TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.100 GENERAL DESCRIPTION
Section 128.100 General Description
This Part implements the Veterans'
Health Insurance Program
Act of 2008 [330 ILCS 126] that
authorizes the Department to administer a program to offer uninsured veterans and
their spouses in Illinois access to health benefits. The Department
coordinates with the Illinois Department of Veterans' Affairs to assist
veterans to apply for the program. Eligible veterans are not eligible for
Veterans Administration Healthcare or other State-administered health
benefits. The Department shall provide health benefits coverage to eligible
veterans and their spouses through purchasing or providing health care
benefits. When cost-effective, the Department may offer veterans and spouses subsidies
toward the cost of privately sponsored health insurance, including
employer-sponsored health insurance.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
 | TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.110 DEFINITIONS
Section 128.110 Definitions
For the purpose of this Part, the
terms shall be defined as follows:
"Act"
means the Veterans' Health Insurance Program Act of 2008 [330 ILCS 126].
"Department"
means the Department of Healthcare and Family Services and any successor
agencies.
"DVA" means the Illinois Department of Veterans
Affairs.
"Family"
means the veteran applying for the program and the following individuals living
with the veteran who are counted in determining eligibility:
The spouse of the veteran;
Children under 19 years of age of the veteran or the
veteran's spouse;
If the veteran or the spouse is pregnant, the unborn
children.
"Federal
Poverty Level" means the federal poverty income guidelines as established
by the federal Department of Health and Human Services and published in the
Federal Register.
"Health
Insurance" means health insurance coverage as defined in 215 ILCS 105/2.
"Practitioner"
means a physician (including a hospital billing a physician office visit),
osteopath, podiatrist, optometrist, chiropractor, advanced practice nurse,
Federally Qualified Health Center, Rural Health Clinic or Encounter Rate
Clinic.
"Program"
means the program created under the Veterans' Health Insurance Program Act and
this Part, commonly called Veterans Care.
"Resident"
means an individual who has an Illinois residence, as provided in Section 5-3
of the Illinois Public Aid Code.
"Spouse"
means the person who, under the laws of the State of Illinois, is married to an
eligible veteran at the time of application and subsequent redetermination for
the program and includes enrolled spouses surviving the death of the eligible veteran.
"Uninsured"
means the person is not covered by group or individual health insurance that
provides coverage for hospitalization and physician visits.
"Veteran"
means an individual who served for at least 180 days after initial training in
any branch of the U.S. military including the Reserves and National Guard. The
veteran must not be currently on active duty in the U.S. military.
"Veterans
Administration Geographic Means Test" means the U.S. Department of
Veterans Affairs Healthcare Program Enhancement Act of 2009 (38 USC 1705(a)(7))
income guidelines established annually by county and published in the Federal
Register for determining eligibility for Veterans Administration healthcare.
The income guidelines can also be found at:http://www.va.gov/healtheligibility/Library/pubs/
GMTIncomeThresholds.
"Veterans
Administration Healthcare" means any of the health programs or services
provided or administered by the U.S. Department of Veterans Affairs.
"Veterans Care" means the common name for this
program under the Act.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
SUBPART B: GENERAL ELIGIBILITY AND ENROLLMENT
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.200 ELIGIBILITY
Section 128.200 Eligibility
A veteran may be eligible for
Veterans Care provided that all of the following eligibility criteria are met:
a) The veteran is not eligible for Veterans
Administration healthcare, medical assistance under the Public Aid Code or
benefits, including rebates, under the Children's Health Insurance Program Act;
b) The
veteran was not dishonorably discharged;
c) The veteran is a
resident of the State of Illinois;
d) The veteran is at least
19 and is no more than 64 years of age; and
e) The veteran meets one of
the following:
1) The veteran has been
uninsured for at least three months;
2) The
veteran lost health insurance when the veteran's or the veteran's spouse's job
ended within six months prior to applying under this Part;
3) The
veteran has exhausted the life-time benefit limit of his or her health
insurance within six months prior to applying under this Part;
4) The
veteran's health insurance is purchased under the provisions of the
Consolidated Omnibus Budget Reconciliation Act (COBRA);
5) The
veteran was disenrolled for medical assistance under the Public Aid Code or
benefits, including rebates under the Children's Health Insurance Program Act,
within six months prior to applying under this Part;
6) The
veteran has health insurance provided by the veteran's spouse but the veteran
is unable to access such health insurance benefits;
7) The veteran has post-active
duty related TRICARE healthcare coverage.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.210 ELIGIBILITY EXCLUSIONS AND TERMINATIONS
Section 128.210 Eligibility Exclusions and Terminations
a) A veteran or spouse shall
not be determined eligible for Veterans Care if:
1) The
veteran or spouse is an inmate of a public institution.
