89 Ill. Adm. Code 120.500. HEALTH BENEFITS FOR PERSONS WITH BREAST OR CERVICAL CANCER

Section 120.500 Health Benefits for Persons with Breast or Cervical Cancer

a) A person shall be eligible for medical assistance if the person meets the following eligibility requirements under Health Benefits for Persons with Breast or Cervical Cancer (BCC):

1) Cooperates in establishing eligibility as described in Section 120.308.

2) Meets citizenship/immigration status as described in Section 120.310.

3) Meets residency requirements as described in Section 120.311.

4) Assigns rights to medical support and collection of payment as described in Section 120.319.

5) Furnishes a Social Security number as described in Section 120.327.

6) Is under the age of 65 years.

7) Has been screened for breast or cervical cancer under the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) administered by the Illinois Department of Public Health (IDPH) as described in subsection (c) of this Section, and has been found to need treatment, as defined in subsection (d) of this Section, for breast or cervical cancer or a precancerous condition as defined in subsection (e) of this Section.

8) Continues to need treatment as defined in subsection (d) of this Section.

9) Is uninsured, that is, must not have creditable coverage, as defined under the Health Insurance Portability and Accountability Act, for breast or cervical cancer treatment.

b) A person shall not be determined eligible for Health Benefits for Persons with Breast or Cervical Cancer:

1) if, upon screening by the Department, the person is found to be otherwise eligible for medical assistance under Section 120.11, 120.20 or 120.30 without a spenddown; or

2) if the person is in a correctional facility pursuant to 42 CFR 435.1008.

c) A person shall meet the screening requirement if:

1) the person's breast or cervical cancer screening was conducted within the scope of a grant, sub-grant or contract under the NBCCEDP administered by IDPH; or

2) beginning September 1, 2006, the person's diagnosis of breast or cervical cancer or precancerous cervical condition was confirmed by an entity receiving a grant, sub-grant or contract under the NBCCEDP administered by IDPH.

d) A person shall be considered to need treatment if, in the opinion of the person's treating physician, the person requires therapy directed toward cure or palliation of breast or cervical cancer, including recurrent metastatic cancer that is a known or presumed complication of breast or cervical cancer and complications resulting from the treatment modalities themselves. Treatment includes diagnostic services that may be necessary to determine the extent and proper course of treatment. Persons who require only routine monitoring services (for example, pap smears or mammograms) are not considered to need treatment.

e) For the purposes of this Section, a precancerous condition means:

1) Cervical intraepithelial neoplasia, grade III (CIN III);

2) Severe dysplasia of the cervix;

3) High-grade squamous intraepithelial lesion (HGSIL); or

4) Atypical glandular cells of undetermined significance (AGUS) with a suspicion of adenocarcinoma in situ.

f) All assets shall be exempt from consideration in determining eligibility under this Section.

g) A person's eligibility for medical assistance under this Section shall be terminated when the person no longer meets the requirements of this Section.

h) Application Process

1) The process of applying for medical assistance shall be initiated by the submission to the Department, by an entity designated by IDPH, of a statement certifying that a person meets the condition of eligibility described in subsection (a)(7) of this Section.

2) The Department shall contact the person by telephone, mail or other appropriate means to complete an application.

3) The application date shall be the date a signed application is received in the Department's central breast and cervical cancer eligibility unit.

4) Application may be made by additional methods that the Department establishes.

5) Applications shall meet all requirements found at 89 Ill. Adm. Code 110.10(a), (c), (e) and (i).

6) A BCC application is only an application for Health Benefits for Persons with Breast or Cervical Cancer.

i) Authorization of Medical Assistance Eligibility

1) Eligibility will be effective no earlier than the third month before the month of application if the applicant would have been eligible if he or she had applied. In no case shall eligibility be effective prior to July 1, 2001, for persons meeting the screening requirement described in subsection

(c)(1) of this Section, or prior to September 1, 2006, for persons meeting the screening requirement described in subsection (c)(2) of this Section.

2) Eligibility can begin no earlier than the following:

A) for persons meeting the screening requirement described in subsection (c)(1) of this Section, the month in which the applicant was screened as described in subsection (a)(7) of this Section; or

B) for persons meeting the screening requirement described in subsection (c)(2) of this Section, the month in which the applicant received the test or procedure that resulted in a diagnosis of breast or cervical cancer or one of the precancerous cervical conditions described in subsection (e) of this Section.

j) Persons enrolled in Health Benefits for Persons with Breast or Cervical Cancer shall be exempt from Sections 102.210 and 102.230.

k) Persons enrolled in Health Benefits for Persons with Breast or Cervical Cancer who enter a nursing facility must provide income information sufficient for the Department to calculate a group care credit, as established in Sections 120.40 and 120.60, except that assets shall not be counted. The Department will not pay for nursing facility services for any person who refuses to provide the required information.

l) Persons applying for or enrolled in Health Benefits for Persons with Breast or Cervical Cancer shall be entitled to appeal rights as described at 89 Ill. Adm. Code 102.80-83.

(Source: Amended at 31 Ill. Reg. 2629, effective January 28, 2007)