Section 120.510 Health Benefits for Workers with Disabilities

Section 120.510  Health

Benefits for Workers with Disabilities

a)         To be eligible for medical assistance under Health Benefits

for Workers with Disabilities, an individual must meet all of the following

eligibility requirements:

1)         Cooperate in establishing eligibility as described in Section

120.308.

2)         Meet citizenship/immigration status as described in Section

120.310.

3)         Meet residency requirements as described in Section 120.311.

4)         Be disabled as described in Section 120.314.

5)         Assign rights to medical support and collection of payment as

described in Section 120.319.

6)         Furnish a Social Security number(s) as described in Section

120.327.

7)         Be 16 through 64 years of age.

8)         Have countable monthly income at or below 350 percent of the

Federal Poverty Level.

9)         Have non-exempt assets at or below $25,000.

10)         Be employed pursuant to subsection (l)(1) of this Section or

qualify for an exception as described in subsection (l)(2) of this Section.

11)         Pay a premium pursuant to subsections (m) and (n) of this

Section.

b)         An individual shall not be determined eligible if the

individual is otherwise eligible for medical assistance without a spenddown.

c)         An individual who is otherwise eligible for medical assistance

with a spenddown and who meets the requirements of this Section shall have the

option of enrolling in medical assistance with a spenddown or Health Benefits

for Workers with Disabilities.

d)         An individual's eligibility shall be terminated if the

individual no longer meets the requirements of this Section.

e)         Certain assets shall be exempt from consideration in

determining eligibility in accordance with Section 120.381.  In addition,

retirement accounts that the individual cannot access without penalty before

the age of 59½ and medical savings accounts established pursuant to 26 USC 220

shall be exempt

all be terminated if the

individual no longer meets the requirements of this Section.

e)         Certain assets shall be exempt from consideration in

determining eligibility in accordance with Section 120.381.  In addition,

retirement accounts that the individual cannot access without penalty before

the age of 59½ and medical savings accounts established pursuant to 26 USC 220

shall be exempt.

f)         The earned and unearned income of the following persons shall

be counted when determining eligibility, except as specified in subsections

(g), (h) and (i) of this Section.

1)         Income of the individual.

2)         Income of the spouse.

3)         Unearned income of a dependent child under the age of 18 years

who is included in the income standard (see Section 120.20) because it is to

the advantage of the individual.

g)         Monthly unearned income shall be counted as described in

Sections 120.330 through 120.345 and Sections 120.350, 120.355, 120.371 and

120.376.

h)         Monthly earned income shall be considered as described in

Sections 120.360, 120.361, 120.371, 120.372, 120.373 and 120.375.

i)          The Department shall exempt earned income as provided in

Section 120.362(a) and (b)(1).  In addition, work related expenses that are

allowed as deductions for AABD MANG as described in Section 120.370 shall be

deducted.

j)          Application Process

1)         Individuals can apply by completing an application provided by

the Department and submitting it to an address specified by the Department.

2)         The application must meet all requirements found at 89 Ill.

Adm. Code 110.10(a), (c), (e) and (i).

k)         Authorization of Medical Assistance Eligibility

1)         Medical assistance coverage will not be provided for any month

for which eligibility is established unless a premium is paid in accordance

with subsections (m) and (n) of this Section

ress specified by the Department.

2)         The application must meet all requirements found at 89 Ill.

Adm. Code 110.10(a), (c), (e) and (i).

k)         Authorization of Medical Assistance Eligibility

1)         Medical assistance coverage will not be provided for any month

for which eligibility is established unless a premium is paid in accordance

with subsections (m) and (n) of this Section.

2)         Subject to subsections (k)(2)(A), (B) and (C) of this Section,

the applicant may choose to receive medical assistance for months prior to the

initial month of prospective eligibility as determined in accordance with

subsections (m) and (n) of this Section.

A)        Eligibility will be effective no earlier than the third month

before the month of application if the applicant received covered medical

services during that period and would have been eligible if he or she had

applied for Health Benefits for Workers with Disabilities.

B)        Months of backdated coverage selected must be consecutive and

must be continuous with the initial month of prospective eligibility.

C)        Monthly premiums must be paid for all the months of coverage.

l)          Individuals Considered Employed

1)         For purposes of this program, an individual shall be

considered employed if the individual provides verification that current

payment under the Federal Insurance Contributions Act (FICA) or Illinois

Municipal Retirement Fund (IMRF) has been made on behalf of the individual.

