State of Illinois
2019 and 2020


Introduced 2/15/2019, by Sen. John G. Mulroe


305 ILCS 5/11-5.4

    Amends the Illinois Public Aid Code. Makes technical changes to specify in provisions concerning provisional eligibility for long-term care services that: (i) the Department of Healthcare and Family Services must maintain the applicant's provisional Medicaid enrollment status until a final eligibility determination is approved or the applicant's appeal has been adjudicated and eligibility is denied; (ii) the Department of Healthcare and Family Services or the managed care organization, if applicable, must reimburse providers for services rendered during an applicant's provisional eligibility period; (iii) the Department of Healthcare and Family Services must submit payment vouchers for all retroactive reimbursement due to the Office of the Comptroller within 10 business days of issuing provisional eligibility to an applicant; and (iv) the Department of Healthcare and Family Services must adopt rules.

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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 5. The Illinois Public Aid Code is amended by
5changing Section 11-5.4 as follows:
6    (305 ILCS 5/11-5.4)
7    Sec. 11-5.4. Expedited long-term care eligibility
8determination and enrollment.
9    (a) Establishment of the expedited long-term care
10eligibility determination and enrollment system shall be a
11joint venture of the Departments of Human Services and
12Healthcare and Family Services and the Department on Aging.
13    (b) Streamlined application enrollment process; expedited
14eligibility process. The streamlined application and
15enrollment process must include, but need not be limited to,
16the following:
17        (1) On or before July 1, 2019, a streamlined
18    application and enrollment process shall be put in place
19    which must include, but need not be limited to, the
20    following:
21            (A) Minimize the burden on applicants by
22        collecting only the data necessary to determine
23        eligibility for medical services, long-term care



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1        services, and spousal impoverishment offset.
2            (B) Integrate online data sources to simplify the
3        application process by reducing the amount of
4        information needed to be entered and to expedite
5        eligibility verification.
6            (C) Provide online prompts to alert the applicant
7        that information is missing or not complete.
8            (D) Provide training and step-by-step written
9        instructions for caseworkers, applicants, and
10        providers.
11        (2) The State must expedite the eligibility process for
12    applicants meeting specified guidelines, regardless of the
13    age of the application. The guidelines, subject to federal
14    approval, must include, but need not be limited to, the
15    following individually or collectively:
16            (A) Full Medicaid benefits in the community for a
17        specified period of time.
18            (B) No transfer of assets or resources during the
19        federally prescribed look-back period, as specified in
20        federal law.
21            (C) Receives Supplemental Security Income payments
22        or was receiving such payments at the time of admission
23        to a nursing facility.
24            (D) For applicants or recipients with verified
25        income at or below 100% of the federal poverty level
26        when the declared value of their countable resources is



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1        no greater than the allowable amounts pursuant to
2        Section 5-2 of this Code for classes of eligible
3        persons for whom a resource limit applies. Such
4        simplified verification policies shall apply to
5        community cases as well as long-term care cases.
6        (3) Subject to federal approval, the Department of
7    Healthcare and Family Services must implement an ex parte
8    renewal process for Medicaid-eligible individuals residing
9    in long-term care facilities. "Renewal" has the same
10    meaning as "redetermination" in State policies,
11    administrative rule, and federal Medicaid law. The ex parte
12    renewal process must be fully operational on or before
13    January 1, 2019.
14        (4) The Department of Human Services must use the
15    standards and distribution requirements described in this
16    subsection and in Section 11-6 for notification of missing
17    supporting documents and information during all phases of
18    the application process: initial, renewal, and appeal.
19    (c) The Department of Human Services must adopt policies
20and procedures to improve communication between long-term care
21benefits central office personnel, applicants and their
22representatives, and facilities in which the applicants
23reside. Such policies and procedures must at a minimum permit
24applicants and their representatives and the facility in which
25the applicants reside to speak directly to an individual
26trained to take telephone inquiries and provide appropriate



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2    (d) Effective 30 days after the completion of 3 regionally
3based trainings, nursing facilities shall submit all
4applications for medical assistance online via the Application
5for Benefits Eligibility (ABE) website. This requirement shall
6extend to scanning and uploading with the online application
7any required additional forms such as the Long Term Care
8Facility Notification and the Additional Financial Information
9for Long Term Care Applicants as well as scanned copies of any
10supporting documentation. Long-term care facility admission
11documents must be submitted as required in Section 5-5 of this
12Code. No local Department of Human Services office shall refuse
13to accept an electronically filed application. No Department of
14Human Services office shall request submission of any document
15in hard copy.
16    (e) Notwithstanding any other provision of this Code, the
17Department of Human Services and the Department of Healthcare
18and Family Services' Office of the Inspector General shall,
19upon request, allow an applicant additional time to submit
20information and documents needed as part of a review of
21available resources or resources transferred during the
22look-back period. The initial extension shall not exceed 30
23days. A second extension of 30 days may be granted upon
24request. Any request for information issued by the State to an
25applicant shall include the following: an explanation of the
26information required and the date by which the information must



