Bill Text: IL HB5113 | 2009-2010 | 96th General Assembly | Engrossed

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Prohibits the Department of Healthcare and Family Services, the Department of Human Services, the Department on Aging, or any other State agency from utilizing a third-party managed care organization, a health maintenance organization, or any similar provider to administer or pay for medical assistance benefits made available under the Social Security Act or basic maintenance benefits made available by federal waiver to those persons eligible under specified provisions of the Code, unless the third party has an existing contractual relationship with the State to provide benefits to those eligible persons on or before December 31, 2009. Effective immediately.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced - Dead) 2010-03-26 - Rule 19(a) / Re-referred to Rules Committee [HB5113 Detail]

Download: Illinois-2009-HB5113-Engrossed.html

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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 5-2 as follows:
(305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
Sec. 5-2. Classes of Persons Eligible. Medical assistance
under this Article shall be available to any of the following
classes of persons in respect to whom a plan for coverage has
been submitted to the Governor by the Illinois Department and
approved by him:
1. Recipients of basic maintenance grants under
Articles III and IV.
2. Persons otherwise eligible for basic maintenance
under Articles III and IV, excluding any eligibility
requirements that are inconsistent with any federal law or
federal regulation, as interpreted by the U.S. Department
of Health and Human Services, but who fail to qualify
thereunder on the basis of need or who qualify but are not
receiving basic maintenance under Article IV, and who have
insufficient income and resources to meet the costs of
necessary medical care, including but not limited to the
following:

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(a) All persons otherwise eligible for basic
maintenance under Article III but who fail to qualify
under that Article on the basis of need and who meet
either of the following requirements:
(i) their income, as determined by the
Illinois Department in accordance with any federal
requirements, is equal to or less than 70% in
fiscal year 2001, equal to or less than 85% in
fiscal year 2002 and until a date to be determined
by the Department by rule, and equal to or less
than 100% beginning on the date determined by the
Department by rule, of the nonfarm income official
poverty line, as defined by the federal Office of
Management and Budget and revised annually in
accordance with Section 673(2) of the Omnibus
Budget Reconciliation Act of 1981, applicable to
families of the same size; or
(ii) their income, after the deduction of
costs incurred for medical care and for other types
of remedial care, is equal to or less than 70% in
fiscal year 2001, equal to or less than 85% in
fiscal year 2002 and until a date to be determined
by the Department by rule, and equal to or less
than 100% beginning on the date determined by the
Department by rule, of the nonfarm income official
poverty line, as defined in item (i) of this

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subparagraph (a).
At no time shall the Department of Healthcare and
Family Services, the Department of Human Services, the
Department on Aging, or any other State agency utilize
a third-party managed care organization, a health
maintenance organization, or any similar provider to
administer or pay for any and all benefits made
available to those persons eligible under Article III,
unless the third party has an existing contractual
relationship with the State to provide benefits to
those persons eligible under Article III on or before
December 31, 2009. Nothing in this subparagraph (a)
shall prohibit the Department from contracting with
vendors to continue the operation of care or disease
management programs that existed prior to December 31,
2009. This provision does not apply to programs
administered by the Department on Aging if federal law
or regulations require that any willing and qualified
providers be granted access to the program.
(b) All persons who, excluding any eligibility
requirements that are inconsistent with any federal
law or federal regulation, as interpreted by the U.S.
Department of Health and Human Services, would be
determined eligible for such basic maintenance under
Article IV by disregarding the maximum earned income
permitted by federal law.

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3. Persons who would otherwise qualify for Aid to the
Medically Indigent under Article VII.
4. Persons not eligible under any of the preceding
paragraphs who fall sick, are injured, or die, not having
sufficient money, property or other resources to meet the
costs of necessary medical care or funeral and burial
expenses.
5.(a) Women during pregnancy, after the fact of
pregnancy has been determined by medical diagnosis, and
during the 60-day period beginning on the last day of the
pregnancy, together with their infants and children born
after September 30, 1983, whose income and resources are
insufficient to meet the costs of necessary medical care to
the maximum extent possible under Title XIX of the Federal
Social Security Act.
(b) The Illinois Department and the Governor shall
provide a plan for coverage of the persons eligible under
paragraph 5(a) by April 1, 1990. Such plan shall provide
ambulatory prenatal care to pregnant women during a
presumptive eligibility period and establish an income
eligibility standard that is equal to 133% of the nonfarm
income official poverty line, as defined by the federal
Office of Management and Budget and revised annually in
accordance with Section 673(2) of the Omnibus Budget
Reconciliation Act of 1981, applicable to families of the
same size, provided that costs incurred for medical care

