(215 ILCS 106/20)
Sec. 20. Eligibility.
(a) To be eligible for this Program, a person must be a person who has a child eligible under this Act and who is eligible under a waiver of federal requirements pursuant to an application made pursuant to subdivision (a)(1) of Section 40 of this Act or who is a child who:
(1) is a child who is not eligible for medical |
|
(2) is a child whose annual household income, as |
| determined by the Department, is above 133% of the federal poverty level and at or below 200% of the federal poverty level; |
|
(3) is a resident of the State of Illinois; and
(4) is a child who is either a United States citizen |
| or included in one of the following categories of non‑citizens: |
|
(A) unmarried dependent children of either a |
| United States Veteran honorably discharged or a person on active military duty; |
|
(B) refugees under Section 207 of the Immigration |
|
(C) asylees under Section 208 of the Immigration |
|
(D) persons for whom deportation has been |
| withheld under Section 243(h) of the Immigration and Nationality Act; |
|
(E) persons granted conditional entry under |
| Section 203(a)(7) of the Immigration and Nationality Act as in effect prior to April 1, 1980; |
|
(F) persons lawfully admitted for permanent |
| residence under the Immigration and Nationality Act; and |
|
(G) parolees, for at least one year, under |
| Section 212(d)(5) of the Immigration and Nationality Act. |
|
Those children who are in the categories set forth in subdivisions (4)(F) and (4)(G) of this subsection, who enter the United States on or after August 22, 1996, shall not be eligible for 5 years beginning on the date the child entered the United States.
(b) A child who is determined to be eligible for assistance may remain eligible for 12 months, provided the child maintains his or her residence in the State, has not yet attained 19 years of age, and is not excluded pursuant to subsection (c). A child who has been determined to be eligible for assistance must reapply or otherwise establish eligibility at least annually. An eligible child shall be required, as determined by the Department by rule, to report promptly those changes in income and other circumstances that affect eligibility. The eligibility of a child may be redetermined based on the information reported or may be terminated based on the failure to report or failure to report accurately. A child's responsible relative or caretaker may also be held liable to the Department for any payments made by the Department on such child's behalf that were inappropriate. An applicant shall be provided with notice of these obligations.
(c) A child shall not be eligible for coverage under this Program if:
(1) the premium required pursuant to Section 30 of |
| this Act has not been paid. If the required premiums are not paid the liability of the Program shall be limited to benefits incurred under the Program for the time period for which premiums had been paid. Re‑enrollment shall be completed prior to the next covered medical visit and the first month's required premium shall be paid in advance of the next covered medical visit. The Department shall promulgate rules regarding grace periods, notice requirements, and hearing procedures pursuant to this subsection; |
|
(2) the child is an inmate of a public institution or |
| a patient in an institution for mental diseases; or |
|
(3) the child is a member of a family that is |
| eligible for health benefits covered under the State of Illinois health benefits plan on the basis of a member's employment with a public agency. |
|
(Source: P.A. 96‑1272, eff. 1‑1‑11.) |
(215 ILCS 106/25)
Sec. 25. Health benefits for children.
(a) The Department shall, subject to appropriation, provide health benefits coverage to eligible children by:
(1) Subsidizing the cost of privately sponsored |
| health insurance, including employer based health insurance, to assist families to take advantage of available privately sponsored health insurance for their eligible children; and | |
(2) Purchasing or providing health care benefits for |
| eligible children. The health benefits provided under this subdivision (a)(2) shall, subject to appropriation and without regard to any applicable cost sharing under Section 30, be identical to the benefits provided for children under the State's approved plan under Title XIX of the Social Security Act. Providers under this subdivision (a)(2) shall be subject to approval by the Department to provide health care under the Illinois Public Aid Code and shall be reimbursed at the same rate as providers under the State's approved plan under Title XIX of the Social Security Act. In addition, providers may retain co‑payments when determined appropriate by the Department. | |
(b) The subsidization provided pursuant to subdivision (a)(1) shall be credited to the family of the eligible child.
(c) The Department is prohibited from denying coverage to a child who is enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) because the plan does not meet federal benchmarking standards or cost sharing and contribution requirements. To be eligible for inclusion in the Program, the plan shall contain comprehensive major medical coverage which shall consist of physician and hospital inpatient services. The Department is prohibited from denying coverage to a child who is enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) because the plan offers benefits in addition to physician and hospital inpatient services.
