Section 101.1  Incorporation By Reference

 

Any rules or regulations of an agency of the United States or of a nationally recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified, and do not include any later amendments or editions.

 

(Source:  Added at 13 Ill. Reg. 3897, effective March 17, 1989)

 

Section 101.10  Applicability

 

a)         This Part applies to activities of the Department of Healthcare and Family Services, the Department of Human Services and local governmental units in administering those programs and activities authorized by the Illinois Public Aid Code [305 ILCS 5] and any other applicable statutes.

 

b)         Should any provision of this Part be unconstitutional or invalid for any reason whatsoever, these holdings shall not affect the validity of the remaining portions of this Part.

 

c)         All rules and regulations of the Illinois Department of Public Aid previously filed with the Secretary of State, with the exception of the Rules for Medical Vendor Administrative Proceedings filed and effective on an emergency basis December 27, 1977, were replaced by adoption of this Part.

 

d)         This Part shall be operative only to the extent that it does not conflict with any Federal law or regulation governing Federal grants to this State for public assistance programs.

 

(Source:  Amended at 37 Ill. Reg. 10152, effective June 27, 2013)

 

Section 101.20  Definitions

 

The definitions in this Section apply to terms used by the Department of Healthcare and Family Services, the Department of Human Services and local governmental units in administering programs under the Public Aid Code.  These definitions apply to the rules of those entities unless a specific, alternative definition is created in those rules.

 

"AABD" or "Aid to the Aged, Blind or Disabled" – Financial assistance and medical assistance available to individuals who have been determined to be aged, blind or disabled as defined by the Social Security Administration.

 

"Adequate Consideration" − The receipt of goods, monies or services at least in the amount of the fair market value of the property sold.

 

"Adult Cases" − A case in which no child is included in the assistance unit.

 

"Adverse Action" − Any action that reduces SNAP benefits or terminates participation in SNAP within a certification period.

 

"AFDC" or "Aid to Families with Dependent Children" – Financial assistance and medical assistance available to families with one or more dependent children or in behalf of dependent children placed in foster care by the Department of Children and Family Services (DCFS).

 

"AFDC-F" − Medical assistance for an eligible child under DCFS guardianship.

 

"Agency Error" − An action or inaction of DHS or HFS resulting in assistance benefits being furnished to or in behalf of a client for which the client is not eligible.

 

"Applicant" − An individual requesting assistance by completion of a signed, written application form or a person in whose behalf a signed written application form is completed requesting assistance.

 

"Application" − A request for assistance by means of a completed, signed designated form.  For SNAP purposes, only a name, address and signature are needed on the form.

 

"Assistance Unit" − The individual or individuals living together for whom DHS or HFS determines eligibility and, if eligible, provides financial and/or medical assistance as one unit.

 

"Benefit Allotment" – The total dollar value of the SNAP benefits that a household is authorized to receive.

 

"Caretaker Relative" − A relative, as specified in this definition, with whom a child must live to be eligible for TANF and who is providing care, supervision and a home for the child.

 

Blood or adoptive relatives within the fifth degree of kinship:

 

Father – Mother

 

Brother – Sister

 

Grandmother – Grandfather (including up to great-great-great)

 

Uncle – Aunt (including up to great-great)

 

Nephew – Niece (including up to great-great)

 

First Cousin

 

First Cousin once removed (child of first cousin)

 

Second Cousin (child of great-aunt/uncle)

 

Step-Relatives:

 

Step-Father – Step-Mother

 

Step-Brother – Step-Sister

 

Person who is or has been married to one of the listed blood, adopted or step-relatives.

 

"Categorical Assistance Programs" − TANF, AABD and related MANG programs.

 

"Categorically Eligible" − The meeting of all eligibility requirements for a categorical assistance program other than financial needs.

 

"Certification for SNAP Benefits" − Authorization of eligibility of a household for SNAP.

 

"Certification Period" − The period of time for which a household is authorized to participate in SNAP.

 

"Certifying Office" − The DHS local office responsible for certification of SNAP participants.

 

"Client" − The adult in the family or unit applying for assistance or receiving assistance on behalf of the family.

