Sec. 530.117 - Claim Filing Procedures

ยง 530.117. Claim Filing Procedures

a) Pharmaceutical Assistance Claims

1) A claim for pharmaceutical assistance benefits under the Act must be filed on the appropriatepaper or electronicforms approved by the Department in a timely manner.The claim must be filed after January 1 but on or before December 31 of the calendar year following the claim year as evidenced by the postmark on metered and posted claims, or the date-stamp of receipt on hand-delivered claims at the Department or its regional offices, or the transmission date to confirm receipt of facsimile claims and electronic applications filed with the Department via the Internet. [320 ILCS 25/5(a)]

2) Only one applicant may file a claim for each household for a claim year. If more than one person in a household and, for the 2000 claim year and later claim years, any additional resident, is eligible to file a claim under the Act, they must agree as to which of them will file the claim for the claim year as the claimant and the other person or additional resident must sign the claim as an applicant. [320 ILCS 25/5(c)]

3) An applicant must submit proof of his or her eligibility qualifications as set forth in Section 530.115.

A) Examples of proof of date of birth include:

i) a baptismal record; or

ii) a birth certificate; or

iii) a driver's license; or

iv) an identification card from the Secretary of State's office; or

v) an insurance policy; or

vi) naturalization papers; or

vii) a passport.

B) Examples of proof of disability include:

i) proof that an applicant is eligible to receive disability benefits under the federal Social Security Act of 1935 (see 42 USC 423); or

ii) 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

iii) status of applicant as a disabled person determined by a physician designated by the Department 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

iv) receipt by applicant of Railroad (see 45 USC 231), Civil Service, or Veterans' total disability benefits (see 38 USC 101). [320 ILCS 25/3.14]

4) For the 2000 claim year and thereafter, an applicant may request that projected income for the coverage year be used as current income in determining eligibility at the time a claim is filed if projected income for the coverage year will be lower than current income for the claim year. The claim must be filed in a timely manner and the request must include an itemized listing of current income for the claim year and projected income for the coverage year, together with documentation for the lost sources of income used in calculating projected income. The Department will allow such a request and use projected income as current income in processing the claim if its use will enable an applicant to qualify for this program. (See 320 ILCS 25/5(e).)

b) Amended Pharmaceutical Assistance Claims

1) For the 2000 claim year and thereafter, an applicant whose claim has been denied for exceeding maximum household income eligibility qualifications may file an amended claim requesting use of projected income for the coverage year as current income for the claim year in re-determining eligibility if projected income for the coverage year will be lower than current income for the claim year. The amended claim must be filed in a timely manner and the request must include an itemized listing of current income for the claim year and projected income for the coverage year, together with documentation for the lost sources of income used in calculating projected income. The Department will allow such a request and use projected income as current income in processing the amended claim if its use will enable an applicant to qualify for this program. (See 320 ILCS 25/5(e).)

2) For the 2000 claim year and thereafter, a beneficiary whose claim has been approved may file an amended claim requesting use of projected income for the coverage year as current income for the claim year in re-determining the co-payment for covered prescription drugs if projected income for the coverage year will be lower than current income for the claim year. The amended claim must be filed in a timely manner and the request must include an itemized listing of current income for the claim year and projected income for the coverage year, together with documentation for the lost sources of income used in calculating projected income. The Department will allow such a request and use projected income as current income in processing the amended claim if its use will enable a beneficiary to qualify for a lower co-payment for covered prescription drugs. (See 320 ILCS 25/5(e).)

3) Amended claims for pharmaceutical assistance benefits must be filed on the appropriate paper forms approved by the Department prior to the expiration of the coverage year for the claim year at issue.

4) For the 2000 claim year and later claim years, in the event that a beneficiary has been issued a card for the coverage year and an amended claim using projected income as current income is processed and approved subsequently by the Department, the amount of the co-payment will be reduced accordingly at the beginning of the next qualifying month of coverage. There will be no change in the fee that has already been paid for a card.

c) Refunds

A beneficiary may submit a written request prior to the expiration of the coverage year for a refund of the card fee if pharmaceutical assistance benefits have not been used.

d) Appeal Rights

1) Any applicant or beneficiary aggrieved by action of the Department under the Act, whether in the denial of a claim or amended claim, or in the determination of the fee for a card or the amount of a deductible, co-payment, or ancillary charge, may request in writing that the Department reconsider its action, setting out the facts on which the request is based. The Department will consider the request and either affirm or modify its action. [320 ILCS 25/7(c)]

2) The decision of the Department to affirm its action, or the failure of the Department to act on a request for reconsideration within 60 days, is a final administrative decision that is subject to judicial review under the Administrative Review Law [735 ILCS 5 /Art. III]. [320 ILCS 25/7(d)]

(

Amended at 26 Ill. Reg. 8437, effective May 24, 2002

)

The following state regulations pages link to this page.