reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart F - FEDERAL CLAIMING FOR STATE AND LOCAL GOVERNMENTAL ENTITIES › Section 140.850 - Reimbursement of Administrative Expenditures

Current through Register Vol. 48, No. 28, July 12, 2024
The Department may seek federal reimbursement for
				  expenditures incurred by other State agencies and local government entities
				  that are in support of any medical assistance program or programs administered
				  by the Department if that agency or entity meets all of the following
				  requirements:
a) Executed Agreement
The Department will only accept, process and submit a claim
				  for federal reimbursement if the claiming State agency has on file with the
				  Department an executed interagency agreement relating to the subject matter for
				  which the claiming State agency is seeking federal reimbursement. A non-State
				  government claiming entity must have an executed intergovernmental agreement on
				  file with the Department in order for the Department to accept, process and
				  submit a claim for federal reimbursement relating to the subject matter for
				  which the claiming non-State government agency is seeking federal
				  reimbursement.
b) Cost
				Allocation Plan
Claims for federal reimbursement of administrative
				  expenditures must be submitted to the Department in accordance with a cost
				  allocation plan that has been approved by the Department and is acceptable to
				  the appropriate federal agency.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart F - FEDERAL CLAIMING FOR STATE AND LOCAL GOVERNMENTAL ENTITIES › Section 140.855 - Administrative Claim Review and Reconsideration Procedure

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department may reject all or any
				portion of a claim for federal reimbursement that is not in compliance with
				State or federal law, regulation, policy or applicable intergovernmental or
				interagency agreement. The claiming entity may request an informal review and
				reconsideration of the Department's decision to reject all or any portion of a
				claim for federal administrative reimbursement.
b) The Department provides the following
				review procedure by which the State agency or local government entity may seek
				an informal review and reconsideration of the Department's decision to reject
				all or any part of a request for federal administrative reimbursement:
1) The request for review must be submitted
				in writing to the Department.
2)
				The request for review must be received by the Department within 30 days after
				the date of the Department's notice to the claiming entity of a Department
				adjustment to a claim.
3) A request
				for review from the claiming entity shall include a clear explanation of the
				reason for the request and documentation supporting the desired
				correction.
4) Review shall be
				limited to technical errors in calculations related to the cost allocation
				plan.
5) The Department shall
				notify the claiming entity, in writing, of the results of the review within 30
				days after receipt of the claiming entity's request for review.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart F - FEDERAL CLAIMING FOR STATE AND LOCAL GOVERNMENTAL ENTITIES › Section 140.860 - County Owned or Operated Nursing Facilities

Current through Register Vol. 48, No. 28, July 12, 2024
a) Subject to federal approval, the
				Department shall draw the eligible amounts of federal monies for the covered
				expenditures in accordance with Section
				140.530(c)(2),
				intergovernmental agreements between the county and State, and applicable
				federal regulations.
b) Subject to
				federal approval, the Department shall authorize payment to the county within
				45 days after receipt of the federal monies drawn for the certified
				expenditures unless the county has not provided complete, accurate and valid
				expenditure reports with appropriate documentation.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart F - FEDERAL CLAIMING FOR STATE AND LOCAL GOVERNMENTAL ENTITIES › Section 140.896 - Reimbursement For Program Costs (Active Treatment) For Clients in Long Term Care Facilities For the Developmentally Disabled (Recodified)

Current through Register Vol. 48, No. 28, July 12, 2024
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart G - MATERNAL AND CHILD HEALTH PROGRAM › Section 140.920 - General Description

