Section 240.920  Reasons for Denial

Denial of Community Care Program (CCP) eligibility shall be based upon one or more of the reasons identified below:

a)         Applicant is less than 60 years of age at the time of the determination of eligibility.

b)         Applicant is not in need of CCP services:  scored less than 29 total points/less than 15 points on Part A, Level of Impairment, of the Determination of Need.

c)         Applicant/authorized representative refuses to sign Client Agreement – Plan of Care.

d)         Applicant/authorized representative refuses to sign Client Agreement – Plan of Care based upon the expense to be incurred monthly as required on the Client Agreement – Plan of Care.

e)         Applicant/authorized representative does not agree with plan of care/hours of service.

f)          Applicant is deceased.

g)         Applicant has been institutionalized for more than 60 calendar days from the date of application.

h)         Applicant/authorized representative voluntarily withdraws application.

i)          Applicant cannot be located to determine eligibility/provide CCP services.

j)          Applicant/authorized representative has not provided reasonable documentation supporting eligibility as required by the Department or its Case Coordination Unit (CCU) within 90 calendar days from the date of receipt of the completed application.

k)         Applicant/authorized representative has not cooperated with the Department/CCU/vendor as required and as specified by Section 240.350.

l)          Applicant does not meet citizenship requirements.

m)        Applicant does not meet residency requirements.

n)         A plan of care cannot be developed that adequately meets the applicant's determined needs.

1)         The determination that an adequate plan of care cannot be developed shall be sought first through the Physician/Nurse Practitioner/Registered Nurse/Christian Science Practitioner endorsement. Failure to obtain the supportive endorsement that an adequate plan of care cannot be developed shall be so documented.

2)         If the Physician/Nurse Practitioner/Registered Nurse/Christian Science Practitioner fails to provide the supportive endorsement, the CCU shall make the determination that an adequate plan of care cannot be developed in accordance with Section 240.715.

o)         The total value of applicant's non-exempt assets is in excess of $17,500.

p)         Applicant has not provided the Physician, Nurse Practitioner, Registered Nurse or Christian Science Practitioner endorsement as required by Section 240.730(d).

q)         Eligibility could not be established for an applicant who was receiving interim services based upon presumptive eligibility as required by Section 240.1020.

r)          Applicant/authorized representative provided fraudulent information.

s)         Applicant whose CCP services were previously denied or terminated for non-cooperation as set forth in Section 240.350 shall be denied services upon re-application, except as the situation or condition which led to the memorandum of understanding (see Section 240.350) has been permanently resolved.

t)          Applicant has an outstanding bill for CCP services provided prior to this application which he/she refuses to pay.

u)         Applicant chooses not to receive CCP services from the list of authorized vendors and has so indicated on the Client's Vendor Selection form.

v)         Applicant received interim services in the past for which an incurred expense was never paid.

w)        Applicant has transferred non-exempt assets within the past 36 months for the purpose of obtaining CCP services.

x)         Applicant/authorized representative has not reported or refused to provide documentation of changes in circumstances which have occurred prior to eligibility determination as required by Section 240.360.

y)         Effective July 1, 2002, applicant refuses to apply for medical assistance (Medicaid) under Article V of the Illinois Public Aid Code [305 ILCS 5/Art. V].

(Source:  Amended at 30 Ill. Reg. 17756, effective October 26, 2006)