(215 ILCS 106/7)
Notwithstanding any other provision of this Act, with respect to applications for benefits provided under the Program, eligibility shall be determined in a manner that ensures program integrity and that complies with federal law and regulations while minimizing unnecessary barriers to enrollment. To this end, as soon as practicable, and unless the Department receives written denial from the federal government, this Section shall be implemented:
(a) The Department of Healthcare and Family Services or its designees shall:
(1) By no later than July 1, 2011, require
verification of, at a minimum, one month's income from all sources required for determining the eligibility of applicants to the Program. Such verification shall take the form of pay stubs, business or income and expense records for self-employed persons, letters from employers, and any other valid documentation of income including data obtained electronically by the Department or its designees from other sources as described in subsection (b) of this Section.
(2) By no later than October 1, 2011, require
verification of, at a minimum, one month's income from all sources required for determining the continued eligibility of recipients at their annual review of eligibility under the Program. Such verification shall take the form of pay stubs, business or income and expense records for self-employed persons, letters from employers, and any other valid documentation of income including data obtained electronically by the Department or its designees from other sources as described in subsection (b) of this Section. A month's income may be verified by a single pay stub with the monthly income extrapolated from the time period covered by the pay stub. The Department shall send a notice to the recipient at least 60 days prior to the end of the period of eligibility that informs them of the requirements for continued eligibility. Information the Department receives prior to the annual review, including information available to the Department as a result of the recipient's application for other non-health care benefits, that is sufficient to make a determination of continued eligibility for medical assistance or for benefits provided under the Program may be reviewed and verified, and subsequent action taken including client notification of continued eligibility for medical assistance or for benefits provided under the Program. The date of client notification establishes the date for subsequent annual eligibility reviews. If a recipient does not fulfill the requirements for continued eligibility by the deadline established in the notice, a notice of cancellation shall be issued to the recipient and coverage shall end no later than the last day of the month following the last day of the eligibility period. A recipient's eligibility may be reinstated without requiring a new application if the recipient fulfills the requirements for continued eligibility prior to the end of the third month following the last date of coverage (or longer period if required by federal regulations). Nothing in this Section shall prevent an individual whose coverage has been cancelled from reapplying for health benefits at any time.
(3) By no later than July 1, 2011, require
verification of Illinois residency.
(b) The Department shall establish or continue cooperative
arrangements with the Social Security Administration, the
Illinois Secretary of State, the Department of Human Services,
the Department of Revenue, the Department of Employment Security, and any other appropriate entity to gain electronic
access, to the extent allowed by law, to information available to those entities that may be appropriate for electronically
verifying any factor of eligibility for benefits under the
Program. Data relevant to eligibility shall be provided for no
other purpose than to verify the eligibility of new applicants or current recipients of health benefits under the Program. Data will be requested or provided for any new applicant or current recipient only insofar as that individual's circumstances are relevant to that individual's or another individual's eligibility.
(c) Within 90 days of the effective date of this amendatory Act of the 96th General Assembly, the Department of Healthcare and Family Services shall send notice to current recipients informing them of the changes regarding their eligibility verification.
(Source: P.A. 101-209, eff. 8-5-19.)
(215 ILCS 106/20)
(a) To be eligible for this Program, a person must be a person who
has a child eligible under this Act and who is eligible under a waiver
of federal requirements pursuant to an application made pursuant to
subdivision (a)(1) of Section 40 of this Act or who is a child who:
(1) is a child who is not eligible for medical
(2) is a child whose annual household income, as
determined by the Department, is above 133% of the federal poverty level and at or below 200% of the federal poverty level;
(3) is a resident of the State of Illinois; and
(4) is a child who is either a United States citizen
or included in one of the following categories of non-citizens:
(A) unmarried dependent children of either a
United States Veteran honorably discharged or a person on active military duty;
(B) refugees under Section 207 of the Immigration
(C) asylees under Section 208 of the Immigration
(D) persons for whom deportation has been
withheld under Section 243(h) of the Immigration and Nationality Act;
(E) persons granted conditional entry under
Section 203(a)(7) of the Immigration and Nationality Act as in effect prior to April 1, 1980;
(F) persons lawfully admitted for permanent
residence under the Immigration and Nationality Act; and
(G) parolees, for at least one year, under
Section 212(d)(5) of the Immigration and Nationality Act.
Those children who are in the categories set forth in subdivisions
(4)(F) and (4)(G) of this subsection, who enter the United States on or
after August 22, 1996, shall not be eligible for 5 years beginning on the
date the child entered the United States.
(b) A child who is determined to be eligible for assistance may remain
eligible for 12 months, provided the child maintains his or
her residence in the State, has not yet attained 19 years of age, and is not
excluded pursuant to subsection (c). A child who has been determined to
be eligible for assistance must reapply or otherwise establish eligibility
at least annually.
