Public Act 100-1141
HB4771 EnrolledLRB100 18554 KTG 33773 b

    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 Section 11-5.4 as follows:
    (305 ILCS 5/11-5.4)
    Sec. 11-5.4. Expedited long-term care eligibility
determination and enrollment.
    (a) An expedited long-term care eligibility determination
and enrollment system shall be established to reduce long-term
care determinations to 90 days or fewer by July 1, 2014 and
streamline the long-term care enrollment process.
Establishment of the system shall be a joint venture of the
Department of Human Services and Healthcare and Family Services
and the Department on Aging. The Governor shall name a lead
agency no later than 30 days after the effective date of this
amendatory Act of the 98th General Assembly to assume
responsibility for the full implementation of the
establishment and maintenance of the system. Project outcomes
shall include an enhanced eligibility determination tracking
system accessible to providers and a centralized application
review and eligibility determination with all applicants
reviewed within 90 days of receipt by the State of a complete
application. If the Department of Healthcare and Family
Services' Office of the Inspector General determines that there
is a likelihood that a non-allowable transfer of assets has
occurred, and the facility in which the applicant resides is
notified, an extension of up to 90 days shall be permissible.
On or before December 31, 2015, a streamlined application and
enrollment process shall be put in place based on the following
        (1) Minimize the burden on applicants by collecting
    only the data necessary to determine eligibility for
    medical services, long-term care services, and spousal
    impoverishment offset.
        (2) Integrate online data sources to simplify the
    application process by reducing the amount of information
    needed to be entered and to expedite eligibility
        (3) Provide online prompts to alert the applicant that
    information is missing or not complete.
    (b) The Department shall, on or before July 1, 2014, assess
the feasibility of incorporating all information needed to
determine eligibility for long-term care services, including
asset transfer and spousal impoverishment financials, into the
State's integrated eligibility system identifying all
resources needed and reasonable timeframes for achieving the
specified integration.
    (c) The lead agency shall file interim reports with the
Chairs and Minority Spokespersons of the House and Senate Human
Services Committees no later than September 1, 2013 and on
February 1, 2014. The Department of Healthcare and Family
Services shall include in the annual Medicaid report for State
Fiscal Year 2014 and every fiscal year thereafter information
concerning implementation of the provisions of this Section.
    (d) No later than August 1, 2014, the Auditor General shall
report to the General Assembly concerning the extent to which
the timeframes specified in this Section have been met and the
extent to which State staffing levels are adequate to meet the
requirements of this Section.
    (e) The Department of Healthcare and Family Services, the
Department of Human Services, and the Department on Aging shall
take the following steps to achieve federally established
timeframes for eligibility determinations for Medicaid and
long-term care benefits and shall work toward the federal goal
of real time determinations:
        (1) The Departments shall review, in collaboration
    with representatives of affected providers, all forms and
    procedures currently in use, federal guidelines either
    suggested or mandated, and staff deployment by September
    30, 2014 to identify additional measures that can improve
    long-term care eligibility processing and make adjustments
    where possible.
        (2) No later than June 30, 2014, the Department of
    Healthcare and Family Services shall issue vouchers for
    advance payments not to exceed $50,000,000 to nursing
    facilities with significant outstanding Medicaid liability
    associated with services provided to residents with
    Medicaid applications pending and residents facing the
    greatest delays. Each facility with an advance payment
    shall state in writing whether its own recoupment schedule
    will be in 3 or 6 equal monthly installments, as long as
    all advances are recouped by June 30, 2015.
        (3) The Department of Healthcare and Family Services'
    Office of Inspector General and the Department of Human
    Services shall immediately forgo resource review and
    review of transfers during the relevant look-back period
    for applications that were submitted prior to September 1,
    2013. An applicant who applied prior to September 1, 2013,
    who was denied for failure to cooperate in providing
    required information, and whose application was
    incorrectly reviewed under the wrong look-back period
    rules may request review and correction of the denial based
    on this subsection. If found eligible upon review, such
    applicants shall be retroactively enrolled.
        (4) As soon as practicable, the Department of
    Healthcare and Family Services shall implement policies
    and promulgate rules to simplify financial eligibility
    verification in the following instances: (A) for
    applicants or recipients who are receiving Supplemental
    Security Income payments or who had been receiving such
    payments at the time they were admitted to a nursing
    facility and (B) for applicants or recipients with verified
    income at or below 100% of the federal poverty level when
    the declared value of their countable resources is no
    greater than the allowable amounts pursuant to Section 5-2
    of this Code for classes of eligible persons for whom a
    resource limit applies. Such simplified verification
    policies shall apply to community cases as well as
    long-term care cases.
        (5) As soon as practicable, but not later than July 1,
    2014, the Department of Healthcare and Family Services and
    the Department of Human Services shall jointly begin a
    special enrollment project by using simplified eligibility
    verification policies and by redeploying caseworkers
    trained to handle long-term care cases to prioritize those
    cases, until the backlog is eliminated and processing time
    is within 90 days. This project shall apply to applications
    for long-term care received by the State on or before May
    15, 2014.
        (6) As soon as practicable, but not later than
    September 1, 2014, the Department on Aging shall make
    available to long-term care facilities and community
    providers upon request, through an electronic method, the
    information contained within the Interagency Certification
    of Screening Results completed by the pre-screener, in a
    form and manner acceptable to the Department of Human
        (7) Effective 30 days after the completion of 3
    regionally based trainings, nursing facilities shall
    submit all applications for medical assistance online via
    the Application for Benefits Eligibility (ABE) website.