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				Maternal and Child Health Program is a primary health care program coupled with
				case management services for Medicaid enrolled pregnant women and children. The
				program is designed to ensure access to quality health care services.
b) Case Management Component
The Maternal and Child Health Program shall include a case
				  management component which shall be in place statewide. Under the case
				  management component, pregnant women and infants under the age of 12 months
				  will be provided with case management services, as described in Section
				  140.922(c),
				  by a community-based case management agency that will be responsible for
				  assisting the client in accessing health care and support services necessary to
				  comply with their physicians' recommendations. Such case management services
				  will be provided through age five years for DCFS wards.
c) The Maternal and Child Health Program is
				designed to increase provider participation through special incentives for
				providers for certain services provided to pregnant women and children under
				age 21. These include increased payment rates for selected services, as
				described in Section
				140.930, and
				expedited payment. To participate in the program, providers must meet specific
				participation requirements, as described in Section
				140.924,
				and sign a Maternal and Child Health provider agreement, in addition to being
				enrolled as a Medicaid Provider. Under the Maternal and Child Health Program
				the Department agrees to:
1) Pay enhanced
				rates for prenatal risk assessment, which includes substance abuse
				information,
2) Pay enhanced rates
				for delivery services,
3) Pay
				enhanced rates for primary care office visits and screening services provided
				to children,
4) Provide prospective
				payment or expedited processing of claims for physicians who request special
				processing,
5) Upon request of
				medical providers, furnish client eligibility and profiles of prior services
				reimbursed by the Department,
6)
				Facilitate access to medical care for clients in cooperation with the physician
				and case management entity.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart G - MATERNAL AND CHILD HEALTH PROGRAM › Section 140.922 - Covered Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Medical
				Services
All services covered under the Illinois Medical Assistance
				  Program shall be available to recipients participating in the Maternal and
				  Child Health Program.
b)
				Case Management Services
Case management for Medicaid recipients is defined as a
				  function necessary for the proper and efficient operation of the Medicaid State
				  Plan. Services include but are not limited to:
1) Coordination of Medicaid covered
				services;
2) Arranging for
				transportation to and from a source of medical care;
3) Client education regarding covered
				services, the benefits of preventive medical and dental care, and how to
				efficiently utilize the health care system and access services;
4) Prenatal education or health
				education;
5) Referral for services
				such as Women, Infants and Children (WIC);
6) Assistance to ensure client compliance
				with services prescribed/recommended by the Maternal and Child Health Provider
				(such as, substance abuse treatment, Early Intervention services, psychiatric
				services/mental health, specialty care); and
7) Outreach and case finding.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart G - MATERNAL AND CHILD HEALTH PROGRAM › Section 140.924 - Maternal and Child Health Provider Participation Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a) Primary Care
				Providers
1) Basic Requirements
Maternal and Child Health primary care providers may include
				  physicians, Advanced Practice Registered Nurses meeting all requirements set
				  forth in Section
				  140.435,
				  Federally Qualified Health Centers (FQHCs), hospital clinics per Section
				  140.461(f)
				  and encounter rate clinics per Section
				  140.461(b).
				  Maternal and Child Health providers shall meet the qualifications (see Section
				  140.12)
				  as are applicable for all medical providers under the Illinois Medical
				  Assistance Program and, with the exception of APRNs, shall meet all of the
				  following requirements:
A) maintain
				hospital admitting privileges;
B)
				maintain delivery privileges if providing care to pregnant women;
C) be enrolled and in good standing with the
				Medical Assistance Program; and
D)
				complete a Maternal and Child Health Primary Care Provider Agreement, or have
				been enrolled as a provider under the Healthy Moms/Healthy Kids Program, in
				which they agree to:
i) provide periodic
				health screening (EPSDT), including age appropriate immunizations, and primary
				pediatric care as needed for children served in their practice, consistent with
				guidelines published by the American Academy of Pediatrics or American Academy
				of Family Physicians;
ii) provide
				obstetrical care and delivery services as appropriate for pregnant women served
				through their practice, consistent with guidelines published by the American
				College of Obstetricians and Gynecologists or the American Academy of Family
				Physicians;
iii) provide risk
				assessments for pregnant women and/or children;
iv) provide medical care coordination,
				including arranging for diagnostic consultation and specialty care;
v) communicate with the case management
				entity;
vi) maintain 24-hour
				telephone coverage for assessment and consultation; and
vii) provide equal access to quality medical
				care for assigned clients.
AGENCY NOTE: FQHCs are federally exempt from subsections
				  (a)(1)(A) and (B).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart G - MATERNAL AND CHILD HEALTH PROGRAM › Section 140.930 - Reimbursement