An eligible child shall be required, as determined by the
Department by rule, to report promptly those changes in income and other
circumstances that affect eligibility. The eligibility of a child may be
redetermined based on the information reported or may be terminated based on
the failure to report or failure to report accurately. A child's responsible
relative or caretaker may also be held liable to the Department for any
payments made by the Department on such child's behalf that were inappropriate.
An applicant shall be provided with notice of these obligations.
(c) A child shall not be eligible for coverage under this Program if:
(1) the premium required pursuant to Section 30 of
this Act has not been paid. If the required premiums are not paid the liability of the Program shall be limited to benefits incurred under the Program for the time period for which premiums had been paid. Re-enrollment shall be completed prior to the next covered medical visit and the first month's required premium shall be paid in advance of the next covered medical visit. The Department shall promulgate rules regarding grace periods, notice requirements, and hearing procedures pursuant to this subsection;
(2) the child is an inmate of a public institution or
a patient in an institution for mental diseases; or
(3) the child is a member of a family that is
eligible for health benefits covered under the State of Illinois health benefits plan on the basis of a member's employment with a public agency.
(Source: P.A. 96-1272, eff. 1-1-11.)
(215 ILCS 106/23)
(a) At least 50% of recipients eligible for comprehensive medical benefits in all medical assistance programs or other health benefit programs administered by the Department, including the Children's Health Insurance Program Act and the Covering ALL KIDS Health Insurance Act, shall be enrolled in a care coordination program by no later than January 1, 2015. For purposes of this Section, "coordinated care" or "care coordination" means delivery systems where recipients will receive their care from providers who participate under contract in integrated delivery systems that are responsible for providing or arranging the majority of care, including primary care physician services, referrals from primary care physicians, diagnostic and treatment services, behavioral health services, in-patient and outpatient hospital services, dental services, and rehabilitation and long-term care services. The Department shall designate or contract for such integrated delivery systems (i) to ensure enrollees have a choice of systems and of primary care providers within such systems; (ii) to ensure that enrollees receive quality care in a culturally and linguistically appropriate manner; and (iii) to ensure that coordinated care programs meet the diverse needs of enrollees with developmental, mental health, physical, and age-related disabilities.
(b) Payment for such coordinated care shall be based on arrangements where the State pays for performance related to health care outcomes, the use of evidence-based practices, the use of primary care delivered through comprehensive medical homes, the use of electronic medical records, and the appropriate exchange of health information electronically made either on a capitated basis in which a fixed monthly premium per recipient is paid and full financial risk is assumed for the delivery of services, or through other risk-based payment arrangements.
(c) To qualify for compliance with this Section, the 50% goal shall be achieved by enrolling medical assistance enrollees from each medical assistance enrollment category, including parents, children, seniors, and people with disabilities to the extent that current State Medicaid payment laws would not limit federal matching funds for recipients in care coordination programs. In addition, services must be more comprehensively defined and more risk shall be assumed than in the Department's primary care case management program as of the effective date of this amendatory Act of the 96th General Assembly.
(d) The Department shall report to the General Assembly in a separate part of its annual medical assistance program report, beginning April, 2012 until April, 2016, on the progress and implementation of the care coordination program initiatives established by the provisions of this amendatory Act of the 96th General Assembly. The Department shall include in its April 2011 report a full analysis of federal laws or regulations regarding upper payment limitations to providers and the necessary revisions or adjustments in rate methodologies and payments to providers under this Code that would be necessary to implement coordinated care with full financial risk by a party other than the Department.
(Source: P.A. 96-1501, eff. 1-25-11.)
(215 ILCS 106/25)
Health benefits for children.
(a) The Department shall, subject to appropriation, provide health
benefits coverage to eligible children by:
(1) Until December 31, 2013 and providing that no
application for such coverage shall be accepted after September 30, 2013, subsidizing the cost of privately sponsored health insurance, including employer based health insurance, to assist families to take advantage of available privately sponsored health insurance for their eligible children; and
(2) Purchasing, until December 31, 2013, or
providing health care benefits for eligible children. The health benefits provided under this subdivision (a)(2) shall, subject to appropriation and without regard to any applicable cost sharing under Section 30, be identical to the benefits provided for children under the State's approved plan under Title XIX of the Social Security Act. Providers under this subdivision (a)(2) shall be subject to approval by the Department to provide health care under the Illinois Public Aid Code and shall be reimbursed at the same rate as providers under the State's approved plan under Title XIX of the Social Security Act. In addition, providers may retain co-payments when determined appropriate by the Department.