 

"Client Error" − A client's mistake, misunderstanding, misrepresentation or concealment of information or failure to report information promptly that results in financial and/or medical assistance being paid to or in behalf of a recipient for which the recipient is not eligible.

 

"Correspondent" − A specific individual who has been legally designated to handle the affairs of another individual, that is, parents, court appointed guardian or conservator.

 

"DCFS" − Illinois Department of Children and Family Services.

 

"Department" or "HFS" − Illinois Department of Healthcare and Family Services.

 

"Dependent Child" − A child age 18 or under who is living with a relative.  If age 18, the child must be a full-time high school (or equivalent) student.

 

"DHS" − Illinois Department of Human Services.

 

"DHS-MH/DD" – The Divisions of Mental Health and Developmental Disabilities of the Department of Human Services.

 

"DHS-DRS" – The Division of Rehabilitation Services of the Department of Human Services.

 

"Disbursing Order" − An invoice voucher form given to a client authorizing a vendor to provide specified goods and/or services.

 

"Disposition of an Application" − The determination of eligibility or ineligibility.

 

"Diverted Income" − Earned or unearned income of a parent used to meet the needs of ineligible persons, including the parent, his or her dependent children or his or her spouse.

 

"DOC" − Illinois Department of Corrections.

 

"DOL" − Illinois Department of Labor.

 

"Earmarked Income" − Income restricted for the use of an individual by court order or by legal stipulation of a contributor.  Only income of a child may be considered earmarked for HFS or DHS purposes.  The income of an eligible child who has siblings in the home receiving TANF financial assistance cannot be earmarked.

 

"Earned Income" − Remuneration derived through the receipt of wages or salary for services performed as an employee or profits from activity in which the individual is self-employed.

 

"Effective Date" − The date for which case action is authorized.

 

"Enrolled MANG Participant" − Person or unit meeting the nonfinancial factors of eligibility.

 

"Established Twelve-Month Period" − The period of 12 calendar months over which income is compared to the applicable MANG standard.

 

"Expedited Issuance" − Authorization of SNAP benefits after the household has been determined to be destitute or to have zero net income.

 

"Expedited Service" − An immediate processing of a SNAP application and determination of eligibility for expedited issuance.

 

"FNS" − The Food and Nutrition Service of the United States Department of Agriculture.

 

"Final Administrative Decision" − A decision made by HFS or DHS as a result of an appeal.  It either upholds or reverses the appealed action or determines a lack of jurisdiction.

 

"Financial Assistance" − Public assistance paid in the form of a cash benefit to a recipient for income maintenance needs.  Medical assistance and SNAP benefits are not considered financial assistance.

 

"Financial Factors of Eligibility" − Income, assets and Department levels of assistance.

 

"Financially Eligible" − The meeting of all financial factors of eligibility.

 

"Fiscal Month" − Begins on a given day in one calendar month and ends on the day prior to the same given day in the next calendar month.

 

"Full-Time Employment" − Employment of 30 hours per week or more.

 

"GA" or "General Assistance" – Financial and medical assistance provided by a local governmental unit to eligible needy families or individuals who are ineligible to receive assistance through a categorical assistance program.

 

"Grant" − The total amount of a monthly financial assistance payment.

 

"Grant Cases" − Public assistance cases authorized for financial assistance payments to the recipient.

 

"Head of Household" − The person in whose name application is made for participation in SNAP.  This person is normally the individual who is the household's primary source of income.

 

"Health Maintenance Organization" or "HMO" − Licensed by the Illinois Department of Insurance as a non-profit incorporated agency whose purpose is to provide preventive health care and medical services.

 

"Healthy Kids" − Early and periodic screening, diagnosis and treatment services provided to children from birth through 20 years of age.

 

"Hearing" − The actual presentation and consideration of the issue under appeal before a hearing officer of the Department.

 

"HFS" − Illinois Department of Healthcare and Family Services.

 

"HIB" − Hospital Insurance Benefits provided by Title XVIII of the Social Security Act (Medicare) (42 USC, 1395 et seq.).

