86 Ill. Adm. Code 535.110
Grant Applications/Distribution Agents
Section 535
Section 535.110 Grant
Applications/Distribution Agents
a) An application under the Act is completed by the payment on or
after July 1, 1992, by an eligible individual of at least $1.00 in a calendar
quarter to a nursing home and by the receipt by a nursing home of at least
$1.00 from an eligible individual that is a resident of the home.
b) A nursing home which receives one or more applications under
the Act is a "distribution agent" under that Act. A distribution
agent is required to gather such information, submit such certifications and
distribute such payments as are required to be gathered, submitted and
distributed by the Act. A distribution agent, and the responsible officers and
employees of such an agent, are subject to penalties and enforcement action
under the Act and this Part for failing to perform such functions as are
required by the Act for submitting certifications to the Department, receiving
grant payments from the Department and making grant distributions to eligible
individuals.
c) A nursing home must at all times maintain for its records, subject
to inspection by the Department, a statement signed and executed by each
eligible individual or the eligible individual's legally authorized
representative in substantially the following form:
I (eligible individual's
name), for purposes of receiving such payments as I may be entitled to
receive under the Nursing Home Grant Assistant Act, do hereby authorize
(distribution agent's name) to disclose to the Illinois Department of Revenue
that:
My name is:
;
My Social Security Number is:
;
I am not a recipient of
federal, State, or combined federal and State medical care program payments
(other than Medicare Part B benefits);
My Annual Adjusted Gross
Income After Subtraction For Nursing Home Care Expenses not paid for, in
whole or in part, by a federal, State or combined federal-State medical care
program (other than Medicare Part B benefits), is:
$
; and
I understand that the
(distribution agent's name) is required to pay to the Department of Revenue a
fee of $1.00 per occupied bed day after June 30, 1992 and before July 1,
1993, and that (distribution agent's name) is prohibited by law from passing
on to me, or otherwise charging to me, directly or indirectly, the $1.00 fee.
Signed: (eligible
individual's signature)
Eligible Individual's Printed
Name
Date:
Such a
statement shall be made for each eligible individual in the first quarter for
which such individual becomes eligible to receive a Nursing Home Grant
Assistance Act payment.
d) A distribution agent that receives Nursing Home Grant
Assistance Act grant payments for an individual for whom no statement was
executed and maintained as required by subsection (c) above, will be presumed
to have received a grant payment and not have distributed the payment to the
eligible individual within two working days from the date of receipt and shall
be subject to the penalties applicable under the Act for such failure, as
provided by Section 535.150 of this Part.