Current through Register Vol. 48, No. 28, July 12, 2024
a) Reimbursement
				Rates for Maternal and Child Health Providers
1) Participating FQHC, as described in
				Section
				140.461(d),
				that meet the criteria specified in
				140.924(a)(2)(A),
				shall be reimbursed in accordance with Section
				140.464(b)
				for covered services provided to a Maternal and Child Health Program
				participant, as described in Section
				140.922.
2) Participating encounter rate clinics shall
				be reimbursed in accordance with Section
				140.464(b)
				for covered services provided to a Maternal and Child Health Program
				participant, as described in Section 140.922.
3) Participating providers described in
				Section
				140.924(a)(1)
				 shall be eligible to receive a Well Child
				Visit Incentive Payment.
A) The provider will
				receive a one time annual payment of $30 for each qualifying child.
B) A qualifying child is a child who had its
				first, second, third, fourth or fifth birthday during the calendar year and for
				whom the provider personally, or through an affiliated provider, rendered all
				recommended well child visits, as described in Section
				140.488.
C) Recommended services must be rendered
				during the 13-month period ending one month after the child's birthday. For
				children turning one year old, the period begins ten days after birth and ends
				one month after the child's birthday. Rendering of services will be based on
				Department claims data.
D) Payments
				will be made at least annually.
E)
				For the purpose of payments under this Section, "affiliated provider" shall
				mean providers designated pursuant to Section
				140.994.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart H - ILLINOIS COMPETITIVE ACCESS AND REIMBURSEMENT EQUITY (ICARE) PROGRAM › Section 140.940 - Illinois Competitive Access and Reimbursement Equity (ICARE) Program (Recodified)

Current through Register Vol. 48, No. 28, July 12, 2024
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart H - ILLINOIS COMPETITIVE ACCESS AND REIMBURSEMENT EQUITY (ICARE) PROGRAM › Section 140.960 - Inpatient Hospital Care or Services by Non-Contracting Hospitals Eligible for Payment (Recodified)

Current through Register Vol. 48, No. 28, July 12, 2024
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart H - ILLINOIS COMPETITIVE ACCESS AND REIMBURSEMENT EQUITY (ICARE) PROGRAM › Section 140.962 - Payment to Hospitals for Inpatient Services or Care not Provided under the ICARE Program (Recodified)

Current through Register Vol. 48, No. 28, July 12, 2024
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart J - ALTERNATE PAYEE PARTICIPATION › Section 140.1002 - Participation Requirements for Alternate Payees

Current through Register Vol. 48, No. 28, July 12, 2024
In order for an individual practitioner to designate that
				  payments that may be due to the practitioner be made to a specific alternate
				  payee, there must be a written alternate payee agreement between the individual
				  practitioner and that alternate payee. This alternate payee agreement, which
				  must be on file with the Department, shall be in the form and manner prescribed
				  by the Department. In executing such an alternate payee agreement, an alternate
				  payee shall agree to:
a) Comply with
				the Department's policies, rules and regulations, and with the terms and
				conditions prescribed by the Department in its alternate payee registration and
				alternate payee agreements;
b)
				Comply with the requirements of applicable federal and State laws and not
				engage in practices prohibited by those laws;
c) Hold confidential, and use for authorized
				program purposes only, all Medical Assistance information regarding
				recipients;
d) Furnish to the
				Department, in the form and manner requested by the Department, any information
				it requests regarding payments in connection with the rendering of goods or
				services or supplies to recipients by the provider or his or her agent,
				employer or employee; and
e) Ensure
				maintenance of any and all professional records that relate to the quality of
				care given by the provider and that document the care for which payment is
				claimed for the designated alternate payee.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart J - ALTERNATE PAYEE PARTICIPATION › Section 140.1003 - Recovery of Money for Alternate Payees

