101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB2021

 

Introduced 2/15/2019, by Sen. Heather A. Steans

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Creates the Medicaid Eligibility Determination and Renewal Reform Act. Requires the Department of Healthcare and Family Services (Department) to work with the Department of Human Services to achieve the following goals related to eligibility determinations and renewals under the Medical Assistance Program: (i) reduce procedural terminations so that no more than 10% of medical assistance beneficiaries who remain eligible for medical assistance experience any lapse in contemporaneous medical coverage; and (ii) use technology to lower administrative burdens and increase beneficiary continuity of coverage by providing real-time eligibility determination decisions for at least 75% of all medical assistance applicants, increasing automatic renewals for medical assistance beneficiaries, and offering an electronic means by which medical assistance beneficiaries can track and maintain their benefits. Provides that the goals must be meet by December 31, 2020. Requires the Department to submit Medicaid and CHIP State Plan amendments to implement express lane eligibility for all beneficiaries of medical assistance and benefits under the Children's Health Insurance Program Act. Contains provisions concerning community-based enrollment and redetermination assistance; the creation of enhanced user permission; and other matters. Amends the Illinois Public Aid Code. Requires the Department to reduce administrative burdens and minimize delay utilizing its income, residency, and identity verification system; and to utilize federal or State electronic data sources to obtain certain financial, employment, and residency information. Contains provisions concerning data matching; the waiver of residency verification requirements; rulemaking authority; and other matters. Effective immediately.


LRB101 10004 KTG 55106 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB2021LRB101 10004 KTG 55106 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be referred to as the
5Medicaid Eligibility Determination and Renewal Reform Act.
 
6    Section 5. Purpose. The processes currently in place for
7eligibility determination and renewal (also known as
8redetermination) under the State's medical assistance programs
9lead to delayed access to benefits, disruptions in care
10delivery, decreased quality of care, waste in spending on
11unnecessary administrative costs, and worse overall health and
12well-being for enrollees. To improve continuity of care for
13beneficiaries and remedy significant administrative
14challenges, to the benefit of both the State and beneficiaries,
15this Act implements improvements and efficiencies to increase
16accountability and transparency, minimize delay and procedural
17terminations, and improve the overall integrity of the State's
18medical assistance programs.
 
19    Section 10. Medicaid eligibility determination and renewal
20goals.
21    (a) The Department of Healthcare and Family Services shall
22work with the Department of Human Services, as well as other

 

 

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1stakeholders, to achieve the following goals related to
2eligibility determinations and renewals under the Medical
3Assistance Program established under Article V of the Illinois
4Public Aid Code:
5        (1) Reduce procedural terminations under the Medical
6    Assistance Program so that no more than 10% of medical
7    assistance beneficiaries who remain eligible for medical
8    assistance experience any lapse in contemporaneous medical
9    coverage.
10        (2) Use technology to lower administrative burdens and
11    increase beneficiary continuity of coverage by providing
12    real-time eligibility determination decisions under the
13    Medical Assistance Program for at least 75% of all medical
14    assistance applicants, increasing automatic renewals for
15    medical assistance beneficiaries, and offering an
16    electronic means by which a broad array of medical
17    assistance beneficiaries can track and maintain their
18    benefits.
19    (b) The Department of Healthcare and Family Services and
20the Department of Human Services shall work together with
21stakeholders, including, but not limited to, beneficiaries of
22medical assistance, consumer advocates, governmental staff,
23provider, and managed care organizations, to achieve the goals
24described in subsection (a) by December 31, 2020. The
25Department of Healthcare and Family Services shall provide a
26report to the General Assembly on the Department's progress

 

 

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1toward achieving those goals by December 31, 2019. The report
2shall be posted on the Department of Healthcare and Family
3Services' website and shall describe the policy changes the
4Department has made, any challenges the Department has faced,
5the Department's plan to achieve the goals by the deadline, and
6the current rate of procedural termination, data-driven
7renewals, and electronic portal use.
 
