Current through Register Vol. 48, No. 38, September 20, 2024
a) Any person who
applies for or receives benefits under the Program shall have the right to
appeal any of the following actions:
1)
Refusal to accept, or failure to act on, an application or
reapplication;
2) Denial of an
application or cancellation at the redetermination of eligibility, including
denial based on failure to meet one or more of the eligibility requirements
specified in this Subpart.
A) No eligibility
exists during the appeal process.
B) If the appeal is decided in the
individual's favor, the individual will have the opportunity to receive
coverage back to the original application date, including possible backdated
months or the cancellation month;
3) Termination of coverage based on failure
to continue to meet one or more of the eligibility requirements specified in
this Subpart.
A) If the termination is decided
in the individual's favor on appeal, coverage under the Program shall be
reinstated retroactive to the termination date.
B) If coverage is reinstated pursuant to
subsection (a)(3)(A), the individual may choose coverage for all or some of the
months during the appeal process as long as the retroactive months are
consecutive to the new initial month of regular eligibility.
4) Individuals or their
representatives do not have the right to appeal Department decisions necessary
to keep the cost of the Program within the annual appropriations, such as a
Department decision to:
A) Deny an application
due to closing of enrollment for the Program;
B) Make a change to the Program pursuant to
Section 118.860; and
C) Require
more frequent redeterminations of eligibility.
b) In addition to the actions that are
appealable under subsection (a), individuals shall have the right to appeal any
of the following actions:
1) Denial of payment
for a medical service or item that requires prior approval; or
2) Decision granting prior approval for a
lesser or different medical service or item than was originally
requested.
c)
Individuals may initiate the appeal process by submitting a request for appeal
to the Department's Bureau of Administrative Hearings.
d) The request for a hearing may be filed by
the individual affected by the action or by the individual's authorized
representative.
e) For purposes of
initiating the appeal process, a copy of a written, signed request for a
hearing is considered the same as the original written, signed
request.
f) The request for a
hearing must be filed no later than 60 days after notice of the appealable
action was given.
g) The provisions
of 89 Ill. Adm. Code 104.Subpart A (Practice in Administrative Hearings) shall
govern the handling of appeals and the conduct of hearings under the
Program.
h) An individual can,
prior to a decision being rendered on the appeal, reapply for the
Program.