2)         Under the following circumstances, an individual may be

enrolled in this program without providing evidence of employment as described

in subsection (l)(1) of this Section:

A)        Individuals who are not employed at the time of application,

but who can verify that they will be employed within 60 days, may be enrolled

but will not be considered eligible until they begin employment and pay the

appropriate premium in accordance with subsections (m) and (n) of this Section

without providing evidence of employment as described

in subsection (l)(1) of this Section:

A)        Individuals who are not employed at the time of application,

but who can verify that they will be employed within 60 days, may be enrolled

but will not be considered eligible until they begin employment and pay the

appropriate premium in accordance with subsections (m) and (n) of this Section.

B)        Individuals who become unable to work for medical reasons after

enrollment in this program who wish to remain in the program. Such individuals:

i)          Must report to the Department within 30 days after the first

day that they were unable to work.

ii)         Must provide a physician's written statement that they are

unable to work, but that the anticipated date for the return to work is within

90 days after the first day they were unable to work.

iii)        Must pay premiums in accordance with subsections (m) and (n)

of this Section for the months during which they do not work.

C)        Individuals who cease employment for any other reason may

continue to be enrolled for 30 days after the employment ends provided they pay

premiums in accordance with subsections (m) and (n) of this Section for the

period during which they do not work.

3)         Eligibility shall be terminated:

A)        If an individual determined to be employed according to

subsection (l)(2)(A) of this Section does not provide evidence of employment

pursuant to subsection (l)(1) of this Section within 30 days after enrollment.

B)        If an individual is unable to work for medical reasons, as

described in subsection (l)(2)(B) of this Section, for 90 days or more.

C)        If an individual ceases employment for any other reason

(subsection (l)(2)(C) of this Section) and does not obtain new employment

within 30 days after cessation of employment

t to subsection (l)(1) of this Section within 30 days after enrollment.

B)        If an individual is unable to work for medical reasons, as

described in subsection (l)(2)(B) of this Section, for 90 days or more.

C)        If an individual ceases employment for any other reason

(subsection (l)(2)(C) of this Section) and does not obtain new employment

within 30 days after cessation of employment.

m)        Premiums

1)         The Department must receive payment of the monthly premium for

an applicant's initial prospective month of eligibility before the applicant

can be enrolled in this program.  If payment of the premium is received by the

20th day of the month, the initial month of prospective eligibility shall begin

the first day of the following month.  (For example, if the premium payment is

received on February 20, coverage shall begin on March 1.  If the premium

payment is received after February 20 but before March 21, coverage shall begin

on April 1.)

2)         Premiums for months of backdated coverage must be paid within

90 days after the date of the notice of eligibility approval.

3)         Subsequent premiums are due on the 20th day of the month prior

to the month of coverage.

4)         If payment of the premium is not received in full by the end

of the month following the due date of the premium, coverage will terminate

effective the end of the second month following the due date and collection action

may be initiated by the Department for the unpaid premiums for months of

coverage.

n)         Determination of Premium Amount

1)         Premiums shall be based upon an individual's combined gross

unearned and countable earned income as determined at the point of application

or review or redetermination of eligibility.

2)         The Department shall reset a premium prospectively based on

verified income.

3)         Premium amounts shall be established as set forth in the

following monthly premium tables

emium Amount

1)         Premiums shall be based upon an individual's combined gross

unearned and countable earned income as determined at the point of application

or review or redetermination of eligibility.

2)         The Department shall reset a premium prospectively based on

verified income.

3)         Premium amounts shall be established as set forth in the

following monthly premium tables.