    This requirement shall extend to scanning and uploading
    with the online application any required additional forms
    such as the Long Term Care Facility Notification and the
    Additional Financial Information for Long Term Care
    Applicants as well as scanned copies of any supporting
    documentation. Long-term care facility admission documents
    must be submitted as required in Section 5-5 of this Code.
    No local Department of Human Services office shall refuse
    to accept an electronically filed application.
        (8) Notwithstanding any other provision of this Code,
    the Department of Human Services and the Department of
    Healthcare and Family Services' Office of the Inspector
    General shall, upon request, allow an applicant additional
    time to submit information and documents needed as part of
    a review of available resources or resources transferred
    during the look-back period. The initial extension shall
    not exceed 30 days. A second extension of 30 days may be
    granted upon request. Any request for information issued by
    the State to an applicant shall include the following: an
    explanation of the information required and the date by
    which the information must be submitted; a statement that
    failure to respond in a timely manner can result in denial
    of the application; a statement that the applicant or the
    facility in the name of the applicant may seek an
    extension; and the name and contact information of a
    caseworker in case of questions. Any such request for
    information shall also be sent to the facility. In deciding
    whether to grant an extension, the Department of Human
    Services or the Department of Healthcare and Family
    Services' Office of the Inspector General shall take into
    account what is in the best interest of the applicant. The
    time limits for processing an application shall be tolled
    during the period of any extension granted under this
        (9) The Department of Human Services and the Department
    of Healthcare and Family Services must jointly compile data
    on pending applications, denials, appeals, and
    redeterminations into a monthly report, which shall be
    posted on each Department's website for the purposes of
    monitoring long-term care eligibility processing. The
    report must specify the number of applications and
    redeterminations pending long-term care eligibility
    determination and admission and the number of appeals of
    denials in the following categories:
            (A) Length of time applications, redeterminations,
        and appeals are pending - 0 to 45 days, 46 days to 90
        days, 91 days to 180 days, 181 days to 12 months, over
        12 months to 18 months, over 18 months to 24 months,
        and over 24 months.
            (B) Percentage of applications and
        redeterminations pending in the Department of Human
        Services' Family Community Resource Centers, in the
        Department of Human Services' long-term care hubs,
        with the Department of Healthcare and Family Services'
        Office of Inspector General, and those applications
        which are being tolled due to requests for extension of
        time for additional information.
            (C) Status of pending applications, denials,
        appeals, and redeterminations.
    (f) Beginning on July 1, 2017, the Auditor General shall
report every 3 years to the General Assembly on the performance
and compliance of the Department of Healthcare and Family
Services, the Department of Human Services, and the Department
on Aging in meeting the requirements of this Section and the
federal requirements concerning eligibility determinations for
Medicaid long-term care services and supports, and shall report
any issues or deficiencies and make recommendations. The
Auditor General shall, at a minimum, review, consider, and
evaluate the following:
        (1) compliance with federal regulations on furnishing
    services as related to Medicaid long-term care services and
    supports as provided under 42 CFR 435.930;
        (2) compliance with federal regulations on the timely
    determination of eligibility as provided under 42 CFR
        (3) the accuracy and completeness of the report
    required under paragraph (9) of subsection (e);
        (4) the efficacy and efficiency of the task-based
    process used for making eligibility determinations in the
    centralized offices of the Department of Human Services for
    long-term care services, including the role of the State's
    integrated eligibility system, as opposed to the
    traditional caseworker-specific process from which these
    central offices have converted; and
        (5) any issues affecting eligibility determinations
    related to the Department of Human Services' staff
    completing Medicaid eligibility determinations instead of
    the designated single-state Medicaid agency in Illinois,
    the Department of Healthcare and Family Services.
    The Auditor General's report shall include any and all
other areas or issues which are identified through an annual
review. Paragraphs (1) through (5) of this subsection shall not
be construed to limit the scope of the annual review and the
Auditor General's authority to thoroughly and completely
evaluate any and all processes, policies, and procedures
concerning compliance with federal and State law requirements
on eligibility determinations for Medicaid long-term care
services and supports.
    (g) The Department shall adopt rules necessary to
administer and enforce any provision of this Section.
Rulemaking shall not delay the full implementation of this
    (h) Beginning on June 29, 2018, provisional eligibility, in
the form of a recipient identification number and any other
necessary credentials to permit an applicant to receive
benefits, must be issued to any applicant who has not received
a final eligibility determination on his or her application for
Medicaid or Medicaid long-term care benefits or a notice of an
opportunity for a hearing within the federally prescribed
deadlines for the processing of such applications. The
Department 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. The Department or the managed care
organization, if applicable, must reimburse providers for
services rendered during an applicant's provisional
eligibility period.
        (1) Claims for services rendered to an applicant with
    provisional eligibility status must be submitted and
    processed in the same manner as those submitted on behalf
    of beneficiaries determined to qualify for benefits.
        (2) An applicant with provisional enrollment status
    must have his or her benefits paid for under the State's
    fee-for-service system until the State makes a final
    determination on the applicant's Medicaid or Medicaid
    long-term care application. If an individual is enrolled
    with a managed care organization for community benefits at
    the time the individual's provisional status is issued, the
    managed care organization is only responsible for paying
    benefits covered under the capitation payment received by
    the managed care organization for the individual.
        (3) The Department, within 10 business days of issuing
    provisional eligibility to an applicant, must submit to the
    Office of the Comptroller for payment a voucher for all
    retroactive reimbursement due. The Department must clearly
    identify such vouchers as provisional eligibility
(Source: P.A. 99-153, eff. 7-28-15; 100-380, eff. 8-25-17.)
    Section 99. Effective date. This Act takes effect upon
becoming law.