HB4622 93RD GENERAL ASSEMBLY

LRB093 16750 DRJ 42401 b

93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB4622

Introduced 02/04/04, by Kathleen A. Ryg

SYNOPSIS AS INTRODUCED:

305 ILCS 5/3-1	from Ch. 23, par. 3-1
305 ILCS 5/3-4	from Ch. 23, par. 3-4
305 ILCS 5/5-2.4 new

Amends the Illinois Public Aid Code. For purposes of the AABD program, provides that "disabled person" is defined as in the Social Security Act (instead of providing a definition separate from that Act). Sets forth standards to be used by the Department of Human Services in determining whether persons are disabled for purposes of the AABD program. Provides Medicaid eligibility for non-citizens in the case of medical care needed for treatment of an emergency condition, if the non-citizen otherwise meets the financial eligibility requirements for the AABD MAG program or Family Care program. Effective immediately.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Public Aid Code is amended by changing Sections 3-1 and 3-4 and by adding Section 5-2.4 as follows:

(305 ILCS 5/3-1) (from Ch. 23, par. 3-1)

Sec. 3-1. Eligibility Requirements. Financial aid in meeting basic maintenance requirements for a livelihood compatible with health and well-being shall be given under this Article to or in behalf of aged, blind, or disabled persons who meet the eligibility conditions of Sections 3-1.1 through 3-1.7. Financial aid under this Article shall be available only for persons who are receiving Supplemental Security Income (SSI) or who have been found ineligible for SSI on the basis of income.

"Aged person" means a person who has attained age 65, as demonstrated by such evidence of age as the Illinois Department may by rule prescribe.

"Blind person" means a person who has no vision or whose vision with corrective glasses is so defective as to prevent the performance of ordinary duties or tasks for which eyesight is essential. The Illinois Department shall define blindness in terms of ophthalmic measurements or ocular conditions. For purposes of this Act, an Illinois Disabled Person Identification Card issued pursuant to The Illinois Identification Card Act, indicating that the person thereon named has a Type 3 disability shall be evidence that such person is a blind person within the meaning of this Section; however, such a card shall not qualify such person for aid as a blind person under this Act, and eligibility for aid as a blind person shall be determined as provided in this Act.

"Disabled person" means, as defined by the Social Security Act and implementing federal regulations, a person over the age of 18 who is unable to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. To meet this definition, the person must have a severe impairment that makes the person unable to do his or her previous work or any other substantial gainful activity that exists in the national economy. To determine whether the person is able to do any other work, the person's residual functional capacity, age, education, and work experience must be considered under the guidelines used to determine disability under the Social Security Act as set forth in 20 CFR 416, Subpart I. a person age 18 or over who has a physical or mental impairment, disease, or loss which is of a permanent nature and which substantially impairs his ability to perform labor or services or to engage in useful occupations for which he is qualified, as determined by rule and regulation of the Illinois Department. For purposes of this Act, an Illinois Disabled Person Identification Card issued pursuant to The Illinois Identification Card Act, indicating that the person thereon named has a Type 1 or 2, Class 2 disability shall be evidence that such person is a disabled person under this Section; however, such a card shall not qualify such person for aid as a disabled person under this Act, and eligibility for aid as a disabled person shall be determined as provided in this Act. If federal law or regulation permit or require the inclusion of blind or disabled persons whose blindness or disability is not of the degree specified in the foregoing definitions, or permit or require the inclusion of disabled persons under age 18 or aged persons under age 65, the Illinois Department, upon written approval of the Governor, may provide by rule that all aged, blind or disabled persons toward whose aid federal funds are available be eligible for assistance under this Article as is given to those who meet the foregoing definitions of blind person and disabled person or aged person.

(Source: P.A. 89-21, eff. 7-1-95.)

(305 ILCS 5/3-4) (from Ch. 23, par. 3-4)

Sec. 3-4. Examination as to disability.

(a) For all purposes, in determining whether an applicant is a "disabled person", the Client Assessment Unit or its successor office shall rely on all regulations and other guidance that are used by the Illinois Bureau of Disability Determination Services in the Office of Rehabilitation Services in determining disability under the Social Security Act.

(b) As part of making a disability determination, the Client Assessment Unit or its successor office shall determine whether an applicant (i) has applied for Supplemental Security Income (SSI) or Old-Age, Survivors, and Disability Insurance (OASDI) disability benefits from the Social Security Administration and received a decision on that application within the last 12 months or (ii) has a pending application for such benefits. In the case of a person who has received a decision on such an application within the last 12 months or is receiving SSI or OASDI benefits at the time of application based on disability, the Client Assessment Unit or its successor office shall follow the procedures set forth in subsection (c). In the case of a person who has such an application pending with the Social Security Administration or the Bureau of Disability Determination Services, the Client Assessment Unit or its successor office shall request copies of medical and other records held by the Social Security Administration or the Bureau of Disability Determination Services for use in determining disability for purposes of Article III or Article V of this Code.

