Section 128.250  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 an application.

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 Part.  No eligibility exists during the appeal process.  If the appeal is upheld, the veteran or spouse will have the opportunity to receive coverage back to the original application date, including possible backdated months or the cancellation month. All premium and co-payment requirements shall apply to the retroactive period.

3)         Termination of coverage based on failure to continue to meet one or more of the eligibility requirements specified in this Part.  If the termination is not upheld on appeal, coverage under the Program shall be reinstated retroactive to the termination date.  All premium and co-payment requirements shall apply to any retroactive period.  The veteran or spouse 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)         Determination of the amount of the premium or co-payments required.  Any premium or co-payment requirements shall remain in force during the appeal process.

5)         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)        cease accepting applications pursuant to Section 128.220(d).

B)        increase premium levels for all individuals within an income range.

C)        require more frequent redeterminations of eligibility.

D)        increase the income standard.

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

1)         Termination of coverage due to non-payment of the required premium.

2)         Denial of payment for a medical service or item that requires prior approval.

3)         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:

1)         Filing a written, signed request for a hearing directed to the Department's Bureau of Administrative Hearings;

2)         Calling a toll free telephone number designated by the Department.

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 Subpart A of the Department's administrative rules at 89 Ill. Adm. Code 104, 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:  Amended at 36 Ill. Reg. 17062, effective November 26, 2012)