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1be submitted; a statement that failure to respond in a timely
2manner can result in denial of the application; a statement
3that the applicant or the facility in the name of the applicant
4may seek an extension; and the name and contact information of
5a caseworker in case of questions. Any such request for
6information shall also be sent to the facility. In deciding
7whether to grant an extension, the Department of Human Services
8or the Department of Healthcare and Family Services' Office of
9the Inspector General shall take into account what is in the
10best interest of the applicant. The time limits for processing
11an application shall be tolled during the period of any
12extension granted under this subsection.
13    (f) The Department of Human Services and the Department of
14Healthcare and Family Services must jointly compile data on
15pending applications, denials, appeals, and redeterminations
16into a monthly report, which shall be posted on each
17Department's website for the purposes of monitoring long-term
18care eligibility processing. The report must specify the number
19of applications and redeterminations pending long-term care
20eligibility determination and admission and the number of
21appeals of denials in the following categories:
22        (A) Length of time applications, redeterminations, and
23    appeals are pending - 0 to 45 days, 46 days to 90 days, 91
24    days to 180 days, 181 days to 12 months, over 12 months to
25    18 months, over 18 months to 24 months, and over 24 months.
26        (B) Percentage of applications and redeterminations



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1    pending in the Department of Human Services' Family
2    Community Resource Centers, in the Department of Human
3    Services' long-term care hubs, with the Department of
4    Healthcare and Family Services' Office of Inspector
5    General, and those applications which are being tolled due
6    to requests for extension of time for additional
7    information.
8        (C) Status of pending applications, denials, appeals,
9    and redeterminations.
10    (g) Beginning on July 1, 2017, the Auditor General shall
11report every 3 years to the General Assembly on the performance
12and compliance of the Department of Healthcare and Family
13Services, the Department of Human Services, and the Department
14on Aging in meeting the requirements of this Section and the
15federal requirements concerning eligibility determinations for
16Medicaid long-term care services and supports, and shall report
17any issues or deficiencies and make recommendations. The
18Auditor General shall, at a minimum, review, consider, and
19evaluate the following:
20        (1) compliance with federal regulations on furnishing
21    services as related to Medicaid long-term care services and
22    supports as provided under 42 CFR 435.930;
23        (2) compliance with federal regulations on the timely
24    determination of eligibility as provided under 42 CFR
25    435.912;
26        (3) the accuracy and completeness of the report



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1    required under paragraph (9) of subsection (e);
2        (4) the efficacy and efficiency of the task-based
3    process used for making eligibility determinations in the
4    centralized offices of the Department of Human Services for
5    long-term care services, including the role of the State's
6    integrated eligibility system, as opposed to the
7    traditional caseworker-specific process from which these
8    central offices have converted; and
9        (5) any issues affecting eligibility determinations
10    related to the Department of Human Services' staff
11    completing Medicaid eligibility determinations instead of
12    the designated single-state Medicaid agency in Illinois,
13    the Department of Healthcare and Family Services.
14    The Auditor General's report shall include any and all
15other areas or issues which are identified through an annual
16review. Paragraphs (1) through (5) of this subsection shall not
17be construed to limit the scope of the annual review and the
18Auditor General's authority to thoroughly and completely
19evaluate any and all processes, policies, and procedures
20concerning compliance with federal and State law requirements
21on eligibility determinations for Medicaid long-term care
22services and supports.
23    (h) The Department of Healthcare and Family Services shall
24adopt any rules necessary to administer and enforce any
25provision of this Section. Rulemaking shall not delay the full
26implementation of this Section.



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1    (g) The Department shall adopt rules necessary to
2administer and enforce any provision of this Section.
3Rulemaking shall not delay the full implementation of this
5    (i) (h) Beginning on June 29, 2018, provisional
6eligibility, in the form of a recipient identification number
7and any other necessary credentials to permit an applicant to
8receive benefits, must be issued to any applicant who has not
9received a final eligibility determination on his or her
10application for Medicaid or Medicaid long-term care benefits or
11a notice of an opportunity for a hearing within the federally
12prescribed deadlines for the processing of such applications.
13The Department of Healthcare and Family Services must maintain
14the applicant's provisional Medicaid enrollment status until a
15final eligibility determination is approved or the applicant's
16appeal has been adjudicated and eligibility is denied. The
17Department of Healthcare and Family Services or the managed
18care organization, if applicable, must reimburse providers for
19services rendered during an applicant's provisional
20eligibility period.
21        (1) Claims for services rendered to an applicant with
22    provisional eligibility status must be submitted and
23    processed in the same manner as those submitted on behalf
24    of beneficiaries determined to qualify for benefits.
25        (2) An applicant with provisional enrollment status
26    must have his or her benefits paid for under the State's



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1    fee-for-service system until the State makes a final
2    determination on the applicant's Medicaid or Medicaid
3    long-term care application. If an individual is enrolled
4    with a managed care organization for community benefits at
5    the time the individual's provisional status is issued, the
6    managed care organization is only responsible for paying
7    benefits covered under the capitation payment received by
8    the managed care organization for the individual.
9        (3) The Department of Healthcare and Family Services,
10    within 10 business days of issuing provisional eligibility
11    to an applicant, must submit to the Office of the
12    Comptroller for payment a voucher for all retroactive
13    reimbursement due. The Department of Healthcare and Family
14    Services must clearly identify such vouchers as
15    provisional eligibility vouchers.
16(Source: P.A. 99-153, eff. 7-28-15; 100-380, eff. 8-25-17;
17100-665, eff. 8-2-18; 100-1141, eff. 11-28-18.)