Section 120.64  Determination of Eligibility for Cases Subject to Modified Adjusted Gross Income (MAGI) Methodology

a)         The eligibility period for a client shall begin with:

1)         the first day of the month of application; or

2)         the first day of any month prior to the month of application, if the client so desires, up to three months prior to the month of application; or

3)         the first day of the month after the month of application; or

4)         the first day of a month a pregnant woman and/or child under age 19 meets the requirements of Sections 120.11 and 120.31.

b)         The pregnant woman shall be eligible to receive medical assistance until 60 days following the last day of pregnancy.  The 60 day medical coverage continues through the last day of the calendar month in which the 60 day period ends.  The 60 day medical coverage period shall be provided for all women determined eligible for medical assistance under Section 120.11(a)(1), including women who are no longer pregnant at the time of application because the woman gave birth or had a miscarriage or an abortion, and including women who signed an adoption agreement.

c)         Children shall be eligible to receive medical assistance as determined pursuant to Section 120.400.

d)         Covered services received during the entire eligibility period will be paid by the Department (see 89 Ill. Adm. Code 140.3).

e)         A redetermination of eligibility will be made every 12 months.

f)         The client is responsible to report any changes that occur during the eligibility period that might affect eligibility for medical assistance.  If changes in income or family composition occur that would make the client ineligible for medical assistance, appropriate action shall be taken by the Department, including evaluation of eligibility for other programs or termination of eligibility for medical assistance.  Income changes occurring after a pregnant woman is determined eligible for coverage are not considered through the 60 day postpartum period following the last day of pregnancy.

g)         A review of case eligibility will be conducted for a pregnant woman during the second month of the 60 day extended medical coverage period.  If eligible, the case shall be transferred by the Department to the appropriate program without interruption in benefit eligibility.  If ineligible, the Department shall notify the client in writing.

h)         A review of case eligibility will be conducted when a child is determined ineligible for medical assistance as a child.  If the child is otherwise eligible for medical assistance, the case shall be transferred by the Department without interruption in benefit eligibility.  If ineligible, written notification shall be provided to the client.

i)          For applications received on or after October 1, 2013, the determination of eligibility under this Section shall comply with the Modified Adjusted Gross Income (MAGI) methodology established at section 1902(e)(14) of the Social Security Act (42 USC 1396a(e)(14)) and federal regulations established at 42 CFR 435.110 (77 FR 17204, March 3, 2012, as amended at 78 FR 42302, July 15, 2013) regarding parents and other caretaker relatives, 42 CFR 435.116 (77 FR 17204, March 23, 2012, as amended at 78 FR 42302, July 15, 2013) regarding pregnant women, 42 CFR 435.118 (77 FR 17205, March 23, 2012) regarding infants and children under age 19, 42 CFR 435.119 (77 FR 17205, March 23, 2012, as amended at 78 FR 42302, July 15, 2013) regarding ACA adults, and 42 CFR 435.603 (77 FR 17206, March 23, 2012, as amended at 78 FR 42302, July 15, 2013) regarding application of MAGI methodologies .

1)         For the purpose of determining whether a person is a parent or caretaker relative of a "dependent child", a "dependent child" means a child who is younger than age 18.

2)         For purposes of determining household size:

A)        the total number of children a pregnant woman is expected to deliver shall be counted in the determination of the household size of any person in the household seeking benefits (42 CFR 435.603(b)).

B)        For applicants who expect to file a tax return and who are not claimed as a dependent, household size shall be determined in accordance with 42 CFR 435.603(f)(1).

C)        For applicants who expect to be claimed as a tax dependent and who do not meet an exception under 42 CFR 435.603(f)(2), household size shall be determined in accordance with 42 CFR 435.603(f)(2).

D)        For applicants who do not file a tax return nor expect to be claimed as a tax dependent, or who are tax dependents who meet an exception under 42 CFR 435.603(f)(2), household size shall be determined in accordance with 42 CFR 435.603(f)(3).

E)        For purposes of determining household size in accordance with 42 CFR 435.603(f)(3), the specified age is 19.

j)          This Section 120.64 shall apply to the initial determination of eligibility and, for renewals effective April 1, 2014, and later pursuant to 42 CFR 435.603(a)(3), for persons eligible under Section 5-2(5), (6)(a), (8), (15), (17) and (18) of the Public Aid Code.

k)         The provisions in this subsection are intended to comport with federal requirements related to eligibility for long term care, in particular, requirements under 42 USC 1396p (section 1917 of the Social Security Act), federal regulations and guidance from the US Department of Health and Human Services related to those statutory requirements for cases under this Section 120.64.  Interpretation and application of this subsection shall be made in light of those requirements.  Effective January 1, 2014, for the purposes of determining long term care eligibility for cases under this Section 120.64, the following provisions shall apply: 89 Ill. Adm. Code 120.61, except Section 120.61(e) and (f) until such time as federal rules are promulgated expanding post-eligibility treatment of income to cases under this Section, and those Sections of Subpart H relating to long term care eligibility, including Sections 120.346, 120.347, 120.379, 120.385 and 120.388.

(Source:  Amended at 38 Ill. Reg. 18432, effective August 19, 2014)