Ill. Admin. Code tit. 89, § 120.61 - Long Term Care
This Section applies to persons residing in long term care facilities or State-certified, State-licensed, or State-contracted residential care programs who, as a condition of eligibility for medical assistance, are required to pay all of their income, less certain protected amounts, for the cost of their own care.
a) The term
"long term care facility" refers to:
1) an
institution (or a distinct part of an institution) that meets the definition of
a "nursing facility" as that term is defined in
42 USC
1396r;
2) licensed Intermediate Care Facilities (ICF
and ICF/DD), licensed Skilled Nursing Facilities (SNF and SNF/Ped) and licensed
hospital-based long term care facilities (see 89 Ill. Adm. Code
148.50(c))
; and
3) Supportive Living
Facilities (SLF) and Community Integrated Living Facilities
(CILA).
b) The
eligibility period shall begin with:
1) the
first day of the month of application;
2) up to three months prior to the month of
application for any month in which the person meets both financial and
non-financial eligibility requirements. Eligibility will be effective the first
day of a retroactive month if the person meets eligibility requirements at any
time during that month; or
3) the
first day of a month, after the month of application, in which the person meets
non-financial and financial eligibility requirements.
c) Eligibility Without Spenddown
1) A one-month eligibility period will be
used. If a person's nonexempt income available during the eligibility period is
equal to or below the applicable income standard and nonexempt resources are
not in excess of the applicable resource disregard (see Section
120.382) , the
person is eligible for medical assistance from the first day of the eligibility
period without a spenddown.
2) A
person eligible under this subsection (c) is responsible for reporting any
changes that occur during the eligibility period that might affect eligibility
for medical assistance. If changes occur, appropriate action shall be taken by
the Department, including termination of eligibility for medical assistance. If
changes in income, resources or family composition occur that would make the
person a spenddown case, a spenddown obligation will be determined and
subsection (d) will apply. A redetermination of eligibility shall be made at
least every 12 months.
d)
Eligibility with Spenddown
1) If countable
income available during the eligibility period exceeds the applicable income
standard and/or nonexempt resources exceed the applicable resource disregard, a
person has a spenddown obligation that must be met before financial eligibility
for medical assistance can be established. The spenddown obligation is the
amount by which the person's countable income exceeds the applicable income
standard or nonexempt resources exceed the applicable resource
disregard.
2) A person meets the
spenddown obligation by incurring or paying for medical expenses in an amount
equal to the spenddown obligation. Medical expenses shall be applied to the
spenddown obligation as provided in Section
120.60(c).
3) Projected expenses for services provided
by a long term care facility that have not yet been incurred, but are
reasonably expected to be, may also be used to meet a spenddown obligation. The
amount of the projected expenses is based on the private pay rate of the long
term care facility at which the person resides or is seeking
admission.
4) A person who has both
an income spenddown and a resource spenddown cannot apply the same incurred
medical benefits to both. Incurred medical expenses are first applied to an
income spenddown.
e)
Post-eligibility Treatment of Income. If non-financial and financial
eligibility is established, a person's total income, including income exempt
and disregarded in determining eligibility, must be applied to the cost of the
person's care, minus any applicable deductions provided under subsection
(f).
f) Post-eligibility Income
Deductions. From a person's total income that is payable for a person's care,
certain deductions are allowed. Allowed deductions shall increase the amount
paid by the Department for residential services on behalf of the person, up to
the Department's payment rate for the facility. Deductions shall be allowed for
the following amounts in the following order:
1) SSI benefits paid under
42 USC 1382(e)(1)(E) or
(G) and, for residents of Supportive Living
Facilities, the minimum current SSI payment standard for an individual (or a
couple, if spouses reside together), less the personal needs allowance
specified in subsection (f)(2)(C) of this Section, shall be deducted for room
and board charges (see 89 Ill. Adm. Code
146.225(c)
and (d)) ;
2) a personal needs allowance:
A) for persons other than those specified in
subsections (f)(2)(B) through (H), $30 per month;
B) for spouses residing together, $60 per
couple per month ($30 per spouse);
C) for persons or spouses residing in
Supportive Living Facilities, $90;
D) for persons residing in Community
Integrated Living Arrangements (see 59 Ill. Adm. Code 115):
i) $50 per month, for dates of service prior
to 9/1/14;
ii) $60 per month, for
dates of service on or after 9/1/14 through 6/30/15;
iii) $50 per month, for dates of service on
or after 7/1/15;
iv) $60 per month,
for dates of service on or after 7/1/17;
E) for veterans who have neither a spouse nor
