305 ILCS 5/11-5.1
2021 Illinois Compiled Statutes|Chapter 305 - PUBLIC AID|305 ILCS 5/ - Illinois Public Aid Code.|Article XI - General Provisions Pertaining To Rights And Responsibilities Of Applicants And Recipients

Sec. 11-5.1. Eligibility verification. Notwithstanding any other provision of this Code, with respect to applications for medical assistance provided under Article V of this Code, eligibility shall be determined in a manner that ensures program integrity and complies with federal laws 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 for medical assistance under this Code. 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.(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 for medical assistance under this Code. 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-Medicaid benefits, that is sufficient to make a determination of continued Medicaid eligibility may be reviewed and verified, and subsequent action taken including client notification of continued Medicaid eligibility. The date of client notification establishes the date for subsequent annual Medicaid eligibility reviews. 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   recipients  at  least  60  days  prior  to  the  end  of  their  period   of eligibility that informs them of the   requirements  for  continued  eligibility.  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.The Department, with federal approval, may choose to adopt continuous financial eligibility for a full 12 months for adults on Medicaid.(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  availableto  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 shall 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.(d)  As soon as practical if the data is reasonably available, but no later than January 1, 2017, the Department shall compile on a monthly basis data on eligibility redeterminations of beneficiaries of medical assistance provided under Article V of this Code. This data shall be posted on the Department's website, and data from prior months shall be retained and available on the Department's website. The data compiled and reported shall include the following:(1) The total number of redetermination decisions     made in a month and, of that total number, the number of decisions to continue or change benefits and the number of decisions to cancel benefits.(2) A breakdown of enrollee language preference for     the total number of redetermination decisions made in a month and, of that total number, a breakdown of enrollee language preference for the number of decisions to continue or change benefits, and a breakdown of enrollee language preference for the number of decisions to cancel benefits. The language breakdown shall include, at a minimum, English, Spanish, and the next 4 most commonly used languages.(3) The percentage of cancellation decisions made in     a month due to each of the following:(A) The beneficiary's ineligibility due to excess         income.(B) The beneficiary's ineligibility due to not         being an Illinois resident.(C) The beneficiary's ineligibility due to being         deceased.(D) The beneficiary's request to cancel benefits.(E) The beneficiary's lack of response after         notices mailed to the beneficiary are returned to the Department as undeliverable by the United States Postal Service.(F) The beneficiary's lack of response to a         request for additional information when reliable information in the beneficiary's account, or other more current information, is unavailable to the Department to make a decision on whether to continue benefits.(G) Other reasons tracked by the Department for         the purpose of ensuring program integrity.(4) If a vendor is utilized to provide services in     support of the Department's redetermination decision process, the total number of redetermination decisions made in a month and, of that total number, the number of decisions to continue or change benefits, and the number of decisions to cancel benefits (i) with the involvement of the vendor and (ii) without the involvement of the vendor.(5) Of the total number of benefit cancellations in a     month, the number of beneficiaries who return from cancellation within one month, the number of beneficiaries who return from cancellation within 2 months, and the number of beneficiaries who return from cancellation within 3 months. Of the number of beneficiaries who return from cancellation within 3 months, the percentage of those cancellations due to each of the reasons listed under paragraph (3) of this subsection.(e)  The Department shall conduct a complete review of the Medicaid redetermination process in order to identify changes that can increase the use of ex parte redetermination processing. This review shall be completed within 90 days after the effective date of this amendatory Act of the 101st General Assembly. Within 90 days of completion of the review, the Department shall seek written federal approval of policy changes the review recommended and implement once approved.  The review shall specifically include, but not be limited to, use of ex parte redeterminations of the following populations:(1) Recipients of developmental disabilities     services.(2) Recipients of benefits under the State's Aid to     the Aged, Blind, or Disabled program.(3) Recipients of Medicaid long-term care services     and supports, including waiver services.(4) All Modified Adjusted Gross Income (MAGI)     populations.(5) Populations with no verifiable income.(6) Self-employed people.The report shall also outline populations and circumstances in which an ex parte redetermination is not a recommended option.(f) The Department shall explore and implement, as practical and technologically possible, roles that stakeholders outside State agencies can play to assist in expediting eligibility determinations and redeterminations within 24 months after the effective date of this amendatory Act of the 101st General Assembly. Such practical roles to be explored to expedite the eligibility determination processes shall include the implementation of hospital presumptive eligibility, as authorized by the Patient Protection and Affordable Care Act.(g) The Department or its designee shall seek federal approval to enhance the reasonable compatibility standard from 5% to 10%.(h) Reporting. The Department of Healthcare and Family Services and the Department of Human Services shall publish quarterly reports on their progress in implementing policies and practices pursuant to this Section as modified by this amendatory Act of the 101st General Assembly.(1) The reports shall include, but not be limited to,     the following:(A) Medical application processing, including a         breakdown of the number of MAGI, non-MAGI, long-term care, and other medical cases pending for various incremental time frames between 0 to 181 or more days.(B) Medical redeterminations completed,         including: (i) a breakdown of the number of households that were redetermined ex parte and those that were not; (ii) the reasons households were not redetermined ex parte; and (iii) the relative percentages of these reasons.(C) A narrative discussion on issues identified         in the functioning of the State's Integrated Eligibility System and progress on addressing those issues, as well as progress on implementing strategies to address eligibility backlogs, including expanding ex parte determinations to ensure timely eligibility determinations and renewals.(2) Initial reports shall be issued within 90 days     after the effective date of this amendatory Act of the 101st General Assembly.(3) All reports shall be published on the     Department's website. (Source: P.A. 101-209, eff. 8-5-19; 101-649, eff. 7-7-20.)