8    Section 15. Express lane eligibility State Plan amendment;
9implementation timeline.
10    (a) As used in this Section:
11        "CHIP" means the Children's Health Insurance Program
12    established under the Children's Health Insurance Program
13    Act.
14        "Medicaid" means medical assistance authorized under
15    Section 1902 of the Social Security Act.    
16    (b) Federal approval for express lane eligibility. The
17Department of Healthcare and Family Services shall submit
18Medicaid and CHIP State Plan amendments to the federal Centers
19for Medicare and Medicaid Services to implement express lane
20eligibility for all Medicaid and CHIP beneficiaries as
21permitted by Section 203 of the Children's Health Insurance
22Program Reauthorization Act of 2009 (Public Law 111-3), no
23later than 90 days after the effective date of this Act. The
24Department of Healthcare and Family Services shall cooperate
25with the federal Centers for Medicare and Medicaid Services to

 

 

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1obtain approval, if necessary, to implement an express lane
2eligibility option to ensure that children eligible for
3Medicaid or CHIP have a fast and simplified process for having
4their eligibility determined or renewed to facilitate
5enrollment in Medicaid and CHIP.
6    (c) Content of State Plan amendment. At a minimum, the
7State Plan amendment shall specify that express lane
8eligibility shall apply to all Medicaid and CHIP beneficiaries.
9If federal approval is granted, the Department of Healthcare
10and Family Services shall seek an 1115 waiver to apply the
11express lane eligibility option to beneficiaries age 21 or
12older no later than 90 days after approval. The State Plan
13amendment shall identify, at a minimum, the Supplemental
14Nutrition Assistance Program as its express lane agency. The
15State Plan amendment shall also specify that the express lane
16eligibility option will be used for both applications and
17renewals. The Department of Healthcare and Family Services may
18select more than one express lane agency, consistent with the
19Centers for Medicare and Medicaid Services' rules governing
20express lane eligibility. The Department of Healthcare and
21Family Services may also elect to obtain and use information
22directly from State income tax records or returns, consistent
23with the Centers for Medicare and Medicaid Services' rules
24governing express lane eligibility.
25    (d) Implementation. After the Department of Healthcare and
26Family Services secures federal approval (if required) from the

 

 

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1Centers for Medicare and Medicaid Services, the Department
2shall implement express lane eligibility within 90 days after
3the date of federal approval.
 
4    Section 20. Reinstatement upon renewal.
5    (a) If an individual who failed to cooperate during the
6renewal process cooperates and submits all required
7verifications prior to the end of the third month (or 90 days
8if longer) following the last day of coverage, and the case
9remains eligible, the Department of Healthcare and Family
10Services shall restore assistance immediately, with no loss of
11coverage and back to the date of cancellation, without
12requiring a new application from the individual. In restoring
13assistance, the Department shall act to ensure that an eligible
14individual has the shortest time possible, if any, when his or
15her case shows as inactive to providers. Retroactive coverage
16alone does not satisfy the objective of this Section if
17eligible individuals still experience real-time periods of an
18inactive case.
19    (b) Individuals who are reinstated and who are enrolled in
20a managed care organization prior to initial cancellation of
21coverage shall be reinstated to the same managed care
22organization, regardless of when the individual's coverage is
23reinstated, and the annual HealthChoice Illinois open
24enrollment period for the individual shall remain the same.
25Managed care organizations shall be paid the appropriate per

 

 

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1member per month payment retroactively for reinstated members.
2    (c) Providers serving individuals in the State's
3fee-for-service system may submit prior approval requests to
4the Department of Healthcare and Family Services for review and
5retroactive processing for medical assistance provided during
6the reinstatement period. Providers serving individuals
7enrolled in managed care may have their prior approval requests
8submitted and processed retroactively for medical assistance
9provided during the reinstatement period, provided that
10appropriate member attribution and associated payment are also
11made to the managed care organization for the reinstated
12coverage period.
 
13    Section 25. Community-based enrollment and redetermination
14assistance.
15    (a) The Department of Healthcare and Family Services shall
16create and support agency-associated permission and enhanced
17user permission within the Department's integrated eligibility
18system to provide authorized access to client cases to better
19enable providers and community-based organizations to support
20applicants and clients enrolling in, renewing, or otherwise
21maintaining their benefits.
22    (b) Creation of agency-associated permission.
23        (1) The Department of Healthcare and Family Services
24    shall authorize, create, support, and administer a process
25    by which a provider or community-based organization can

 

 

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1    access each client case that is associated with that
2    provider or community-based organization in the
3    Department's integrated eligibility system for each
4    client, provider, and community-based organization that
5    seeks such access, and cooperates with the Department's
6    screening, training, and security protocols. Such access
7    shall enable the provider or community-based organization
8    to assist its clients with their benefits cases.
9        (2) A client must authorize the Department of
10    Healthcare and Family Services to associate his or her case
11    with one or more particular providers or community-based
12    organizations before the provider or organization may
13    access the client's case. Such authorization must be given
14    in writing and may be revoked in writing by the client,
15    provider, or community-based organization at any time. The
16    permission to access the case shall be granted to the
17    provider or community-based organization as a whole and not
18    specific to any particular employee or staff member. The
19    Department of Healthcare and Family Services shall process
20    all requests to associate a case or revoke an association
21    with particular providers or community-based organizations
22    promptly.
23        (3) For each provider and community-based organization
24    that seeks such access, the Department of Healthcare and
25    Family Services shall authorize and create
26    agency-associated permission within the Department's