 

"Initial Prorated Entitlement" or "IPE" − Financial assistance to cover the period from the initial point of eligibility (application for assistance or initial needs of a person being added to the assistance unit) through two days after the mailing date of the first regular monthly assistance warrant.

 

"In-Kind Income" − Income received by or paid in behalf of an individual in a form other than money.

 

"Intermediate Care Facility" or "ICF" − Provides basic nursing care and other restorative services under periodic medical direction.  Many of these services may require skill in administration.  The facilities are for residents who have long term illnesses or disabilities that may have reached a relatively stable plateau.

 

"Intermediate Care Facility for the Developmentally Disabled" or "ICF/DD" − Provides primarily for ambulatory adults with developmental disabilities and addresses itself to the needs of intellectually disabled persons and/or those with related conditions.  These facilities are for residents who have physical, intellectual, social and emotional needs.

 

"Local Governmental Unit" − Every county, city, village, incorporated town or township charged with the duty of providing public aid under General Assistance and County Veterans Assistance Commissions providing assistance to indigent war veterans and their families.

 

"Local Office" − DHS offices that serve clients living within a designated geographical area.

 

"Lump-Sum Payment" − An extraordinary or non-recurring income payment received by a client.

 

"MAG" or "Medical Assistance Grant" – Medical assistance paid on behalf of a recipient of financial assistance.

 

"MANG" − Medical Assistance No Grant-" – Medical assistance paid on behalf of a recipient of categorical assistance who is not receiving financial assistance.

 

"MANG(AABD)" − Medical assistance available to individuals who have sufficient income and assets to meet all maintenance needs other than medical care and who are receiving Supplemental Security Income benefits or who are determined to be aged, blind or disabled by DHS or HFS.

 

"MANG(C)" or "Medical Assistance to Needy Families with Children" – Available to families with one or more children who would qualify for TANF on the basis of non-financial eligibility factors but have sufficient income and assets to meet all maintenance needs other than medical care.

 

"Medicaid" − Medical assistance issued by HFS under provisions of Title XIX of the Social Security Act (42 USC 1396); MAG and MANG.

 

"Medical Assistance" − Medicaid.

 

"Medical Card" − A means of identification used to verify an individual's eligibility for medical assistance.

 

"Medicare" − Payment for medical care under the provisions of Title XVIII of the Social Security Act (42 USC 1395).

 

"Migrant Worker" − Any person residing temporarily in and employed in Illinois who moves seasonally from one place to another for the purpose of employment in agricultural activities, including the planting, raising or harvesting of any agricultural or horticultural commodities and the handling, packing or processing of those commodities on the farm where produced or at the point of first processing.

 

"OASDI" or "Old Age, Survivors, and Disability Insurance" – Often termed "Social Security".

 

"OJT" or "On the Job Training " – Programs sponsored through the TANF  JOBS Program, SNAP Employment and Training Program or WIA.

 

"Participant" − A person taking part in SNAP or a DHS employment and training program.

 

"Prepaid Health Plan" − An organized system of health care responsible for providing or assuring the delivery of comprehensive health maintenance and treatment services to a voluntarily enrolled population.

 

"Recipient" − An individual who receives benefits under an assistance program.

 

"Skilled Nursing Facility" or "SNF" − A group care facility licensed by the Illinois Department of Public Health that provides skilled nursing care, continuous skilled nursing observations, restorative nursing and other services under professional direction with frequent medical supervision. The facilities are provided for patients who need the type of care and treatment required during the post-acute phase of illness or during reoccurrences of symptoms in long-term illness.

 

"Skilled Nursing Facility for Pediatrics" or "SNF/PED" − A group care facility licensed by the Illinois Department of Public Health that provides nursing care and habilitative and/or rehabilitative care to children under 18 years of age.  The facilities are for residents primarily diagnosed with an intellectual disability or having related conditions.

 

"SMIB" or "Supplementary Medical Insurance Benefits" – Coverage provided under Title XVIII of the Social Security Act for medical services other than hospitalization.

 

"SNAP Benefits" − The cash value of benefits a SNAP unit receives from the program.

 

"SNAP Employment and Training" − Employment and training program for SNAP recipients.