2) The
veteran or spouse is a resident of a nursing facility.
b) A veteran's coverage
under the program shall be terminated if the veteran:
1) Loses
his or her Illinois residency. If the spouse loses Illinois residency, only
the spouse loses eligibility.
2) Attains
65 years of age. If the spouse attains 65 years of age before the veteran,
only the spouse loses eligiblity.
3) Becomes
enrolled in Veterans Administration healthcare, medical assistance under the
Public Aid Code or health benefits including rebates under the Children's
Health Insurance Program Act (CHIPA). If the spouse becomes enrolled in VA
Healthcare, medical assistance under the Public Aid Code or CHIPA, only the
spouse loses eligiblity.
4) Meets
the provisions of subsection (a) of this Section.
5) Fails
to pay the premium as specified in Section 128.330.
6) Fails
to report to the Department changes that affect eligibility for the program.
7) Asks
the Department to terminate the coverage.
8) Is no
longer eligible based on any other applicable State or federal law or
regulation.
9) Failed
to provide eligibility information that was truthful and accurate to the best
of the veteran's knowledge and belief and that affected the veteran's
eligibility.
10) Was
incorrectly determined eligible.
11) Fails
to complete the redetermination of eligibility within the required timeframes
or provide proof of on-going eligibility.
12) Becomes
a resident of a nursing facility or inmate in a public institution. If the
spouse becomes a resident of a nursing facility or inmate in a public
institution, only the spouse loses eligibility.
c) Following
termination of a veteran's coverage under the program, the following action is
required before the veteran and spouse can be re-enrolled:
1) A new
application must be completed and the veteran must be determined otherwise
eligible.
2) There
must be full payment of premiums due under this Part for periods in which a
premium was owed and not paid.
3) If
the termination was the result of non-payment of premiums, the veteran and
spouse are ineligible for the program for three months, starting with the first
month of cancellation or termination from coverage, before becoming eligible
for re-enrollment.
4) If
there was an unpaid premium from a previous coverage period, the unpaid
premium, in addition to the first month's premium, must be paid before new
coverage may begin.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.220 APPLICATION PROCESS
Section 128.220 Application Process
a) Veterans apply for the program by submitting the
Veterans Care application to the Department, or through one of the DVA's
Veterans Service Offices, through the Veterans Assistance Commission serving
the veteran's community, or through a U.S. Veterans Administration facility in Illinois. The Department may designate additional entities that may assist veterans to
submit applications.
b) The application must meet all requirements found
at 89 Ill. Adm. Code 110.10, including provisions regarding who may apply on
behalf of the veteran.
c) Applicants are obligated to provide truthful and
accurate information for determining eligibility and to promptly report any change
in information provided on the application.
d) The Department may stop taking applications if
that is necessary to maintain the cost of the program within the available
funding.
e) An
eligible veteran may choose to apply to add the spouse to his or her existing
case.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.230 DETERMINATION OF MONTHLY COUNTABLE INCOME
Section 128.230 Determination of Monthly Countable
Income
a) The
earned and unearned income of the following persons shall be
counted when determining eligibility, except as specified in subsections (b)
and (c) of this Section.
1) Income
of the veteran;
2) Income
of the veteran's spouse;
3) Unearned
income of a dependent child under the age of 18 years who is included in the
income standard as set forth at 89 Ill. Adm. Code 120.20 because it is to the
advantage of the veteran.
b) Monthly
unearned income shall be counted as described at 89 Ill. Adm. Code 120.330
through 120.345 and Sections 120.350, 120.355, 120.371 and 120.376. However,
89 Ill. Adm. Code 120.335(a) shall not apply.
c) Monthly
earned income shall be considered as described at 89 Ill. Adm. Code 120.360,
120.361 and 120.371 through 120.375.
(Source: Amended at 33 Ill.