 

 

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1    integrated eligibility system to view the specific case for
2    each client associated with the provider or
3    community-based organization. This agency-associated
4    permission shall permit staff authorized by the provider or
5    community-based organization to access and interact with
6    all client cases associated with the provider or
7    community-based organization in ways that are otherwise
8    accessible to the client. The provider or community-based
9    organization shall identify and supervise authorized
10    staff. Such agency-associated permission shall enable the
11    provider or community-based organization to access all
12    client-facing aspects of the case for each client
13    associated with the provider or community-based
14    organization who has authorized such access.
15        (4) The Department of Healthcare and Family Services
16    shall ensure that the provider or community-based
17    organization has been granted permission within the
18    Department's integrated eligibility system (or other
19    electronic systems) to receive and view notifications and
20    alerts for all associated client cases, and to perform
21    certain actions in associated client cases. Permitted
22    actions shall include, but are not limited to: (i) viewing
23    notifications, (ii) uploading documentation such as
24    spend-down verifications and renewal forms, and (iii)
25    initiating contact with and continuing communication with
26    Department staff.

 

 

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1    (c) Administration of agency-associated permission.
2        (1) The Department of Healthcare and Family Services
3    shall develop criteria and policies for granting
4    permission to providers and community-based organizations
5    that seek agency-associated permission.
6        (2) The Department of Healthcare and Family Services
7    shall create criteria and policies to ensure that
8    agency-associated permission is granted only for accounts
9    where the authorized user has agreed to (i) obtain the
10    written consent of the individual, (ii) act in the best
11    interest of the individual, (iii) maintain the integrity of
12    the Department's programs, and (iv) act in compliance with
13    applicable State and federal law.
14        (3) Agency-associated permission shall be authorized
15    by the Department of Healthcare and Family Services in
16    accordance with the criteria and policies to be developed
17    by the Department under this Act.
18        (4) The Department of Healthcare and Family Services
19    shall not unreasonably restrict or limit agency-associated
20    permission.
21    (d) Creation of enhanced user permission.
22        (1) The Department of Healthcare and Family Services
23    shall authorize, create, support, and administer an
24    enhanced user permission under which particular
25    individuals have authority to manually verify information
26    and work around error messages in the Department's

 

 

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1    integrated eligibility system. Individuals who are
2    associated with navigators, providers, or community-based
3    organizations may apply for such access, and the Department
4    shall grant enhanced user permission in compliance with
5    this Section to those who cooperate with the Department's
6    screening, training, and security protocols.
7        (2) Enhanced user permissions shall permit individuals
8    to work in the integrated eligibility system with enhanced
9    permissions beyond the consumer-facing portal. Such
10    enhanced permissions shall include, but not be limited to,
11    addressing common challenges, including (i) resolving
12    common error codes, (ii) manually verifying data in the
13    integrated eligibility system, and (iii) performing
14    identity verification for the purposes of eligibility
15    determination in accordance with requirements set forth by
16    State and federal law. Nothing in this Act shall be
17    interpreted as changing program eligibility or renewal
18    criteria.
19    (e) Administration of enhanced user permission.
20        (1) Providers and community-based organizations shall
21    nominate and supervise individual staff that serve as
22    assisters, navigators, or who are otherwise proficient
23    with Manage My Case to be granted enhanced user permissions
24    by the Department of Healthcare and Family Services.
25        (2) The Department of Healthcare and Family Services
26    shall develop criteria and policies for granting enhanced

 

 

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1    user permission.
2        (3) The Department of Healthcare and Family Services
3    shall provide support and training to individuals granted
4    enhanced user permission.
5        (4) The Department of Healthcare and Family Services
6    shall maintain and publish online a list of providers and
7    community-based organizations that employ staff who have
8    been granted enhanced user permission, to help individuals
9    and families looking for assistance enrolling in and
10    maintaining benefits.
11        (5) The Department of Healthcare and Family Services
12    shall create criteria and policies to ensure that
13    individuals with enhanced user permission agree to (i)
14    obtain the written consent of the individual, (ii) act in
15    the best interest of the individual, (iii) maintain the
16    integrity of the Department's programs, and (iv) act in
17    compliance with applicable State and federal law.
18        (6) Enhanced user permission shall be authorized by the
19    Department of Healthcare and Family Services in accordance
20    with the criteria and policies to be developed by the
21    Department under this Act.
22        (7) The Department of Healthcare and Family Services
23    shall not unreasonably restrict or limit enhanced user
24    permission.
 