(d) The total dollar amount of subsidizing coverage per child per month pursuant to subdivision (a)(1) shall be equal to the average dollar payments, less premiums incurred, per child per month pursuant to subdivision (a)(2). The Department shall set this amount prospectively based upon the prior fiscal year's experience adjusted for incurred but not reported claims and estimated increases or decreases in the cost of medical care. Payments obligated before July 1, 1999, will be computed using State Fiscal Year 1996 payments for children eligible for Medical Assistance and income assistance under the Aid to Families with Dependent Children Program, with appropriate adjustments for cost and utilization changes through January 1, 1999. The Department is prohibited from providing a subsidy pursuant to subdivision (a)(1) that is more than the individual's monthly portion of the premium.
(e) An eligible child may obtain immediate coverage under this Program only once during a medical visit. If coverage lapses, re‑enrollment shall be completed in advance of the next covered medical visit and the first month's required premium shall be paid in advance of any covered medical visit.
(f) In order to accelerate and facilitate the development of networks to deliver services to children in areas outside counties with populations in excess of 3,000,000, in the event less than 25% of the eligible children in a county or contiguous counties has enrolled with a Health Maintenance Organization pursuant to Section 5‑11 of the Illinois Public Aid Code, the Department may develop and implement demonstration projects to create alternative networks designed to enhance enrollment and participation in the program. The Department shall prescribe by rule the criteria, standards, and procedures for effecting demonstration projects under this Section.
(Source: P.A. 90‑736, eff. 8‑12‑98.) |
(215 ILCS 106/30)
Sec. 30. Cost sharing.
(a) Children enrolled in a health benefits program pursuant to subdivision (a)(2) of Section 25 and persons enrolled in a health benefits waiver program pursuant to Section 40 shall be subject to the following cost sharing requirements:
(1) There shall be no co‑payment required for
| well‑baby or well‑child care, including age‑appropriate immunizations as required under federal law. | |
(2) Health insurance premiums for family members, |
| either children or adults, in families whose household income is above 150% of the federal poverty level shall be payable monthly, subject to rules promulgated by the Department for grace periods and advance payments, and shall be as follows: | |
(A) $15 per month for one family member.
(B) $25 per month for 2 family members.
(C) $30 per month for 3 family members.
(D) $35 per month for 4 family members.
(E) $40 per month for 5 or more family members.
(3) Co‑payments for children or adults in families |
| whose income is at or below 150% of the federal poverty level, at a minimum and to the extent permitted under federal law, shall be $2 for all medical visits and prescriptions provided under this Act. | |
(4) Co‑payments for children or adults in families |
| whose income is above 150% of the federal poverty level, at a minimum and to the extent permitted under federal law shall be as follows: | |
(A) $5 for medical visits.
(B) $3 for generic prescriptions and $5 for |
| brand name prescriptions. | |
(C) $25 for emergency room use for a |
| non‑emergency situation as defined by the Department by rule. | |
(5) The maximum amount of out‑of‑pocket expenses for |
| co‑payments shall be $100 per family per year. | |
(b) Individuals enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) of Section 25 shall be subject to the cost sharing provisions as stated in the privately sponsored health insurance plan.
(Source: P.A. 94‑48, eff. 7‑1‑05.) |
(215 ILCS 106/45)
Sec. 45. Study.
(a) The Department shall conduct a study which includes, but is not limited to, the following:
(1) Establishes estimates, broken down by regions of |
| the State, of the number of children with health insurance coverage and without health insurance coverage; the number of children who are eligible for Medicaid, and of that number, the number who are enrolled in Medicaid; the number of children with access to dependent coverage through an employer, and of that number, the number who are enrolled in dependent coverage through an employer. | |
(2) Ascertains, for the population of children |
| potentially eligible for coverage under any component of the Program, the extent of access to dependent coverage, how many children are enrolled in dependent coverage, the comprehensiveness of dependent coverage benefit packages available, and the amount of cost sharing currently paid by the employees. | |
(b) The Department shall submit the preliminary results of the study to the Governor and the General Assembly by December 1, 1998 and shall submit the final results to the Governor and the General Assembly by May 1, 1999.
(Source: P.A. 90‑736, eff. 8‑12‑98.) |
(215 ILCS 106/20)
Sec. 20. Eligibility.