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are not taken into account in determining such income
eligibility.
(c) The Illinois Department may conduct a
demonstration in at least one county that will provide
medical assistance to pregnant women, together with their
infants and children up to one year of age, where the
income eligibility standard is set up to 185% of the
nonfarm income official poverty line, as defined by the
federal Office of Management and Budget. The Illinois
Department shall seek and obtain necessary authorization
provided under federal law to implement such a
demonstration. Such demonstration may establish resource
standards that are not more restrictive than those
established under Article IV of this Code.
6. Persons under the age of 18 who fail to qualify as
dependent under Article IV and who have insufficient income
and resources to meet the costs of necessary medical care
to the maximum extent permitted under Title XIX of the
Federal Social Security Act.
7. Persons who are under 21 years of age and would
qualify as disabled as defined under the Federal
Supplemental Security Income Program, provided medical
service for such persons would be eligible for Federal
Financial Participation, and provided the Illinois
Department determines that:
(a) the person requires a level of care provided by

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a hospital, skilled nursing facility, or intermediate
care facility, as determined by a physician licensed to
practice medicine in all its branches;
(b) it is appropriate to provide such care outside
of an institution, as determined by a physician
licensed to practice medicine in all its branches;
(c) the estimated amount which would be expended
for care outside the institution is not greater than
the estimated amount which would be expended in an
institution.
8. Persons who become ineligible for basic maintenance
assistance under Article IV of this Code in programs
administered by the Illinois Department due to employment
earnings and persons in assistance units comprised of
adults and children who become ineligible for basic
maintenance assistance under Article VI of this Code due to
employment earnings. The plan for coverage for this class
of persons shall:
(a) extend the medical assistance coverage for up
to 12 months following termination of basic
maintenance assistance; and
(b) offer persons who have initially received 6
months of the coverage provided in paragraph (a) above,
the option of receiving an additional 6 months of
coverage, subject to the following:
(i) such coverage shall be pursuant to

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provisions of the federal Social Security Act;
(ii) such coverage shall include all services
covered while the person was eligible for basic
maintenance assistance;
(iii) no premium shall be charged for such
coverage; and
(iv) such coverage shall be suspended in the
event of a person's failure without good cause to
file in a timely fashion reports required for this
coverage under the Social Security Act and
coverage shall be reinstated upon the filing of
such reports if the person remains otherwise
eligible.
9. Persons with acquired immunodeficiency syndrome
(AIDS) or with AIDS-related conditions with respect to whom
there has been a determination that but for home or
community-based services such individuals would require
the level of care provided in an inpatient hospital,
skilled nursing facility or intermediate care facility the
cost of which is reimbursed under this Article. Assistance
shall be provided to such persons to the maximum extent
permitted under Title XIX of the Federal Social Security
Act.
10. Participants in the long-term care insurance
partnership program established under the Illinois
Long-Term Care Partnership Program Act who meet the

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qualifications for protection of resources described in
Section 15 of that Act.
11. Persons with disabilities who are employed and
eligible for Medicaid, pursuant to Section
1902(a)(10)(A)(ii)(xv) of the Social Security Act, and,
subject to federal approval, persons with a medically
improved disability who are employed and eligible for
Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of
the Social Security Act, as provided by the Illinois
Department by rule. In establishing eligibility standards
under this paragraph 11, the Department shall, subject to
federal approval:
(a) set the income eligibility standard at not
lower than 350% of the federal poverty level;
(b) exempt retirement accounts that the person
cannot access without penalty before the age of 59 1/2,
and medical savings accounts established pursuant to
26 U.S.C. 220;
(c) allow non-exempt assets up to $25,000 as to
those assets accumulated during periods of eligibility
under this paragraph 11; and
(d) continue to apply subparagraphs (b) and (c) in
determining the eligibility of the person under this
Article even if the person loses eligibility under this
paragraph 11.
12. Subject to federal approval, persons who are