25    Section 30. The Department shall adopt any rules or

 

 

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1policies necessary to implement this Act.
 
2    Section 35. The Illinois Public Aid Code is amended by
3changing Section 11-5.2 as follows:
 
4    (305 ILCS 5/11-5.2)
5    Sec. 11-5.2. Income, Residency, and Identity Verification
6System.
7    (a) The Department shall ensure that its proposed
8integrated eligibility system shall include the computerized
9functions of income, residency, and identity eligibility
10verification to verify eligibility, eliminate duplication of
11medical assistance, and deter fraud, reduce administrative
12burdens on the Department and the applicant or recipient, and
13minimize delay. Until the integrated eligibility system is
14operational, the Department may enter into a contract with the
15vendor selected pursuant to Section 11-5.3 as necessary to
16obtain the electronic data matching described in this Section.
17This contract shall be exempt from the Illinois Procurement
18Code pursuant to subsection (h) of Section 1-10 of that Code.
19    (b) Prior to awarding medical assistance at application
20under Article V of this Code, the Department shall, to the
21extent such databases are available to the Department, conduct
22data matches using the name, date of birth, address, and Social
23Security Number of each applicant or recipient or responsible
24relative of an applicant or recipient through one or more

 

 

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1federal or State electronic data sources including against the
2following:
3        (1) Income tax information.
4        (2) Employer reports of income and unemployment
5    insurance payment information maintained by the Department
6    of Employment Security.
7        (3) Earned and unearned income, citizenship and death,
8    and other relevant information maintained by the Social
9    Security Administration.
10        (4) Immigration status information maintained by the
11    United States Citizenship and Immigration Services.
12        (5) Wage reporting and similar information maintained
13    by states contiguous to this State.
14        (6) Employment information maintained by the
15    Department of Employment Security in its New Hire Directory
16    database.
17        (7) Employment information maintained by the United
18    States Department of Health and Human Services in its
19    National Directory of New Hires database.
20        (8) Veterans' benefits information maintained by the
21    United States Department of Health and Human Services, in
22    coordination with the Department of Health and Human
23    Services and the Department of Veterans' Affairs, in the
24    federal Public Assistance Reporting Information System
25    (PARIS) database.
26        (9) Residency information maintained by the Illinois

 

 

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1    Secretary of State.
2        (10) A database which is substantially similar to or a
3    successor of a database described in this Section that
4    contains information relevant for verifying eligibility
5    for medical assistance.
6    (c) (Blank).
7    (c-5) Financial information shall be data matched by first
8using the electronic data source with the most recent data. The
9most recent data source shall be accepted as a reliable
10electronic data source for determining reasonable
11compatibility with the applicant's or recipient's attestation
12or records. The Department may use a less recent data source
13only if it will maximize accuracy, minimize delay, and meet
14other applicable requirements.
15    (d) If information provided by or on behalf of an
16individual (on the application or renewal form or otherwise) is
17reasonably compatible with the information obtained by the
18Department in accordance with subsection (b), the Department
19must determine or renew eligibility based on such information
20without making additional requests for verification,
21information, or documentation to the individual. "Reasonable
22compatibility" means an allowable difference or discrepancy
23between the income reported by an applicant or recipient and
24the income reported by an electronic data source. a discrepancy
25results between information provided by an applicant,
26recipient, or responsible relative and information contained

 

 

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1in one or more of the databases or information tools listed
2under subsection (b) of this Section or subsection (c) of
3Section 11-5.3 and that discrepancy calls into question the
4accuracy of information relevant to a condition of eligibility
5provided by the applicant, recipient, or responsible relative,
6the Department or its contractor shall review the applicant's
7or recipient's case using the following procedures:
8        (1) Income information obtained through an electronic
9    data source shall be considered reasonably compatible with
10    income information provided by or on behalf of the
11    individual if both are either above or at or below the
12    applicable income threshold. If the information discovered
13    under subsection (b) of this Section or subsection (c) of
14    Section 11-5.3 does not result in the Department finding
15    the applicant or recipient ineligible for assistance under
16    Article V of this Code, the Department shall finalize the
17    determination or redetermination of eligibility.
18        (1.5) Income information is reasonably compatible if
19    the discrepancy between the information provided by or on
20    behalf of the individual is within 10% of the federal
21    poverty level (above or below) of the information from the
22    electronic data source. "Federal poverty level" means the
23    poverty guidelines updated periodically in the Federal
24    Register by the U.S. Department of Health and Human
25    Services. These guidelines set poverty levels by family
26    size.