Current through Register Vol. 48, No. 28, July 12, 2024
a) An individual practitioner and its
				designated alternate payee shall be jointly and severally liable to the
				Department for payments made to the alternate payee on behalf of that
				individual practitioner.
b)
				Department action to recover money or overpayments from an alternate payee
				shall be subject to an administrative hearing pursuant to 89 Ill. Adm. Code
				104.200, Subpart C,
				Medical Vendor and Alternate Payee Hearings.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart J - ALTERNATE PAYEE PARTICIPATION › Section 140.1004 - Conditional Registration for Alternate Payees

Current through Register Vol. 48, No. 28, July 12, 2024
a) Registration as an alternate payee in the
				Illinois Medical Assistance Program shall be conditional. At any time, the
				Department may deny or cancel an alternate payee's registration in the Illinois
				Medical Assistance Program without cause. Any such denial or cancellation is
				not subject to an administrative hearing. Upon cancellation, payments shall
				cease to the alternate payee.
b)
				The Department shall provide written notice of denial or cancellation. Any
				payments made by the Department after a cancellation notice to a designated
				alternate payee may be recoverable from the alternate payee pursuant to Section
				140.15.
c) An alternate payee whose registration has
				been cancelled may no longer act as a provider's designated payee.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart K - MANDATORY MCO ENROLLMENT › Section 140.1010 - Mandatory Enrollment in MCOs

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				To the extent allowed by federal law and regulations, the Department may
				require individuals to enroll with a Managed Care Organization (MCO) under
				contract with the Department and to receive some or all of their medical
				benefits through that MCO.
b) HFS
				shall send a notice to each individual for whom enrollment in a MCO is
				mandatory, notifying the individual of the need to enroll with an MCO and
				explaining the options for doing so. If the individual has not chosen an MCO
				within 30 days after the date of the first notice, the Department shall send a
				second notice to the individual that the Department will assign him or her to
				an MCO if he or she does not choose one.
c) Individuals who have not chosen an MCO
				within 60 days after the date of their first notice shall be assigned to an MCO
				by HFS. The algorithm used in the default enrollment process shall be in
				compliance with
				42 CFR
				438.50. The individuals will be mailed a
				notice to inform them of their assigned MCO. Assignment to an MCO shall be
				effective no sooner than 60 days after the date that the first notice is mailed
				by the Department. An individual and the MCO with whom that individual is
				enrolled will receive notice of the enrollment.
d) Individuals may change MCOs within the
				first 90 days after the effective date of their enrollment. An individual who
				changes enrollment within the first 90 days may change MCO again within 90 days
				after enrollment in the second MCO. After the first 90 days or, in the case of
				an individual who changed twice, after the second enrollment, an individual may
				not change his or her enrollment until the end of the 12-month period following
				enrollment in the current plan.
e)
				If an individual enrolled in an MCO loses Medical Assistance eligibility and
				his or her Medical Assistance eligibility is reinstated within 60 days, that
				individual will be enrolled with the MCO with which he or she was enrolled when
				Medical Assistance eligibility terminated.
f) In circumstances in which an individual
				does not have a choice of MCO, the procedures outlined in subsections (b)
				through (e) shall be followed for choosing a primary care provider.
g) For purposes of this Section, Managed Care
				Organization includes any entity with a contract for a Care Coordination
				Program pursuant to Section 5-30 of the Public Aid Code [305 ILCS 5/5-30
				], Section 23 of the Children's Health Insurance Program Act [215 ILCS 106/23
				] or Section 56 of the Covering All Kids Health Insurance Act [215
				ILCS 170/56 ]. Any contract subject to this Section
				shall have outcome measures, enrollee protections to assure quality and access,
				and financial accountability for the contractor based on quality
				measures.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Section 140.1300 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
This Subpart adopts the definitions set forth in 89 Ill. Adm.
				  Code
				  104.910.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Section 140.1310 - Recovery of Money

