MERCY HOSPITAL ( U r b a n a ), Claimant, v. THE STATE OF ILLINOIS, Respondent.
Case summary
The claimant sought payment for hospital services rendered to a person whose eligibility for medical assistance was not established. The court awarded $2,649.01, the amount IDPA admitted was due, and dismissed the balance because the claimant failed to show the person was an eligible recipient or had completed spenddown.
Statutes cited: Ill. Rev. Stat., ch. 23, par. 11-13; Ill. Rev. Stat., ch. 23, par. 2-5; Ill. Rev. Stat., ch. 23, par. 2-9; 89 Ill. Admin. Code, sec. 120.60; 89 Ill. Admin. Code. secs. 120.20; 89 Ill. Admin. Code. secs. 120.30; 89 Ill. Admin. Code secs. 120; 89 Ill. Admin. Code secs. 130; 89 Ill. Admin. Code secs. 160
Cases cited: It Zllini Hospital v . State (1977), 32 Ill. Ct. C1. 115
AI-generated summary from the opinion text — may contain errors. The opinion text and PDF above are the official record.
Headnotes
- NEIL F. HARTIGAN, Attorney General (SUZANNE SCHMITZ, Assistant Attorney General, of counsel), for Respondent.
- PUBLIC AID Corm-payment f o r medical services. Illinois Department of Public Aid is only liable for payment of medical services rendered to persons who are eligible to receive medical assistance under any of the Illinois Department of Public Aid programs. SAME-^^ yment for medical services-hospital-eligibility-claim allowed in part. Claim of hospital for medical services provided to public aid recipient allowed to the extent admitted by Illinois Department of Public Aid, but remainder of claim was denied as Claimant failed to prove that recipient met the Department’s eligibility requirements.
The Court being fully advised finds as follows:
The Respondent's liability is limited to paying for services rendered in conformance with the rules and regulations of the Illinois Department of Public Aid (IDPA), as a vendor's right to payment of a claim enforceable against IDPA may be "limited by regulations of the Illinois Department." Ill. Rev. Stat., ch. 23, par. 11-13.
IDPA is only liable to pay for services rendered to [*205] “recipients,” ie., persons who have been determined eligible to receive medical assistance under any of 1
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IDPA’s programs. (Ill. Rev. Stat., ch. 23, par. 2-5, 2-9; It Zllini Hospital v . State (1977), 32 Ill. Ct. C1. 115.) Where 1 IDPA’s records do not indicate eligibility for a person to whom services have been rendered, and where the Claimant has shown no evidence that IDPA had determined such person to be an eligible recipient, no payment for such services rendered to an ineligible person is due from IDPA.
Under the provisions of 89 Ill. Admin. Code, sec. 120.60, a person who meets all eligibility factors for an IDPA medical benefits program except that the person has more income or assets than allowed using the IDPA income and assets standard, such person’s eligibility does not commence until the person has spent enough money (or incurred enough obligations) on medical services to bring his or her income and asset level down to the level of the standard (89 Ill. Admin. Code. secs. 120.20, 120.30). This process is called “spenddown.”
Where IDPA’s records do not indicate eligibility for a person to whom services have been rendered, and where the Claimant has shown no evidence that the person had been determined eligible, no payment for such services is due from IDPA. (89 Ill. Admin. Code secs. 120, 130, 160.) Spenddown is also described in IDPA’s M A P Handbook for Hospitals, sec. 105. Once such a client incurs obligations equal to the spenddown amount, he becomes eligible; the client remains liable for the liability incurred up to that point; IDPA becomes liable to pay its rates for all subsequent covered services, as long as the client remains eligible. IDPA’s liability on a hospitalization is thus equal to the per diem amount for the appropriate number of days, diminished by the [*206]
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amount for which the client remains liable under the spenddown policy.
It is therefore ordered that: 1. The Claimant be awarded the sum of $2,649.01, the liability for which the IDPA has admitted; 2. The balance of this claim be, and hereby is, dismissed.