(a) To be eligible for this Program, a person must be a person who has a child eligible under this Act and who is eligible under a waiver of federal requirements pursuant to an application made pursuant to subdivision (a)(1) of Section 40 of this Act or who is a child who:
(1) is a child who is not eligible for medical |
|
(2) is a child whose annual household income, as |
| determined by the Department, is above 133% of the federal poverty level and at or below 200% of the federal poverty level; |
|
(3) is a resident of the State of Illinois; and
(4) is a child who is either a United States citizen |
| or included in one of the following categories of non‑citizens: |
|
(A) unmarried dependent children of either a |
| United States Veteran honorably discharged or a person on active military duty; |
|
(B) refugees under Section 207 of the Immigration |
|
(C) asylees under Section 208 of the Immigration |
|
(D) persons for whom deportation has been |
| withheld under Section 243(h) of the Immigration and Nationality Act; |
|
(E) persons granted conditional entry under |
| Section 203(a)(7) of the Immigration and Nationality Act as in effect prior to April 1, 1980; |
|
(F) persons lawfully admitted for permanent |
| residence under the Immigration and Nationality Act; and |
|
(G) parolees, for at least one year, under |
| Section 212(d)(5) of the Immigration and Nationality Act. |
|
Those children who are in the categories set forth in subdivisions (4)(F) and (4)(G) of this subsection, who enter the United States on or after August 22, 1996, shall not be eligible for 5 years beginning on the date the child entered the United States.
(b) A child who is determined to be eligible for assistance may remain eligible for 12 months, provided the child maintains his or her residence in the State, has not yet attained 19 years of age, and is not excluded pursuant to subsection (c). A child who has been determined to be eligible for assistance must reapply or otherwise establish eligibility at least annually. An eligible child shall be required, as determined by the Department by rule, to report promptly those changes in income and other circumstances that affect eligibility. The eligibility of a child may be redetermined based on the information reported or may be terminated based on the failure to report or failure to report accurately. A child's responsible relative or caretaker may also be held liable to the Department for any payments made by the Department on such child's behalf that were inappropriate. An applicant shall be provided with notice of these obligations.
(c) A child shall not be eligible for coverage under this Program if:
(1) the premium required pursuant to Section 30 of |
| this Act has not been paid. If the required premiums are not paid the liability of the Program shall be limited to benefits incurred under the Program for the time period for which premiums had been paid. Re‑enrollment shall be completed prior to the next covered medical visit and the first month's required premium shall be paid in advance of the next covered medical visit. The Department shall promulgate rules regarding grace periods, notice requirements, and hearing procedures pursuant to this subsection; |
|
(2) the child is an inmate of a public institution or |
| a patient in an institution for mental diseases; or |
|
(3) the child is a member of a family that is |
| eligible for health benefits covered under the State of Illinois health benefits plan on the basis of a member's employment with a public agency. |
|
(Source: P.A. 96‑1272, eff. 1‑1‑11.) |
(215 ILCS 106/25)
Sec. 25. Health benefits for children.
(a) The Department shall, subject to appropriation, provide health benefits coverage to eligible children by:
(1) Subsidizing the cost of privately sponsored |
| health insurance, including employer based health insurance, to assist families to take advantage of available privately sponsored health insurance for their eligible children; and | |
(2) Purchasing or providing health care benefits for |
| eligible children. The health benefits provided under this subdivision (a)(2) shall, subject to appropriation and without regard to any applicable cost sharing under Section 30, be identical to the benefits provided for children under the State's approved plan under Title XIX of the Social Security Act. Providers under this subdivision (a)(2) shall be subject to approval by the Department to provide health care under the Illinois Public Aid Code and shall be reimbursed at the same rate as providers under the State's approved plan under Title XIX of the Social Security Act. In addition, providers may retain co‑payments when determined appropriate by the Department. | |
(b) The subsidization provided pursuant to subdivision (a)(1) shall be credited to the family of the eligible child.
(c) The Department is prohibited from denying coverage to a child who is enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) because the plan does not meet federal benchmarking standards or cost sharing and contribution requirements. To be eligible for inclusion in the Program, the plan shall contain comprehensive major medical coverage which shall consist of physician and hospital inpatient services. The Department is prohibited from denying coverage to a child who is enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) because the plan offers benefits in addition to physician and hospital inpatient services.
