Current through Register Vol. 48, No. 38, September 20, 2024
a) Illinois Cares
Rx Eligibility Qualifications
To be eligible for Illinois Cares Rx pharmaceutical benefits,
an individual must meet all of the following requirements:
1) Be:
A)
65 years of age or older; or
B) a
disabled person.
2) Be
domiciled in Illinois at the time of filing an application, and during the
coverage period.
3) Be enrolled in
a Coordinating Medicare Part D PDP if eligible for Medicare Part D.
4) Apply for all available subsidies under
Medicare Part D. The Department may deem individuals to be compliant with this
requirement in cases where the Department's data clearly indicates the
individual would not be eligible for any low income subsidy.
5) Have a maximum household income at or
below 200% of the Federal Poverty Level (FPL).
b) Illinois Cares Rx Plus Eligibility
Qualifications
To be eligible for Illinois Cares Rx Plus pharmaceutical
benefits as described in Section
119.60(a),
an individual must meet all of the eligibility requirements described in
subsection (a) and meet the following requirements:
1) Be Medicare-eligible; or
2) Meet the following requirements:
A) Be a U.S. citizen or qualify as an
eligible non-citizen pursuant to 89 Ill. Adm. Code
120.310;
and
B) Be 65 years of age or
older.
c)
Proof of Eligibility Qualifications
An applicant must submit proof of his or her eligibility
qualifications as described in subsections (a) and (b).
1) Examples of proof of date of birth
include:
A) a baptismal record; or
B) a birth certificate; or
C) a driver's license; or
D) an identification card from the Secretary
of State's office; or
E) an
insurance policy; or
F)
naturalization papers.
2) Examples of proof of disability include:
A) proof that an applicant is eligible to
receive disability benefits under the federal Social Security Act of 1935 (see
42 USC
423); or
B) issuance of an Illinois Disabled Person
Identification Card stating that an applicant is under a Class 2 disability, as
defined in Section 4A of the Illinois Identification Card Act [15 ILCS
335/4A] ; or
C) status of an applicant as a disabled
person determined by a physician designated by the Department on Aging using
the same standards as used by the Social Security Administration with the costs
of any required examination paid by the applicant (see
42 USC
423); or
D) receipt by an applicant of Railroad (see
45
USC 231) , Civil Service, or Veterans' total
disability benefits (see
38
USC 101) . (See
320 ILCS
25/3.14.)
3) Applicants age 64 and older who are
ineligible for Medicare must submit proof of citizenship as set forth in
section 6036 of the federal Deficit Reduction Act of 2005. This requirement
becomes inapplicable if federal funding for these individuals becomes
unavailable.
d) Income
Income shall be based on income for the full calendar year
prior to the year the applicant filed an application for pharmaceutical
benefits, unless the applicant requests consideration of projected income as
described in subsections (d)(1)(A), (B), (C), (D) and (E).
1) Projected Income
A) An applicant may request that projected
income for the coverage year be used as current income in determining
eligibility at the time an application is filed if projected income for the
coverage year will be lower than current income for the coverage year. The
application must include an itemized listing of current income for the coverage
year and projected income for the coverage year, together with documentation
for the lost sources of income used in calculating projected income. The
Department on Aging will allow such a request and use projected income as
current income in processing the application if its use will enable an
applicant to qualify for this program.
B) An applicant whose application has been
denied for exceeding maximum household income eligibility qualifications may
file a Schedule P requesting use of projected income for the coverage year as
current income for the coverage year in re-determining eligibility if projected
income for the coverage year will be lower than current income for the coverage
year. The Schedule must include an itemized listing of current income for the
coverage year and projected income for the coverage year, together with
documentation for the lost sources of income used in calculating projected
income. The Department on Aging will allow such a request and use projected
income as current income in processing the application if its use will enable
an applicant to qualify for this program.
C) A beneficiary whose application has been
approved for Illinois Cares Rx Basic may file a Schedule P requesting use of
projected income for the coverage year as current income for the coverage year
in redetermining the eligibility for Illinois Cares Rx Plus if projected income
for the coverage year will be lower than current income for the coverage year.
The Schedule must include an itemized listing of current income for the
coverage year and projected income for the coverage year, together with
documentation for the lost sources of income used in calculating projected
income. The Department on Aging will allow such a request and use projected
income as current income in processing the application if its use will enable a
beneficiary to qualify for Illinois Cares Rx Plus.
D) Amended applications for pharmaceutical
assistance benefits must be filed on the appropriate paper forms approved by
the Department on Aging prior to the expiration of the coverage year for the
coverage year at issue.
E) A
beneficiary may not use projected income for two consecutive years, except in
the case of hardship such as death, change in marital status or
retirement.
2) Countable
Income
The earned and unearned income of the applicant and his or her
spouse (if the spouse resides with the applicant) shall be counted when
determining eligibility.
3)
Assets shall not be considered.
4)
Illinois Cares Rx Plus participants shall be exempt from the requirements of 89
Ill. Adm. Code
102.210,
Estate Claims, with regard to expenditures made for Illinois Cares Rx
benefits.
e) An
individual who is eligible for medical assistance with a spenddown may
participate in Illinois Cares Rx, if that individual meets all of the
eligibility requirements for participation in the program.
f) An individual who receives benefits from
any of the Medicare Savings programs, the Qualified Medicare Beneficiary (QMB)
program, the Specified Low Income Medicare Beneficiary (SLIB) program, or the
Qualified Individual (QI) program may participate in Illinois Cares Rx, if that
individual meets all of the eligibility requirements for participation in the
program.
g) Application Process
1) An application for pharmaceutical
assistance benefits under the Act must be filed on the appropriate paper or
electronic forms approved by the Department on Aging.
2) Individuals shall apply by completing and
submitting an application as specified by the Illinois Department on
Aging.
3) Spouses who live together
in the same residence may apply on the same application as long as the
application contains both signatures.
4) After eligibility is determined by the
Illinois Department on Aging, notice of the outcome shall be sent to the
applicant.
5) An individual
enrolled in Illinois Cares Rx shall receive coverage under his or her own name
and unique Recipient Identification Number.
h) Enrollment Periods
1) Enrollment shall be effective the first of
the month no later than the second month after the date when the applicant was
determined to be eligible for the program.
2) The initial coverage period shall continue
from the effective date of the enrollment through the end of the calendar year
following the year in which the beneficiary filed the application for Illinois
Cares Rx benefits.
3) Individuals
must reapply annually.
4)
Subsequent uninterrupted periods of enrollment shall be for 12 months and shall
be coincident with the calendar year.
i) Authorization of Illinois Cares Rx
Once an individual has been determined eligible for Illinois
Cares Rx, an Illinois Cares Rx identification card shall be sent to the
individual.
j) Illinois
Cares Rx coverage shall terminate:
1) at the
end of a participant's coverage period unless the participant reapplies timely
and is found to continue to be eligible;
2) when a participant no longer resides in
Illinois;
3) when a participant
becomes an inmate of a public institution;
4) upon a participant's death;
5) upon discovery that the initial
determination of the participant's eligibility was incorrect; or
6) when a participant fails to apply for any
low income subsidy available under Medicare Part D, except in cases where the
Department has deemed the individual to be compliant based on the Department's
data.
k) Appeal Rights
Any applicant or beneficiary aggrieved by action of the
Department on Aging under the Act, whether in the denial of an application or
amended application may request in writing that the Department on Aging
reconsider its action, setting out the facts on which the request is based. The
Department on Aging will consider the request and either affirm or modify its
action.
