Section 148.630  Criteria and Information Required to Establish Eligibility

a)         An eligible person shall:

1)         Be a resident of the State of Illinois as provided in 305 ILCS 5/2-10;

2)         Meet requirements of citizenship as provided in 305 ILCS 5/1-11; and

3)         Meet the requirements of the Patient Protection and Affordable Care Act (ACA) (26 USC 5000A) by obtaining health coverage.  Payment of a tax penalty for not obtaining insurance does not meet the requirement.

b)         The following information shall be verified by the dialysis facility and maintained in the patient's record:

1)         Citizenship or immigration status;

2)         Address;

3)         Social Security Number; and

4)         Documentation of health coverage.

c)         Eligibility of patients shall be determined by the Department based on the information required in this Section.  To maintain eligibility for participation in the Program, a patient shall meet the following criteria on an ongoing basis:

1)         A physician's diagnosis of End Stage Renal Disease for the patient must be on file at the dialysis facility;

2)         The designated Department of Human Services office has determined the patient is not eligible for medical assistance; and

3)         The patient shall provide documentation to the dialysis facility of his or her ineligibility for non-spenddown Medicaid or QMB (Qualified Medicare Beneficiary) status.

d)         Participation Fees

1)         Participants in the Program shall be responsible for paying a monthly participation fee to the dialysis facility from which they receive dialysis treatment.  The amount of the Department's payment, as determined under Section 148.620, shall be reduced by the amount of the participation fee. The fee shall be determined by the Department based on income and information contained in the Bureau of Labor Statistics (BLS) standards, as described in Table B, and calculated pursuant to the Direct Care Program Renal Participation Worksheet (Table A).

2)         The following shall be obtained and verified by the dialysis facility and submitted with the patient's application to the Department for determination of the amount of a patient's participation fee.

A)        Pay stubs for the 90 days preceding the date of signature on the application if not employed for the past year; or

B)        Previous year's federal and State Income Tax Returns if employed during the previous year.

3)         The following are allowed as deductions from income:

A)        Federal, State and local taxes;

B)        Special care for children;

C)        Support (child, relative or alimony);

D)        Retirement or Social Security benefits;

E)        Employment expenses (union dues, special tools and clothing);

F)         Transportation to and from the site of dialysis; and

G)        Medical expenses, both paid and outstanding.

4)         If a substantial change in the financial status of any patient occurs after the patient has been found eligible for the Program, the patient shall report the change to the dialysis center.  Based on the extent of the change, a new participation fee may be determined and imposed by the Department.

e)         The following shall be verified by the dialysis facility and submitted with the patient's application to the Department for determination of nonfinancial eligibility by the Department:

1)         Third Party Liability

A)        Proof of insurance coverage; and

B)        Proof of Medicare coverage.

2)         Consent form required under subsection (f), signed by the patient or his or her representative.

f)         The applicant or the applicant's parent or guardian must sign a consent form authorizing the release of all medical and financial records to the Department and to an approved chronic renal disease treatment facility.

(Source:  Amended at 38 Ill. Reg. 13263, effective June 11, 2014)