$s Per Month

Countable Earned Income

Gross Unearned Income

0-

250

251-500

501-750

751-1000

1001-1250

1251-1500

1501-1750

1751-2000

2001-2250

2251-2500

2501-2750

2751-3000

0-250

--

19

38

56

75

94

113

131

150

169

188

206

251-500

6

25

44

63

81

100

119

137

156

175

194

212

501-750

13

31

50

69

88

107

126

144

163

182

201

219

751-1000

19

38

56

75

94

113

132

150

169

188

207

225

1001-1250

25

44

63

81

100

119

137

156

175

194

213

231

1251-1500

31

50

79

87

106

125

144

162

181

200

219

237

1501-1750

38

57

76

94

113

132

151

169

188

206

226

244

1751-2000

44

63

82

100

119

138

157

175

194

213

232

250

2001-2250

50

69

88

106

125

144

163

181

200

219

238

256

2251-2500

56

75

94

112

131

150

169

187

206

225

244

262

2501-2750

63

82

101

119

138

157

176

194

213

232

251

269

2751-3000

69

88

107

125

144

163

182

200

219

238

257

275

3001-3250

75

94

113

131

150

169

188

206

225

244

263

281

3251-3500

81

100

119

137

156

175

194

212

231

250

269

287

3501-3750

88

107

126

144

163

182

201

219

238

257

276

294

3751-4000

94

113

132

150

169

188

207

225

244

263

282

300

4001-4250

100

119

138

156

175

194

213

231

250

269

288

306

4251-4500

106

125

144

162

181

200

219

237

256

275

294

312

4501-4750

113

132

151

169

188

207

226

244

263

282

301

319

4751-5000

119

138

157

175

194

213

232

250

269

288

307

325

5000 +

125

144

163

181

200

219

238

256

275

294

313

331

$s Per Month

Countable Earned

Income

Gross Unearned

Income

3001-3250

3251-3500

3501-3750

3751-4000

4001-4250

4251-4500

4501-4750

4751-5000

5000+

0-250

225

244

263

281

300

319

338

356

375

251-500

231

250

269

287

306

325

344

362

381

501-750

238

257

276

294

313

332

351

369

388

751-1000

244

263

282

300

319

338

357

375

394

232

250

269

288

307

325

5000 +

125

144

163

181

200

219

238

256

275

294

313

331

$s Per Month

Countable Earned

Income

Gross Unearned

Income

3001-3250

3251-3500

3501-3750

3751-4000

4001-4250

4251-4500

4501-4750

4751-5000

5000+

0-250

225

244

263

281

300

319

338

356

375

251-500

231

250

269

287

306

325

344

362

381

501-750

238

257

276

294

313

332

351

369

388

751-1000

244

263

282

300

319

338

357

375

394

1001-1250

250

269

288

306

325

344

363

381

400

1251-1500

256

275

294

312

331

350

369

387

406

1501-1750

263

282

301

319

338

357

376

394

413

1751-2000

269

288

307

325

344

363

382

400

419

2001-2250

275

294

313

331

350

369

388

406

425

2251-2500

281

300

319

337

356

375

394

412

431

2501-2750

288

307

326

344

363

382

401

419

438

2751-3000

294

313

332

350

369

388

407

425

444

3001-3250

300

319

338

356

375

394

413

431

450

3251-3500

306

325

344

362

381

400

419

437

456

3501-3750

313

332

351

369

388

407

426

444

463

3751-4000

319

338

357

375

394

413

432

450

469

4001-4250

325

344

363

381

400

419

438

456

475

4251-4500

331

350

369

387

406

425

444

462

481

4501-4750

338

357

376

394

413

432

451

469

488

4751-5000

344

363

382

400

419

438

457

475

494

5000+

350

369

388

406

425

444

463

481

500

o)         Medicaid

Buy-In Program Revolving Fund (see 305 ILCS 5/12-10.6)

1)         The

Medicaid Buy-In Revolving Fund consists of premiums paid by eligible

individuals under this Section.

2)         Monies

in the Fund may be used to pay costs incurred by the Department for:

A)        Administering

the Health Benefits for Workers with Disabilities (HBWD) program, including,

but not limited to, staff, equipment, travel, outreach activities and other

operating costs.

B)        Personal

assistance services (PAS) provided at an individual's work site

individuals under this Section.

2)         Monies

in the Fund may be used to pay costs incurred by the Department for:

A)        Administering

the Health Benefits for Workers with Disabilities (HBWD) program, including,

but not limited to, staff, equipment, travel, outreach activities and other

operating costs.

B)        Personal

assistance services (PAS) provided at an individual's work site.  PAS under the

HBWD program is limited to individuals who do not already receive PAS, have a

need for such services on the basis of a disability as described in Section

120.314, and, except for their income and non-exempt assets, would be eligible

for the Community Care Program as described at 89 Ill. Adm. Code 240.  The

need, amount and duration of PAS will be assessed through a determination of

need process.