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				Department shall recover any and all State and federal monies that the
				Director, by his or her final administrative decision, has determined were
				improperly and erroneously paid by:
1) direct
				payment to the Department;
2)
				recoupment from any future assistance provided by the State pursuant to
				305 ILCS
				5/11-14.5, provided that the recoupment from the
				future assistance is the greater of either 20 percent of the household's
				monthly benefit amount or $20;
3)
				recoupment from SNAP benefits pursuant to 305 ILCS 5/11-14.5, provided that the
				recoupment from the SNAP benefits is the greater of either 20 percent of the
				household's monthly benefit amount or $20;
4) initiation of wage garnishment
				proceedings;
5) referral of the
				overpayment to a private collection agency for collection;
6) referral of the overpayment to the
				Comptroller of the State of Illinois for collection under Section 10.5 of the
				State Comptroller Act [15 ILCS 405/10.5 ];
7) initiation of proceedings to obtain a
				civil judgment under Section 8A-7 of the Illinois Public Aid Code
				[305 ILCS 5/8A-7
				];
8) referral of the overpayment
				to the Treasury Offset Program for deduction of the debt from tax refunds
				and/or other federal warrants in accordance with federal regulations (see 7 CFR
				272 - 273 ); or
9) any legal means
				consistent with State and federal law.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Section 140.1320 - Penalties

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department
				may recover a civil penalty in an amount not to exceed $2,000 for each benefit
				or payment received, in addition to any other penalties provided by
				law.
b) A written notice of penalty
				assessment shall be sent to the person against whom the penalty is to be
				assessed. Each notice of penalty assessment shall include:
1) the amount of the penalty being
				assessed;
2) a description of the
				circumstances that led to the assessment of the penalty; and
3) a citation to the provision of the Act or
				the rule the person has violated.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Section 140.1330 - Enforcement

Current through Register Vol. 48, No. 28, July 12, 2024
a) Upon entry of a
				final administrative decision for repayment of any unauthorized medical
				benefits or payments, or for any civil penalties assessed:
1) any unpaid amount of repayment or penalty
				will constitute a debt due and owing to the Department; and
2) a lien shall attach to all property and
				assets of the person, firm, corporation, association, agency, institution or
				other legal entity until the debt is satisfied. The lien may be enforced in the
				same manner as a judgment lien under a judgment of a court of competent
				jurisdiction.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table B - Geographic Areas

Current through Register Vol. 48, No. 28, July 12, 2024
These geographic areas define boundaries, according to
				  counties, that are used in rate setting for long term care facilities.
				  Geographic areas are referenced in Sections
				  140.555,
				  140.560,
				  140.561
				  and
				  140.578, 89 Ill.
				  Adm. Code 144 and 89 Ill. Adm. Code 147.
a) North Suburb - Kane, Lake and
				McHenry.
b) Chicago 1 - City of
				Chicago.
c) Chicago 2 - Cook (other
				than Chicago) and DuPage.
d) South
				Suburb - Grundy, Kankakee, Kendall and Will.
e) South 1 - Alexander, Clay, Crawford,
				Edwards, Effingham, Fayette, Franklin, Gallatin, Hamilton, Hardin, Jackson,
				Jasper, Jefferson, Johnson, Lawrence, Marion, Massac, Perry, Pope, Pulaski,
				Randolph, Richland, Saline, Union, Wabash, Washington, Wayne, White and
				Williamson.
f) South 2 - Bond,
				Clinton, Madison, Monroe and St. Clair.
g) Central 1 - Bureau, Fulton, Henderson,
				Knox, LaSalle, Marshall, McDonough, Peoria, Putnam, Stark, Tazewell, Warren and
				Woodford.
h) Central 2 - Adams,
				Brown, Calhoun, Cass, Christian, Greene, Hancock, Jersey, Logan, Macoupin,
				Mason, Menard, Montgomery, Morgan, Pike, Sangamon, Schuyler and
				Scott.
i) Central 3 - Champaign,
				Clark, Coles, Cumberland, DeWitt, Douglas, Edgar, Ford, Iroquois, Livingston,
				Macon, McLean, Moultrie, Piatt, Shelby and Vermilion.
j) Northwest 1 - Boone, Carroll, DeKalb, Jo
				Daviess, Lee, Ogle, Stephenson, Whiteside and Winnebago.
k) Northwest 2 - Henry, Mercer and Rock
				Island.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table D - Schedule of Dental Procedures