(c) The Client Assessment Unit or its successor office must do all of the following:

(1) Accept as binding a finding of disability made by the Social Security Administration if an applicant is receiving SSI or primary OASDI benefits.

(2) Make a determination of disability if the applicant has been denied SSI on the basis of too much income or if the applicant is applying for medical assistance only and not receiving SSI or OASDI.

If an individual applying for or receiving medical assistance is determined currently "not disabled" by the Social Security Administration under the SSI or OASDI program, the Client Assessment Unit or its successor office shall accept the Social Security Administration's determination of disability and deny or cancel the case, no matter which agency made the original determination of eligibility. Notwithstanding the preceding sentence, however:

(A) If the individual appeals the Social Security Administration's determination of disability to the Social Security Administration, medical assistance under Article V shall be continued for recipients through the level of a determination by an Administrative Law Judge.

(B) If medical assistance has been canceled, but the client later appeals to the Social Security Administration, the case shall be reinstated through the level of a determination by an Administrative Law Judge.

(C) If an Administrative Law Judge finds the individual "not disabled", the Client Assessment Unit or its successor office shall accept that finding as final. The individual does not have the right to appeal the determination of disability to the Client Assessment Unit or its successor office at any time during this process.

(d) As part of making disability determinations, the Client Assessment Unit or its successor office shall do the following:

(1) Identify and assist persons who are receiving mental health treatment and services from Office of Mental Health facilities, county health departments, and community mental health agencies pursuant to a Serious Mental Illness (SMI) finding in applying for medical assistance under Article V.

(2) Provide uniform policies and forms for submission of mental health records from Office of Mental Health facilities, county health departments, and community mental health agencies that include completion of a mental health treatment packet that contains the following documents to be used by the Client Assessment Unit or its successor office in determining disability status:

(A) the SMI determination;

(B) the medical evidence underlying the SMI determination;

(C) the treatment plan; and

(D) a residual functional capacity form completed by the treating mental health professional.

(3) Train staff of the Client Assessment Unit or its successor office on the programs provided by the Office of Mental Health, county departments of health, and community mental health agencies and the process and significance of findings of SMI in these settings; and require that a finding of SMI status, with the corresponding receipt of mental health treatment and services, constitutes a presumption of disability that may be overridden only in those cases in which actual medical evidence exists that satisfactorily overrides the SMI designation.

(4) Monitor, on an ongoing basis, the resolution of disability determinations for medical assistance applicants receiving treatment and services from the Office of Mental Health, county departments of health, and community mental health agencies.

(e) As part of making disability determinations, the Client Assessment Unit or its successor office shall do the following:

(1) Identify and assist persons who have had a Determination of Need (DON) assessment with a score of 30 or higher done by staff from the Department on Aging, the Department of Human Services, or the Department of Public Aid in applying for medical assistance under Article V.

(2) Provide uniform policies and forms for submission of health records by staff involved in doing the DON assessment that include completion of a treatment packet that contains the following documents to be used by the Client Assessment Unit or its successor office in determining disability status:

(A) the DON determination;

(B) the medical evidence underlying the DON determination;

(C) the treatment plan, if any; and

(D) a residual functional capacity form completed by the staff who completed the DON assessment.

(3) Train staff of the Client Assessment Unit or its successor office on the DON assessment and programs provided by State agencies for persons with DON assessment scores of 30 or higher; and require that a DON score of 30 or higher, with the corresponding receipt of services from a State agency, constitutes a presumption of disability that may be overridden only in those cases in which actual medical evidence exists that satisfactorily overrides the DON assessment.

(4) Monitor, on an ongoing basis, the resolution of disability determinations for medical assistance applicants who have DON assessment scores of 30 or higher.

(f) Redetermination of disability is a condition of continuing eligibility for individuals who are not applying for or receiving SSI or OASDI benefits.

(g) When appropriate, the Client Assessment Unit or its successor office shall obtain and arrange for payment of a medical examination to determine disability. For all purposes, the Illinois Department may accept determinations as to disability performed under the auspices of the Federal Social Security Administration and properly certified to the Department.

(Source: P.A. 89-21, eff. 7-1-95.)

(305 ILCS 5/5-2.4 new)

Sec. 5-2.4. Non-citizen; emergency medical condition.

(a) For purposes of this Section, "emergency medical condition" means a medical condition (including labor and delivery and including treatment of end stage renal disease, other than organ transplants and related services) of sufficient severity (including severe pain) such that the absence of immediate medical attention could result in:

(1) placing the non-citizen's health in serious jeopardy;

(2) serious impairments to bodily functions; or

(3) serious dysfunction of any organ or part (42 U.S.C. 1396(b)(v)).