 

 

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1        (1.6) The reasonable compatibility standard for
2    financial information shall also be met when the
3    information provided by or on behalf of the individual is
4    zero income or income that is below the program's
5    applicable income standard, or when no income data is
6    available from electronic data sources.
7        (1.7) If information provided by or on behalf of the
8    individual is not reasonably compatible with information
9    obtained through an electronic data match, the Department
10    shall provide written notice to the applicant or recipient
11    which shall describe in sufficient detail the
12    circumstances and sources of the discrepancy, the
13    information or documentation required, the manner in which
14    the applicant or recipient may respond, and the
15    consequences of failing to take action. The applicant or
16    recipient shall have 10 business days to respond.
17        (2) If the information from both the electronic data
18    source and the applicant or recipient discovered results in
19    the Department finding the applicant or recipient
20    ineligible for assistance, the Department shall provide
21    notice as set forth in Section 11-7 of this Article.
22        (3) (Blank). If the information discovered is
23    insufficient to determine that the applicant or recipient
24    is eligible or ineligible, the Department shall provide
25    written notice to the applicant or recipient which shall
26    describe in sufficient detail the circumstances of the

 

 

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1    discrepancy, the information or documentation required,
2    the manner in which the applicant or recipient may respond,
3    and the consequences of failing to take action. The
4    applicant or recipient shall have 10 business days to
5    respond.
6        (4) If the applicant or recipient does not respond to
7    the notice, the Department shall deny assistance for
8    failure to cooperate, in which case the Department shall
9    provide notice as set forth in Section 11-7. Eligibility
10    for assistance shall not be established until the
11    discrepancy has been resolved.
12        (5) If an applicant or recipient responds to the
13    notice, the Department shall determine the effect of the
14    information or documentation provided on the applicant's
15    or recipient's case and shall take appropriate action.
16    Written notice of the Department's action shall be provided
17    as set forth in Section 11-7 of this Article.
18        (6) Suspected cases of fraud shall be referred to the
19    Department's Inspector General.
20    (e) Excepting citizenship and satisfactory immigration
21status, the Department may waive its verification requirements
22for exceptional circumstances, including: The Department shall
23adopt any rules necessary to implement this Section.
24        (1) homelessness;
25        (2) domestic violence;
26        (3) instances where a noncustodial parent refuses to

 

 

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1    release documentation germane to verification of one or
2    more eligibility factors;
3        (4) natural disaster; and
4        (5) other circumstances as identified on a
5    case-by-case basis and approved by the Department,
6    including, but not limited to, when documentation does not
7    exist at the time of application or renewal or is not
8    reasonably available.
9    (f) The Department shall ensure the integrated eligibility
10system shall include an applicant portal that allows electronic
11submission of eligibility documentation, updating of family
12and demographic information, tracking application status, and
13receiving electronic notifications from the Department. The
14Department shall actively promote the use of this portal
15through materials provided at Family and Community Resource
16Centers, staff communications with applicants, and electronic
17and print media. The portal and materials used to promote the
18portal must be available, at a minimum, in English, Spanish,
19and the next 4 most commonly used languages. The portal shall
20be available to all applicants and recipients of medical
21assistance provided they satisfy electronic identity
22verification requirements through one of the following
23processes:
24        (1) Providing personally identifying credit history
25    information.
26        (2) Providing requested personally identifying

 

 

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1    documentation to the Department.
2        (3) Completing an email, text, or mobile phone
3    verification where a message is sent to the email or phone
4    associated with the account and the applicant or recipient
5    must respond to that message.
6        (4) Completing any alternative process developed by
7    the Department for ensuring the electronic security of
8    applicants and recipients.
9    (g) The Department shall adopt any rules necessary to
10implement this Section.
11(Source: P.A. 97-689, eff. 6-14-12; 98-756, eff. 7-16-14.)
 
12    Section 99. Effective date. This Act takes effect upon
13becoming law.

 

 

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1 INDEX
2 Statutes amended in order of appearance
3    New Act
4    305 ILCS 5/11-5.2