Current through Register Vol. 48, No. 28, July 12, 2024
Effective January 1, 2018. Additional dental services may be
				  approved based on medical necessity.
a)
				Diagnostic Services
1) Clinical Oral
				Evaluations
A) Oral Exams
i) For ages 0-20 - Limited to two every 12
				months per patient in an office setting and one per school year in a school
				setting; and
ii) For ages 21 and
				over - Limited to one every 12 months per patient
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table E - Time Limits for Processing of Prior Approval Requests

Current through Register Vol. 48, No. 28, July 12, 2024
ITEM/SERVICE
NUMBER OF DAYS
1. Routine transportation within Illinois or to
							 facilities normally utilized by Illinois residents
10
2 Supplies/sickroom needs costing less than
							 $100
21
3. Standard wheel chairs
21
4. Standard hospital beds
21
5. Specialty-equipped hospital beds
21
6. Custom wheel chairs
30
7. Respiratory equipment
30
8. Other durable equipment
30
9. Braces, artificial limbs and other prosthetic
							 devices
21
10. Custom-built shoes and shoes to which a brace or
							 other corrective device is attached.
30
11. Hearing aids
30
12. In-patient hospital physical rehabilitation
							 services
30
13. Supplies/sickroom needs over $100
30
14. Transportation to remote facilities outside
							 Illinois and extra-ordinary modes of transportation
21
15. Physical therapy
30
16. Speech therapy
30
17. Occupational therapy
30
18. Home Health Agency
21
19. Intermittent services in the home by a registered
							 nurse
21
20. Private duty registered nurse service in a
							 hospital
10
21. Dental Services
30
22. Dental Services for GA/AMI/Refugee
							 Programs
30
23. Eye Care Services
30
24. Chiropractic Services
30
25. Podiatric Services
30
26. All other items or services requiring prior
							 approval.
30
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table F - Podiatry Service Schedule

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Evaluation and Management
1) Office
				visits
2) Home visits
3) Hospital visits
4) Extended care facilities, convalescent
				hospital, nursing home, and boarding home visits
5) Consultations
6) Injections
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table G - Travel Distance Standards

Current through Register Vol. 48, No. 28, July 12, 2024
The Department has defined travel distance standards in miles
				  for each county in Illinois. These standards are to be used in the
				  determination of eligibility for payment for the provision of inpatient
				  services to recipients by non-contracting hospitals as stated in Section
				  140.960.
COUNTY
TRAVEL STANDARD
COUNTY
TRAVEL STANDARD
ADAMS
15
IROQUOUS
30
ALEXANDER
29
JACKSON
22
BOND
28
JASPER
47
BOONE
15
JEFFERSON
19
BROWN
37
JERSEY
19
BUREAU
21
JO DAVIESS
15
CALHOUN
37
JOHNSON
47
CARROLL
25
KANE
15
CASS
28
KANKAKEE
15
CHAMPAIGN
17
KENDALL
20
CHRISTIAN
19
KNOX
15
CLARK
38
LAKE
15
CLAY
37
LASALLE
16
CLINTON
16
LAWARENCE
26
COLES
25
LEE
18
COOK
15
LIVINGSTON
22
CRAWFORD
22
LOGAN
26
CUMBERLAND
30
MCDONOUGH
19
DEKALB
19
MCHENRY
21
DEWITT
21
MACLEAN
15
DOUGLAS
25
MACON
15
DUPAGE
15
MACOUPIN
23
EDGAR
31
MADISON
15
EDWARDS
50
MARION
20
EFFINGHAM
29
MARSHALL
32
FAYETTE
32
MASON
30
FORD
25
MASSAC
19
FRANKLIN
27
MENARD
24
FULTON
18
MERCER
16
GALLATIN
29
MONROE
23
GREEN
22
MONTGOMERY
26
GRUNDY
20
MORGAN
20
HAMILTON
28
MOULTRIE
32
HANCOCK
37
OGLE
28
HARDIN
15
PEORIA
15
HENDERSON
31
PERRY
30
COUNTY
TRAVEL STANDARD
COUNTY
TRAVEL STANDARD
HENRY
15
PIATT
24
PIKE
32
STEPHENSON
15
POPE
34
TAZEWELL
15
PULASKI
30
UNION
48
PUTNAM
16
VERMILION
15
RANDOLPH
20
WABASH
29
RICHARD
25
WARREN
15
ROCK ISLAND
15
WASHINGTON
29
SALINE
22
WAYNE
15
SANGMON
15
WHITE
39
SCHUYLER
35
WHITESIDE
23
SCOTT
30
WILL
15
SHELBY
32
WILLIAMSON
22
ST. CLAIR
15
WINNEBAGO
15
STARK
30
WOODFORD
27
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table J - Rate Regions