 

"SNAP Household or Unit" − For purposes of SNAP, a household or unit is defined as any of the following:

 

An individual living alone;

 

An individual living with others but customarily purchasing food and preparing meals for home consumption separate and apart from others;

 

A group of individuals who live together and customarily purchase food and prepare meals together for home consumption or who, because of their relationship, are required to qualify for SNAP benefits as a unit.

 

"Specified Relative" − Same as caretaker relative.

 

"Spenddown" − The amount by which a client's nonexempt income during the eligibility period exceeds the MANG income and asset standards.

 

"SSA" − The Social Security Administration.

 

"SSI" or "Supplemental Security Income" – A program administered by the Social Security Administration providing monthly aid to aged, blind or disabled individuals.

 

"Student" − An individual who is enrolled at least half time (as defined by the institution) in any elementary school, high school, vocational school, technical school, training program or institution of higher education. Enrollment in a mail, self-study or correspondence course does not meet the definition of a student.

 

"Supervision" − Exercising of responsibility for the child's welfare by the caretaker.

 

"TANF" or "Temporary Assistance for Needy Families" − Financial and medical assistance available to families with one or more dependent children.

 

"Temporary Caretaker" − Another individual temporarily acting as a caretaker (not included in the assistance unit) when no specified relative is available.

 

"UI" − Unemployment Insurance.

 

"Unearned Income" − All income other than earned income.

 

"Utilization Control" − Evaluation and review of a recipient's need for care, and certification of a patient's need for care as established by HFS, DHS and the Department of Public Health or other designated agencies or authorities.

 

"Vendor Payment" − Direct payment to vendors for items or services provided to clients.

 

"WIA" – The Federal Workforce Investment Act of 1998 (29 USC 2801 et seq.).

 

"Work and Basic Skills Training Program" – The DHS employment and training program for TANF recipients.

 

"Work Experience" – The DHS program that provides experience in a job.

 

(Source:  Amended at 37 Ill. Reg. 10152, effective June 27, 2013)

 

Section 101.30  Assistance Programs

 

a)         The types of assistance programs administered by DHS include:  financial assistance and SNAP benefits. The types of assistance programs administered by HFS include: medical assistance and child support services.

 

b)         Financial Assistance Programs – consist primarily of direct cash payments to recipients.  The various financial assistance programs are:

 

1)         Aid to the Aged, Blind or Disabled – State Supplemental Payment

For aged, blind or disabled persons.

 

2)         Temporary Assistance for Needy Families

For families with one or more children.

 

3)         Refugee Resettlement Program (RRP)

For refugees from any country.

 

4)         Repatriate Program

For United States citizens and their dependents returned from a foreign country by the U.S. Department of State.

             

c)         Medical Assistance – under which payments are made to medical providers for services provided to recipients.

 

1)         Medicaid

For persons eligible for financial assistance under the AABD-SSP and TANF programs and for individuals not eligible for financial assistance but who meet the requirements of 89 Ill. Adm. Code 120 for medical assistance.  This includes pregnant women of any age with no other children who would be eligible for TANF or MANG (CR) if the child had already been born.  Medicaid is provided under the AFDC-F program for children under DCFS guardianship who have been placed in licensed foster care or in the home of a relative.

 

2)         Healthy Kids

A preventative health program for all clients who are under 21 years of age and who are receiving AFDC, AABD, RRA, MANG or TANF. Through Healthy Kids, persons are given periodic screening examinations at certain ages from birth through age 20.  The screening is to diagnose and treat health problems at an early stage.

             

d)         SNAP – provides increased food purchasing benefits to recipients.  SNAP benefits are available to individuals who meet the eligibility requirements of the Food and Nutrition Service of the U.S. Department of Agriculture in accordance with the Food and Nutrition Act of 2008 (7 USC 2013 et seq.).

 

e)         Title IV-D – attempts to collect child support payments from absent parents on behalf of children receiving assistance.  HFS enlists the cooperation of the caretaker relative in identifying, locating and securing support from an absent parent or parents or putative father. The support received is subsequently paid directly to HFS.

