Hearings) shall govern the handling of appeals and the conduct of hearings under the Program.

 

h)         An individual can, prior to a decision being rendered on the appeal, reapply for the Program.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.840  Renewals of Eligibility

 

a)         Prior to the eligibility period ending, and in sufficient time for the individual to respond to the Department's request for information, the Department or its designee will send an annual renewal notice to the individual. Failure to respond to the renewal notice when required will result in termination unless good cause is shown for the failure to respond.

 

b)         Renewals shall be subject to all eligibility requirements and exclusions set forth in this Subpart, including Sections 118.810, 118.815, 118.825 and 118.830.

 

c)         The Department may require renewal of eligibility more frequently than annually if necessary to keep spending within available funding.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.845  Covered Services

 

Services available to the population covered in this Subpart shall be consistent with the services covered under section 118.745 of Subpart G.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.850  Service Exclusions

 

The following services shall not be covered under this Subpart:

 

a)         Funeral and burial expenses.

 

b)         Pursuant to Section 12-4.35(b) of the Code, health care services excluded under section 118.750 of Subpart G shall be excluded from this Subpart, unless it is determined by the Department that Section 12-4.35(b) is not applicable.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.855  Provider Reimbursement

 

a)         Provider participation under this Subpart shall be subject to enrollment with, and approval by, the Department.

 

b)         Providers shall be reimbursed in accordance with the established rates of the Department or other appropriate State agency.

 

c)         Providers under this Subpart shall be prohibited from billing individuals covered under this Program for any difference between the charge amount and the amount paid by the Department.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)

 

Section 118.860  Program Limitations

 

There is no entitlement to medical services under this Subpart and those services are available only to the extent that payments made for individuals eligible under this Subpart do not exceed the funding available for this Program. The Department may take any action it deems necessary to assure payments for this Program do not exceed available funding, including but not limited to: ceasing or limiting enrollment, changing standards of eligibility that are not statutorily required, changing enrollment practices, changing eligibility time periods, and reducing available medical services.

 

(Source:  Added at 46 Ill. Reg. 5692, effective March 25, 2022)