(d) The total dollar amount of subsidizing coverage per child per month pursuant to subdivision (a)(1) shall be equal to the average dollar payments, less premiums incurred, per child per month pursuant to subdivision (a)(2). The Department shall set this amount prospectively based upon the prior fiscal year's experience adjusted for incurred but not reported claims and estimated increases or decreases in the cost of medical care. Payments obligated before July 1, 1999, will be computed using State Fiscal Year 1996 payments for children eligible for Medical Assistance and income assistance under the Aid to Families with Dependent Children Program, with appropriate adjustments for cost and utilization changes through January 1, 1999. The Department is prohibited from providing a subsidy pursuant to subdivision (a)(1) that is more than the individual's monthly portion of the premium.
(e) An eligible child may obtain immediate coverage under this Program only once during a medical visit. If coverage lapses, re‑enrollment shall be completed in advance of the next covered medical visit and the first month's required premium shall be paid in advance of any covered medical visit.
(f) In order to accelerate and facilitate the development of networks to deliver services to children in areas outside counties with populations in excess of 3,000,000, in the event less than 25% of the eligible children in a county or contiguous counties has enrolled with a Health Maintenance Organization pursuant to Section 5‑11 of the Illinois Public Aid Code, the Department may develop and implement demonstration projects to create alternative networks designed to enhance enrollment and participation in the program. The Department shall prescribe by rule the criteria, standards, and procedures for effecting demonstration projects under this Section.
(Source: P.A. 90‑736, eff. 8‑12‑98.) |
(215 ILCS 106/30)
Sec. 30. Cost sharing.
(a) Children enrolled in a health benefits program pursuant to subdivision (a)(2) of Section 25 and persons enrolled in a health benefits waiver program pursuant to Section 40 shall be subject to the following cost sharing requirements:
(1) There shall be no co‑payment required for
| well‑baby or well‑child care, including age‑appropriate immunizations as required under federal law. | |
(2) Health insurance premiums for family members, |
| either children or adults, in families whose household income is above 150% of the federal poverty level shall be payable monthly, subject to rules promulgated by the Department for grace periods and advance payments, and shall be as follows: | |
(A) $15 per month for one family member.
(B) $25 per month for 2 family members.
(C) $30 per month for 3 family members.
(D) $35 per month for 4 family members.
(E) $40 per month for 5 or more family members.
(3) Co‑payments for children or adults in families |
| whose income is at or below 150% of the federal poverty level, at a minimum and to the extent permitted under federal law, shall be $2 for all medical visits and prescriptions provided under this Act. | |
(4) Co‑payments for children or adults in families |
| whose income is above 150% of the federal poverty level, at a minimum and to the extent permitted under federal law shall be as follows: | |
(A) $5 for medical visits.
(B) $3 for generic prescriptions and $5 for |
| brand name prescriptions. | |
(C) $25 for emergency room use for a |
| non‑emergency situation as defined by the Department by rule. | |
(5) The maximum amount of out‑of‑pocket expenses for |
| co‑payments shall be $100 per family per year. | |
(b) Individuals enrolled in a privately sponsored health insurance plan pursuant to subdivision (a)(1) of Section 25 shall be subject to the cost sharing provisions as stated in the privately sponsored health insurance plan.
(Source: P.A. 94‑48, eff. 7‑1‑05.) |
(215 ILCS 106/45)
Sec. 45. Study.
(a) The Department shall conduct a study which includes, but is not limited to, the following:
(1) Establishes estimates, broken down by regions of |
| the State, of the number of children with health insurance coverage and without health insurance coverage; the number of children who are eligible for Medicaid, and of that number, the number who are enrolled in Medicaid; the number of children with access to dependent coverage through an employer, and of that number, the number who are enrolled in dependent coverage through an employer. | |
(2) Ascertains, for the population of children |
| potentially eligible for coverage under any component of the Program, the extent of access to dependent coverage, how many children are enrolled in dependent coverage, the comprehensiveness of dependent coverage benefit packages available, and the amount of cost sharing currently paid by the employees. | |
(b) The Department shall submit the preliminary results of the study to the Governor and the General Assembly by December 1, 1998 and shall submit the final results to the Governor and the General Assembly by May 1, 1999.
(Source: P.A. 90‑736, eff. 8‑12‑98.) |