Reg. 17082, effective December 2, 2009)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.240 ELIGIBILITY DETERMINATION AND ENROLLMENT PROCESS
Section 128.240 Eligibility Determination and Enrollment
Process
a) The
applicant's military discharge status, time spent in active duty, health
insurance status and eligibility for Veterans Administration healthcare will be
reviewed first.
b) For
the purpose of determining eligibility under this Part, applicants who are not
found ineligible under subsection (a) of this Section will be screened for
eligibility for medical assistance under the Public Aid Code or health benefits,
including rebates, under the Children's Health Insurance Program Act. Veterans
who are likely to be eligible for these other programs will be directed to
apply for them. Veterans and their spouses may be enrolled under this Part
while an application for coverage under another program is pending.
c) If
the monthly countable income is equal to or less than the Veterans Care income
standard, the application will be approved if all other factors of eligibility
are met. The Veterans Care income standard is 50 percent of the Federal Poverty
Level plus the Veterans Administration Geographic Means Test threshold.
d) Applicants
will be notified, in writing, regarding the outcome of their eligibility
determination.
e) Eligibility
determinations for the program made by the 10th day of a month will
be effective the first day of the following month. Eligibility determinations
for the program made after the 10th day of a month will be effective
no later than the first day of the second month following that determination.
f) The
duration of eligibility for the program will be 12 months unless one of the
events described in Section 128.210(b) occurs or the Department shortens the
enrollment period to maintain program spending within available funding.
g) Veterans
and their spouses may obtain backdated medical coverage for the month of
application plus up to three months prior to the month of application, except
as stated in Section 128.330(a). Spouses are not eligible to be included for
backdated months prior to December 1, 2012. This coverage shall be subject to
the veteran paying the premiums for the months of backdated coverage
requested. The veteran and spouse may choose the month for which backdated
coverage will begin. Backdated months of coverage shall be consecutive
beginning with the initial month of backdated coverage requested.
h) At
the sole discretion of the Department, the Department may reduce the income
threshold established in subsection (c) of this Section if necessary to keep
the cost of the program within available funding.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.250 APPEALS
Section 128.250 Appeals
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 an application.
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 Part. No eligibility exists during the appeal
process. If the appeal is upheld, the veteran or spouse will have the opportunity
to receive coverage back to the original application date, including possible
backdated months or the cancellation month. All premium and co-payment
requirements shall apply to the retroactive period.
3) Termination
of coverage based on failure to continue to meet one or more of the eligibility
requirements specified in this Part. If the termination is not upheld on
appeal, coverage under the Program shall be reinstated retroactive to the
termination date. All premium and co-payment requirements shall apply to any
retroactive period. The veteran or spouse 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) Determination
of the amount of the premium or co-payments required. Any premium or
co-payment requirements shall remain in force during the appeal process.
5) 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) cease
accepting applications pursuant to Section 128.220(d).
B) increase
premium levels for all individuals within an income range.
C) require
more frequent redeterminations of eligibility.
D) increase
the income standard.
b) In
addition to the actions that are appealable under subsection (a) of this
Section, individuals shall have the right to appeal any of the following
actions:
1) Termination
of coverage due to non-payment of the required premium.
2) Denial
of payment for a medical service or item that requires prior approval.
3) 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:
1) Filing
a written, signed request for a hearing directed to the Department's Bureau of
Administrative Hearings;
2) Calling
a toll free telephone number designated by the Department.
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 has been given.
g) The
provisions of Subpart A of the Department's administrative rules at 89 Ill.
Adm. Code 104, 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.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.260 RENEWALS OF ELIGIBILITY
Section 128.260 Renewals of Eligibility
a) Eligibility shall be
reviewed at least annually.
b) Prior
to the eligibility period ending, and in sufficient time for the veteran and
spouse to respond to the Department's request for information, the Department
or its designee will send an annual renewal notice to the veteran.
c) Renewals
shall be subject to all eligibility requirements and exclusions set forth in
Sections 128.200, 128.210, 128.230 and 128.240.
d) The
Department may require renewal of eligibility more frequently than annually if
necessary to keep spending within available funding.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.300 COVERED SERVICES
Section 128.300 Covered Services
Covered health care services shall be the same as covered
services for adults described in the State's approved plan under Title XIX of
the Social Security Act, except as provided in Section 128.310.