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eligible for medical assistance coverage under applicable
provisions of the federal Social Security Act and the
federal Breast and Cervical Cancer Prevention and
Treatment Act of 2000. Those eligible persons are defined
to include, but not be limited to, the following persons:
(1) persons who have been screened for breast or
cervical cancer under the U.S. Centers for Disease
Control and Prevention Breast and Cervical Cancer
Program established under Title XV of the federal
Public Health Services Act in accordance with the
requirements of Section 1504 of that Act as
administered by the Illinois Department of Public
Health; and
(2) persons whose screenings under the above
program were funded in whole or in part by funds
appropriated to the Illinois Department of Public
Health for breast or cervical cancer screening.
"Medical assistance" under this paragraph 12 shall be
identical to the benefits provided under the State's
approved plan under Title XIX of the Social Security Act.
The Department must request federal approval of the
coverage under this paragraph 12 within 30 days after the
effective date of this amendatory Act of the 92nd General
Assembly.
13. Subject to appropriation and to federal approval,
persons living with HIV/AIDS who are not otherwise eligible

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under this Article and who qualify for services covered
under Section 5-5.04 as provided by the Illinois Department
by rule.
14. Subject to the availability of funds for this
purpose, the Department may provide coverage under this
Article to persons who reside in Illinois who are not
eligible under any of the preceding paragraphs and who meet
the income guidelines of paragraph 2(a) of this Section and
(i) have an application for asylum pending before the
federal Department of Homeland Security or on appeal before
a court of competent jurisdiction and are represented
either by counsel or by an advocate accredited by the
federal Department of Homeland Security and employed by a
not-for-profit organization in regard to that application
or appeal, or (ii) are receiving services through a
federally funded torture treatment center. Medical
coverage under this paragraph 14 may be provided for up to
24 continuous months from the initial eligibility date so
long as an individual continues to satisfy the criteria of
this paragraph 14. If an individual has an appeal pending
regarding an application for asylum before the Department
of Homeland Security, eligibility under this paragraph 14
may be extended until a final decision is rendered on the
appeal. The Department may adopt rules governing the
implementation of this paragraph 14.
15. Family Care Eligibility.

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(a) A caretaker relative who is 19 years of age or
older when countable income is at or below 185% of the
Federal Poverty Level Guidelines, as published
annually in the Federal Register, for the appropriate
family size. A person may not spend down to become
eligible under this paragraph 15.
(b) Eligibility shall be reviewed annually.
(c) Caretaker relatives enrolled under this
paragraph 15 in families with countable income above
150% and at or below 185% of the Federal Poverty Level
Guidelines shall be counted as family members and pay
premiums as established under the Children's Health
Insurance Program Act.
(d) Premiums shall be billed by and payable to the
Department or its authorized agent, on a monthly basis.
(e) The premium due date is the last day of the
month preceding the month of coverage.
(f) Individuals shall have a grace period through
the month of coverage to pay the premium.
(g) Failure to pay the full monthly premium by the
last day of the grace period shall result in
termination of coverage.
(h) Partial premium payments shall not be
refunded.
(i) Following termination of an individual's
coverage under this paragraph 15, the following action

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is required before the individual can be re-enrolled:
(1) A new application must be completed and the
individual must be determined otherwise eligible.
(2) There must be full payment of premiums due
under this Code, the Children's Health Insurance
Program Act, the Covering ALL KIDS Health
Insurance Act, or any other healthcare program
administered by the Department for periods in
which a premium was owed and not paid for the
individual.
(3) The first month's premium must be paid if
there was an unpaid premium on the date the
individual's previous coverage was canceled.
The Department is authorized to implement the
provisions of this amendatory Act of the 95th General
Assembly by adopting the medical assistance rules in effect
as of October 1, 2007, at 89 Ill. Admin. Code 125, and at
89 Ill. Admin. Code 120.32 along with only those changes
necessary to conform to federal Medicaid requirements,
federal laws, and federal regulations, including but not
limited to Section 1931 of the Social Security Act (42
U.S.C. Sec. 1396u-1), as interpreted by the U.S. Department
of Health and Human Services, and the countable income
eligibility standard authorized by this paragraph 15. The
Department may not otherwise adopt any rule to implement
this increase except as authorized by law, to meet the