(b) A non-citizen who is not otherwise eligible for medical assistance because he or she is not within a group eligible for medical assistance, as defined by the Department of Public Aid, is eligible for coverage of medical care and services if (i) the medical care and services are necessary for the treatment of an emergency medical condition of the non-citizen and (ii) the non-citizen otherwise meets the income, asset, and categorical requirements of the AABD MAG program or Family Care program.

(c) For purposes of determining whether a non-citizen has an emergency medical condition, the Client Assessment Unit or its successor office must do the following:

(1) Consider all relevant evidence that is submitted in support of the application for assistance.

This evidence may contain medical opinions. For purposes of this item (1), "medical opinions" means statements from physicians and psychologists or other medical sources that reflect judgments about the nature and severity of the applicant's medical condition, including symptoms, diagnosis, and medical care and treatment provided or to be provided. In deciding whether an applicant has an emergency medical condition, the Client Assessment Unit or its successor office must always consider the medical opinions that have been submitted that underlie the medical care and treatment that was provided or is to be provided.

After the Client Assessment Unit or its successor office reviews all of the evidence relevant to the application, including medical opinions, the Client Assessment Unit or its successor office shall make findings about what the evidence shows.

If all of the evidence received by the Client Assessment Unit or its successor office, including all medical opinions stating that emergency medical care and treatment is required, is consistent, and if there is sufficient evidence for the Client Assessment Unit or its successor office to determine whether the applicant has an emergency medical condition, the Client Assessment Unit or its successor office shall make its determination based on that evidence and shall find that the applicant has an emergency medical condition.

If any of the evidence submitted, including any medical opinions, is inconsistent with other evidence submitted, or if any such evidence is internally inconsistent, the Client Assessment Unit or its successor office shall weigh all of the evidence and determine whether it is able to determine whether the applicant has an emergency medical condition based on the evidence that the Client Assessment Unit or its successor office has.

If the evidence is consistent but the Client Assessment Unit or its successor office does not have sufficient evidence to determine whether the applicant has an emergency medical condition, or if after weighing the evidence the Client Assessment Unit or its successor office is unable to reach a conclusion as to whether the applicant has an emergency medical condition, the Client Assessment Unit or its successor office shall try to obtain additional evidence by recontacting the medical staff who treated the applicant for the emergency medical condition and consider any additional evidence that is received, together with the evidence already received.

If there are inconsistencies in the evidence that cannot be resolved or if, despite efforts to obtain additional evidence, the evidence is not complete, the Client Assessment Unit or its successor office shall make a determination or decision based on the evidence it has.

(2) Evaluate every medical opinion it receives.

Unless the Client Assessment Unit or its successor office gives a treating source's opinion controlling weight under item (1) of this subsection, the Client Assessment Unit or its successor office shall consider all of the following factors in deciding the weight that it gives to any medical opinion:

(A) Examining relationship. The Client Assessment Unit or its successor office shall give more weight to the opinion of a source who has examined and treated the applicant than to the opinion of a source who has not examined or treated the applicant.

(B) Treatment relationship. The Client Assessment Unit or its successor office shall give more weight to opinions from treating sources, because these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of the applicant's medical impairment or impairments and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations. If a treating source's opinion on the issue of whether an emergency medical condition exists is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence submitted, the Client Assessment Unit or its successor office shall give it controlling weight. If the Client Assessment Unit or its successor office does not give the treating source's opinion controlling weight, the Client Assessment Unit or its successor office must explain in its notice of determination the weight that it gave the treating source's opinion.

(C) Supportability. The more a medical source presents relevant evidence to support an opinion, particularly medical signs and laboratory findings, the more weight the Client Assessment Unit or its successor office shall give that opinion. Because nonexamining sources have no examining or treating relationship with the applicant, the weight to be given their opinions shall depend on the degree to which they provide supporting explanations for their opinions. The Client Assessment Unit or its successor office shall evaluate the degree to which these opinions consider all of the pertinent evidence in the claim, including opinions of treating and other examining sources.

(D) Consistency. The more consistent an opinion is with the record as a whole, the more weight the Client Assessment Unit or its successor office shall give to that opinion.

(E) Specialization. The Client Assessment Unit or its successor office shall give more weight to the opinion of a specialist about medical issues related to his or her area of specialty than to the opinion of a source who is not a specialist.

(d) For purposes of determining whether a non-citizen has an emergency medical condition, the Client Assessment Unit or its successor office may not require a showing that the medical condition either (i) occurs suddenly and unexpectedly or (ii) is caused by injury or illness.

Section 99. Effective date. This Act takes effect upon becoming law.