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.310 SERVICE EXCLUSIONS
Section 128.310 Service Exclusions
The following health care services shall not be covered
under this Part.
a) Non-emergency medical
transportation.
b) Nursing facility
services.
c) Funeral and burial
expenses.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.320 CO-PAYMENTS AND COST SHARING
Section 128.320 Co-payments and Cost Sharing
a) Co-payments
or cost sharing may be charged for services provided to a veteran and spouse by
a health care provider as described in subsection (b), except for practitioner
visits scheduled for family planning services.
b) Co-payment and cost
sharing requirements are as follows:
1) Practitioner
office visits, $15;
2) Dental
visits, $15;
3) Inpatient
hospitalizations, $150 per hospital stay;
4) Hospital
or Ambulatory Surgical Treatment Center outpatient services set forth at 89
Ill. Adm. Code 148.140(b), 10 percent of the Department rate as set forth in Section
128.350(c);
5) Hospital
Emergency Visits, $50;
6) Prescription
drugs, $6 for a 1- to 30-day supply of generic drugs or $14 for a 1- to 30-day
supply of brand name drugs.
c) Providers are
responsible for collecting co-payments.
d) Providers
may elect not to charge co-payments. If co-payments are charged, the
co-payment may not exceed the amounts established in this Section.
(Source: Amended at 44 Ill.
Reg. 19709, effective December 11, 2020)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.330 PREMIUM REQUIREMENTS
Section 128.330 Premium Requirements
a) Veterans
enrolled in Veterans Care must pay a monthly premium of $20. The veteran may
choose to enroll the eligible spouse for an additional $20 per month. For any
backdated months prior to December 1, 2012, premiums shall be as follows:
1) If
the Veteran's income is equal to or less than 25 percent of the Federal Poverty
Level plus the Veterans Administration Geographic Means Test threshold, the
premium is $40 per month.
2) If
the Veteran's income is more than 25 percent of the Federal Poverty Level plus
the Veterans Administration Geographic Means Test threshold and equal to or
less than 50 percent of the Federal Poverty Level plus the Veterans
Administration Geographic Means Test threshold, the premium is $70 per month.
3) There
are no backdated months for an eligible spouse prior to December 1, 2012.
Premiums for any backdated months after December 1, 2012 for an eligible spouse
are $20 per month.
b) Premiums
are billed by and payable to the Department, or its authorized agent, on a
monthly basis.
c) The
premium due date is the 20th day of the month preceding the month of
coverage.
d) The
premium may increase during the eligibility period if the Department makes a
decision to increase premiums to keep the program costs within available
funding.
e) Premiums
for backdated months must be received by the 90th day after the date
of eligibility determination. Coverage for backdated months is not provided if
the payment is not received by the due date.
(Source: Amended at 36Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.340 NON-PAYMENT OF PREMIUM
Section 128.340 Non-payment of Premium
a) For
initial coverage, the Veteran must pay the first monthly premium by the due
date to begin coverage for the Veteran and spouse. For subsequent months,
veterans will have a grace period of one month following the month in which the
premium was due to pay the premium.
b) Failure
to pay the full monthly premium by the last day of the grace period will result
in termination of coverage.
c) Partial premium payments
will not be refunded.
d) When
termination of coverage is recorded by the 10th day of the month, it
will be effective the first day of the following month. When termination of
coverage is recorded after the 10th day of the month, it will be
effective no later than the first day of the second month following.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
| TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 128
VETERANS' HEALTH INSURANCE PROGRAM
SECTION 128.350 PROVIDER REIMBURSEMENT
Section 128.350 Provider Reimbursement
a) Provider
participation under this Part shall be subject to enrollment with and approval
by the Department to provide health care under 89 Ill. Adm. Code 140.11 and
140.12.
b) Provider participation
under this Part shall be voluntary.
c) Providers
under this Part shall be reimbursed in accordance with the established rates of
the Department or other appropriate State agency (as set forth in 89 Ill. Adm.
Code 140, 143, 144, 148, 149, 152 and 153; 52 Ill. Adm. Code 132; and 77 Ill.
Adm. Code 2090) less co-payments or cost sharing as specified in Section
128.320, regardless of whether the patient share is collected.
d) Providers
under this Part shall be prohibited from billing veterans covered under
Veterans Care for any difference between the charge amount and the amount paid
by the Department other than the co-payment amounts specified in Section
128.320.
e) Providers
shall be responsible for refunding to the veteran and spouse co-payments
collected in excess of the amounts permitted by this Part.
(Source: Amended at 36 Ill.
Reg. 17062, effective November 26, 2012)
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