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eligibility standards authorized by the federal government
in the Medicaid State Plan or the Title XXI Plan, or to
meet an order from the federal government or any court.
16. 15. Subject to appropriation, uninsured persons
who are not otherwise eligible under this Section who have
been certified and referred by the Department of Public
Health as having been screened and found to need diagnostic
evaluation or treatment, or both diagnostic evaluation and
treatment, for prostate or testicular cancer. For the
purposes of this paragraph 16 15, uninsured persons are
those who do not have creditable coverage, as defined under
the Health Insurance Portability and Accountability Act,
or have otherwise exhausted any insurance benefits they may
have had, for prostate or testicular cancer diagnostic
evaluation or treatment, or both diagnostic evaluation and
treatment. To be eligible, a person must furnish a Social
Security number. A person's assets are exempt from
consideration in determining eligibility under this
paragraph 16 15. Such persons shall be eligible for medical
assistance under this paragraph 16 15 for so long as they
need treatment for the cancer. A person shall be considered
to need treatment if, in the opinion of the person's
treating physician, the person requires therapy directed
toward cure or palliation of prostate or testicular cancer,
including recurrent metastatic cancer that is a known or
presumed complication of prostate or testicular cancer and

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complications resulting from the treatment modalities
themselves. Persons who require only routine monitoring
services are not considered to need treatment. "Medical
assistance" under this paragraph 16 15 shall be identical
to the benefits provided under the State's approved plan
under Title XIX of the Social Security Act. Notwithstanding
any other provision of law, the Department (i) does not
have a claim against the estate of a deceased recipient of
services under this paragraph 16 15 and (ii) does not have
a lien against any homestead property or other legal or
equitable real property interest owned by a recipient of
services under this paragraph 16 15.
In implementing the provisions of Public Act 96-20 this
amendatory Act of the 96th General Assembly, the Department is
authorized to adopt only those rules necessary, including
emergency rules. Nothing in Public Act 96-20 this amendatory
Act of the 96th General Assembly permits the Department to
adopt rules or issue a decision that expands eligibility for
the FamilyCare Program to a person whose income exceeds 185% of
the Federal Poverty Level as determined from time to time by
the U.S. Department of Health and Human Services, unless the
Department is provided with express statutory authority.
The Illinois Department and the Governor shall provide a
plan for coverage of the persons eligible under paragraph 7 as
soon as possible after July 1, 1984.
The eligibility of any such person for medical assistance

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under this Article is not affected by the payment of any grant
under the Senior Citizens and Disabled Persons Property Tax
Relief and Pharmaceutical Assistance Act or any distributions
or items of income described under subparagraph (X) of
paragraph (2) of subsection (a) of Section 203 of the Illinois
Income Tax Act. The Department shall by rule establish the
amounts of assets to be disregarded in determining eligibility
for medical assistance, which shall at a minimum equal the
amounts to be disregarded under the Federal Supplemental
Security Income Program. The amount of assets of a single
person to be disregarded shall not be less than $2,000, and the
amount of assets of a married couple to be disregarded shall
not be less than $3,000.
To the extent permitted under federal law, any person found
guilty of a second violation of Article VIIIA shall be
ineligible for medical assistance under this Article, as
provided in Section 8A-8.
The eligibility of any person for medical assistance under
this Article shall not be affected by the receipt by the person
of donations or benefits from fundraisers held for the person
in cases of serious illness, as long as neither the person nor
members of the person's family have actual control over the
donations or benefits or the disbursement of the donations or
benefits.
(Source: P.A. 95-546, eff. 8-29-07; 95-1055, eff. 4-10-09;
96-20, eff. 6-30-09; 96-181, eff. 8-10-09; 96-328, eff.

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8-11-09; 96-567, eff. 1-1-10; revised 9-25-09.)
Section 99. Effective date. This Act takes effect upon
becoming law.