Current through Register Vol. 48, No. 28, July 12, 2024
These geographic regions, comprised of counties, are used in
				  various rate methodologies and are defined as follows:
Region 1 - Northwestern
Illinois Counties:
Boone
Bureau
Carroll
DeKalb
Fulton
Henderson
Henry
JoDaviess
Knox
LaSalle
Lee
Marshall
Mercer
Ogle
Peoria
Putnam
Rock Island
Stark
Stephenson
Tazewell
Warren
Whiteside
Winnebago
Woodford
Out-of-State Counties:
Des Moines IA
Clinton IA
Dubuque IA
Johnson IA
Scott IA
Dane WI
Green WI
Rock WI
Grant WI
LaFayette WI
Jackson IA
Muscatine IA
Louisa IA
Region 2 - Central
Illinois Counties:
Adams
Brown
Calhoun
Cass
Champaign
Christian
Clark
Coles
Cumberland
DeWitt
Douglas
Edgar
Ford
Greene
Hancock
I
roquois
Jersey
Livingston
Logan
Macon
Macoupin
Mason
McDonough
McLean
Menard
Montgomery
Morgan
Moultrie
Piatt
Pike
Sangamon
Schuyler
Scott
Shelby
Vermilion
Out-of-State Counties:
Marion IN
Vigo IN
Marion MO
Clark MO
Lewis MO
Ralls MO
Pike MO
Lincoln MO
Newton IN
Benton IN
Warren IN
Vermillion IN
Region 3 - Southern
Illinois Counties:
Alexander
Bond
Clay
Clinton
Crawford
Edwards
Effingham
Fayette
Franklin
Gallatin
Hamilton
Hardin
Jackson
Jasper
Jefferson
Johnson
Lawrence
Madison
Marion
Massac
Monroe
Perry
Pope
Pulaski
Randolph
Richland
St. Clair
Saline
Union
Wabash
Washington
Wayne
White
Williamson
Out-of-State Counties:
Vanderburgh IN
McCracken KY
Cape Girardeau MO
St. Louis MO
City of St. Louis MO
St. Charles MO
Jefferson MO
Gibson IN
Ste. Genevieve MO
Perry MO
Scott MO
Mississippi MO
Posey KY
Livingston KY
Crittenden KY
Union KY
Sullivan IN
Knox IN
Region 4 - Cook County
Cook
Region 5 - Collar Counties
Illinois Counties:
DuPage
Grundy
Kane
Kankakee
Kendall
Lake
McHenry
Will
Out-of-State Counties:
Milwaukee County WI
Walworth WI
Kenosha WI
Lake IN
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table O - Criteria for Participation as a Behavioral Health Clinic