dependent child, or surviving spouses of veterans who do not have a dependent
child, and whose monthly veterans' benefits are reduced to $90, a $90 income
disregard is allowed in lieu of a personal allowance deduction. Persons allowed
the $90 per month income disregard are not also permitted the $30 per month
personal allowance;
F) for persons
residing in an Intermediate Care Facility for Individuals with Developmental
Disabilities (ICF/DD) licensed under the ID/DD Community Care Act [210 ILCS 47
]:
i) $30 per month, for dates of service
prior to 9/1/14;
ii) $60 per month,
for dates of service on or after 9/1/14 through 6/30/15;
iii) $30 per month, for dates of service on
or after 7/1/15;
iv) $60 per month,
for dates of service on or after 7/1/17;
G) for persons residing in a Specialized
Mental Health Rehabilitation Facility licensed under the Specialized Mental
Health Rehabilitation Act of 2013 [210 ILCS 49 ], $60 per month, for dates of
service on or after 7/1/17; or
H)
for persons residing in a Medically Complex for the Developmentally Disabled
facility licensed under the MC/DD Act [210 ILCS 46 ], $60 per month, for dates
of service on or after 7/1/17;
3) a community spouse income allowance
pursuant to Section
120.379(e);
4) a family allowance pursuant to Section
120.379(e)(2);
5) an amount to meet the needs of qualifying
children (as defined in
26 USC 152)
under age 21 who do not reside with either parent, who do not have enough
income to meet their needs and whose resources do not exceed the resource
limit. To determine needs and resource limits:
A) the MANG(C) and applicable resource
disregard are used (see Sections
120.30
and 120.382); and
B) any payments
made on medical bills for the children can be deducted from the person's
income;
6) amounts for
incurred expenses for certain Medicare and health insurance cost sharing that
are not subject to payment by a third party, limited to:
A) Medicare premiums, deductibles, or
coinsurance charges not paid by Medicaid or another third party
payor;
B) Other health insurance
premiums, deductibles or coinsurance (cost sharing) charges provided the
insurance meets the definition of a "health benefit plan" and is approved for
providing that insurance in Illinois by the Illinois Department of Insurance.
i) "Health benefit plan" means any accident
and health insurance policy or certificate, health services plan contract,
health maintenance organization subscriber contract, plan provided by a MEWA
(Multiple Employer Welfare Arrangement) or plan provided by another benefit
arrangement.
ii) Health benefit
plan does not mean accident only, credit, or disability insurance; long-term
care insurance (except for the month of admission to a long term care
facility); dental only or vision only insurance; specified disease insurance;
hospital confinement indemnity coverage; limited benefit health coverage;
coverage issued as a supplement to liability insurance; insurance arising out
of a workers' compensation or similar law; automobile medical payment
insurance; or insurance under which benefits are payable with or without regard
to fault and that is statutorily required to be contained in any liability
insurance policy or equivalent self-insurance;
7) Expenses Not Subject to Third Party
Payment for Necessary Medical Care Recognized under State Law, but Not a
Covered Service under the Medical Assistance Program. "Necessary medical care"
has the meaning described in Section 2 of the Comprehensive Health Insurance
Plan Act [215 ILCS 105/2 ] and
must be proved as such by a prescription, referral or statement from the
patient's doctor or dentist. The following are allowable deductions from a
person's post-eligibility income for medically necessary services:
A) expenses incurred within the three months
prior to the month of an application, provided those expenses remain a current
liability to the person and were not used to meet a spenddown. Medical expenses
incurred during a period of ineligibility resulting from a penalty imposed
under Section
120.387
or
120.388
are not an allowable deduction;
B)
expenses incurred for necessary medical services from a medical provider
(subject to reasonable dollar limits on specific services) so long as the
provider was not terminated, barred or suspended from participation in the
Medical Assistance Program (pursuant to 89 Ill. Adm. Code
140.16,
140.17
or
140.18)
at the time the medical services were provided; and
C) expenses for long term care services,
subject to the limitations of this subsection (f)(7) and provided that the
services were not provided by a facility to a person admitted during a time the
facility was subject to the sanction of non-payment for new admissions (see
305 ILCS
5/12-4.25(I)(3)
);
8) Amounts to maintain
a residence in the community for up to six months when:
A) the person does not have a spouse and/or
dependent children in the home;
B)
a physician has certified that the stay in the facility is temporary and the
individual is expected to return home within six months;
C) the amount of the deduction is based on:
i) the rent or property expense allowed under
the AABD MANG standard if the person was at home (see 89 Ill. Adm. Code
113.248) ; and
ii) the utility expenses that would be
allowed under the AABD MANG standard if the person was at home (see 89 Ill.
Adm. Code
113.249)
.
Notes
Amended at 35 Ill. Reg. 18645, effective January 1, 2012
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