(b) The subsidization provided pursuant to subdivision (a)(1) shall be
credited to the family of the eligible child.
(c) The Department is prohibited from denying coverage to a child who is
enrolled in a privately sponsored health insurance plan pursuant to subdivision
(a)(1) because the plan does not meet federal benchmarking standards
or cost sharing and contribution requirements.
To be eligible for inclusion in the Program, the plan shall contain
comprehensive major medical coverage which shall consist of physician and
hospital inpatient services.
The Department is prohibited from denying coverage to a child who is enrolled
in a privately sponsored health insurance plan pursuant to subdivision (a)(1)
because the plan offers benefits in addition to physician and hospital
(d) The total dollar amount of subsidizing coverage per child per month
pursuant to subdivision (a)(1) shall be equal to the average dollar payments,
less premiums incurred, per child per month pursuant to subdivision (a)(2).
The Department shall set this amount prospectively based upon the prior fiscal
year's experience adjusted for incurred but not reported claims and estimated
increases or decreases in the cost of medical care. Payments obligated before
July 1, 1999, will be computed using State Fiscal Year 1996 payments for
children eligible for Medical Assistance and income assistance under the Aid to
Families with Dependent Children Program, with appropriate adjustments for cost
and utilization changes through January 1, 1999. The Department is
prohibited from providing a subsidy pursuant to subdivision (a)(1) that is more
than the individual's monthly portion of the premium.
(e) An eligible child may obtain immediate coverage under this Program
only once during a medical visit. If coverage lapses, re-enrollment shall be
completed in advance of the next covered medical visit and the first month's
required premium shall be paid in advance of any covered medical visit.
(f) In order to accelerate and facilitate the development of networks to
deliver services to children in areas outside counties with populations
excess of 3,000,000, in the event less than 25% of the eligible
children in a county or contiguous counties has enrolled with a Health
Maintenance Organization pursuant to Section 5-11 of the Illinois Public Aid
Code, the Department may develop and implement demonstration projects to create
alternative networks designed to enhance enrollment and participation in the
program. The Department shall prescribe by rule the criteria, standards, and
procedures for effecting demonstration projects under this Section.
(g) On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Act or the Illinois Public Aid Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e of the Illinois Public Aid Code.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
(215 ILCS 106/30)
(a) Children enrolled in a health benefits program pursuant to subdivision
(a)(2) of Section 25 and persons enrolled in a health benefits waiver program pursuant to Section 40 shall be subject to the following cost sharing
(1) There shall be no co-payment required for
well-baby or well-child care, including age-appropriate immunizations as required under federal law.
(2) Health insurance premiums for family members,
either children or adults, in families whose household income is above 150% of the federal poverty level shall be payable monthly, subject to rules promulgated by the Department for grace periods and advance payments, and shall be as follows:
(A) $15 per month for one family member.
(B) $25 per month for 2 family members.
(C) $30 per month for 3 family members.
(D) $35 per month for 4 family members.
(E) $40 per month for 5 or more family members.
(3) Co-payments for children or adults in families
whose income is at or below 150% of the federal poverty level, at a minimum and to the extent permitted under federal law, shall be $2 for all medical visits and prescriptions provided under this Act and up to $10 for emergency room use for a non-emergency situation as defined by the Department by rule and subject to federal approval.
(4) Co-payments for children or adults in families
whose income is above 150% of the federal poverty level, at a minimum and to the extent permitted under federal law shall be as follows:
(A) $5 for medical visits.
(B) $3 for generic prescriptions and $5 for brand
(C) $25 for emergency room use for a
non-emergency situation as defined by the Department by rule.
(6) Co-payments shall be maximized to the extent
permitted by federal law and are subject to federal approval.
(Source: P.A. 97-74, eff. 6-30-11; 98-104, eff. 7-22-13.)
(215 ILCS 106/45)
(a) The Department shall conduct a study which includes, but is not
limited to, the following:
(1) Establishes estimates, broken down by regions of
the State, of the number of children with health insurance coverage and without health insurance coverage; the number of children who are eligible for Medicaid, and of that number, the number who are enrolled in Medicaid; the number of children with access to dependent coverage through an employer, and of that number, the number who are enrolled in dependent coverage through an employer.
(2) Ascertains, for the population of children
potentially eligible for coverage under any component of the Program, the extent of access to dependent coverage, how many children are enrolled in dependent coverage, the comprehensiveness of dependent coverage benefit packages available, and the amount of cost sharing currently paid by the employees.
(b) The Department shall submit the preliminary results of the study to
the Governor and the General Assembly by December 1, 1998 and shall submit
the final results to the Governor and the General Assembly by May 1, 1999.
(Source: P.A. 90-736, eff. 8-12-98