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)