 

(Source:  Amended at 37 Ill. Reg. 10152, effective June 27, 2013)

 

Section 101.40  Assistance Program Restrictions

 

a)         An individual shall be eligible to receive financial assistance under only one of the following types of assistance programs at any one time:

 

1)         Categorical Assistance (TANF or AABD); or

           

2)         Assistance to Refugees, Entrants and Repatriates.

 

b)         An individual shall be eligible to receive financial and medical assistance in only one case under one assistance program, at any one time, except that an individual who currently receives Categorical Assistance from another state and has established Illinois residence (in accordance with 89 Ill. Adm. Code 112.20, 113.20, 120.311 or 121.21) may receive Supplemental Categorical Assistance in Illinois when the amount of the Illinois assistance payment level to which the individual is entitled exceeds the amount received from the other state, if the excess is at least $10.

             

c)         An individual shall not be eligible to receive SNAP benefits as a member of more than one household at any one time.

 

(Source:  Amended at 37 Ill. Reg. 10152, effective June 27, 2013)

 

Section 101.50  Reporting Suspected Fraud or Abuse

 

a)         Any suspected fraud or abuse related to the Medical Assistance, Children's Health Insurance, Covering All Kids Health Insurance, Child Support Enforcement,  Aid to the Aged, Blind and Disabled, Temporary Assistance to Needy Families, SNAP and Child Care Programs, and other programs administered by the Department of Human Services, the Department on Aging, or the Department of Healthcare and Family Services, should be reported to the Office of the Inspector General (HFS-OIG):

 

1)         in person or by U.S. Mail to the Office of Inspector General, Department of Healthcare and Family Services, 2200 Churchill Road, A-1, Springfield, Illinois 62702;

 

2)         or by:

 

A)        toll free telephone to the Office of Inspector General at 1-844-453-7283 (1-844-ILFRAUD); or

 

B)        e-mail at hfs.oig.fraudhotline@illinois.gov; or

 

C)        online at: www.illinois.gov/hfs/oig .

 

b)         Referrals

 

1)         Referrals of suspected fraud or abuse, as explained in subsection (a), by providers, contractors, State or other governmental employees, recipients of services or any other person will be accepted.

 

2)         Referrals may be made anonymously.

 

3)         All referrals, other than anonymous referrals, will be acknowledged, either in writing, by telephone, by e-mail or in person, within 45 calendar days after receipt of the referral.

 

c)         Evaluations

 

1)         All referrals of suspected fraud or abuse will be evaluated within 90 calendar days after receipt of the referral to determine what, if any, follow up action is appropriate.

 

2)         Factors considered during the evaluation of any referral include, but are not limited to:

 

A)        source of the allegation;

 

B)        quality of the evidence of wrongdoing;

 

C)        potential loss to the program; and

 

D)        availability of investigative and other resources necessary for successful follow up on the referral.

 

3)         Follow up actions include, but are not limited to, the following measures:

 

A)        If the HFS-OIG's evaluation identifies possible criminal or civil fraud violations of the Medical Assistance Program or the Children's Health Insurance Program or the Covering All Kids Health Insurance Program by a medical provider or contractor, then a referral will be sent to the Medicaid Fraud Control Unit of the Illinois State Police for review for possible criminal investigation.

 

B)        When the evaluation identifies possible criminal or civil fraud violations of any program by a recipient of services or other private citizen and is eligible for follow up action, the Office of Inspector General may initiate an investigation.  Should the investigation establish evidence of a criminal or civil fraud violation, the case may be referred to the appropriate United States Attorney, the Office of Attorney General or the appropriate State's Attorney for prosecutorial consideration.

 

C)        When the evaluation identifies possible administrative violation and is eligible for follow up action, the Office of Inspector General may initiate a review to determine the appropriate administrative action.  Administrative actions include, but are not limited to:

 

i)          claims analysis;

 

ii)         audit;

 

iii)        peer review;

 

iv)        recipient restriction;

 

v)                  eligibility review; or

 

vi)               administrative hearing.

 

(Source:  Amended at 42 Ill. Reg. 16004, effective August 1, 2018)