Current through Register Vol. 48, No. 28, July 12, 2024
a) General
				Requirements. A Behavioral Health Clinic (BHC) shall:
1) Operate in a manner compliant with all
				applicable State and federal laws, regulations and adopted policies and
				procedures;
2) Establish and
				maintain policies and procedures to be used by all staff in the administration
				of programs and delivery of services;
3) Ensure facilities, staff and services are
				culturally competent, consistent with the needs of individuals served.
				Culturally competent shall mean compliance with the national Culturally and
				Linguistically Appropriate Standards (CLAS) (
https://thinkculturalhealth.hhs.gov/clas
),
				as detailed by the HHS Office of Minority Health;
4) Establish policies, protocols, and other
				necessary contracts or agreement to ensure individuals can access and maintain
				active support from an independent practitioner licensed by the State of
				Illinois to provide consultation, evaluation, prescription and management of
				medication; and
5) Hold, at a
				minimum, quarterly meetings with individuals served and community stakeholders
				to obtain feedback.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table O - Criteria for Participation as a Behavioral Health Clinic

Current through Register Vol. 48, No. 28, July 12, 2024
a) General
				Requirements. A Behavioral Health Clinic (BHC) shall:
1) Operate in a manner compliant with all
				applicable State and federal laws, regulations and adopted policies and
				procedures;
2) Establish and
				maintain policies and procedures to be used by all staff in the administration
				of programs and delivery of services;
3) Ensure facilities, staff and services are
				culturally competent, consistent with the needs of individuals served.
				Culturally competent shall mean compliance with the national Culturally and
				Linguistically Appropriate Standards (CLAS) (
https:www.thinkculturalhealth.hhs.gov/clas
),
				as detailed by the HHS Office of Minority Health;
4) Establish policies, protocols, and other
				necessary contracts or agreement to ensure individuals can access and maintain
				active support from an independent practitioner licensed by the State of
				Illinois to provide consultation, evaluation, prescription and management of
				medication; and
5) Hold, at a
				minimum, quarterly meetings with individuals served and community stakeholders
				to obtain feedback.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart A - GENERAL PROVISIONS › Section 141.101 - Incorporation by Reference

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				following materials are incorporated by reference in this Part:
DSM-5 - Diagnostic and Statistical Manual of Mental
				  Disorders, 5th Edition (2022), American Psychiatric Association, 1000 Wilson
				  Blvd., Suite 1825, Arlington, VA 22209-3901
ICD-10-CM - International Classification of Diseases, 10th
				  Revision, Clinical Modification, World Health Organization, 20 Avenue Apia,
				  1211 Geneva 27, Switzerland
b) Any rules of an agency of the United
				States or of a nationally recognized organization or association that are
				incorporated by reference in this Part are incorporated as of the date
				specified, and do not include any later amendments or editions.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart A - GENERAL PROVISIONS › Section 141.115 - Participant Rights and Responsibilities

Current through Register Vol. 48, No. 28, July 12, 2024
Participants shall receive an explanation of their rights and
				  responsibilities. A copy of the rights and responsibilities shall be provided
				  in written format to all participants during the initiation of service planning
				  or upon request by the participant.
a)
				Participants have the right to request and to receive the services identified
				under this Part, as medically necessary.
b) Participants may choose at any time not to
				receive any or all the services for which eligibility has been
				determined.
c) Participants shall
				be informed of and shall have the right to choose from the available, medically
				necessary HCBS services, supports, and providers, as described in this
				Part.
d) Participants have the
				right, and will be informed of the process, to request updates to their service
				plan.
e) Participants have the
				right to request a copy of their assessment and their service plan.
f) Participants shall be responsible for
				providing any information, documentation or paperwork required by the
				Department to appropriately assess and provide services to the
				participant.
g) The participant is
				required to notify the Department or its designee of any changes in
				circumstances that might impact service eligibility or communication with the
				participant including, but not limited to, change of contact information,
				change in service needs or participant availability, change of enrollment
				status in the Medical Assistance Program, or changes to the participant's
				legally responsible parent, guardian, representative or agent, within 30
				calendar days after the effective date of the change.
h) Participants and their parents or legal
				guardians, are required to actively participate in the participant's care
				throughout the course of treatment. This includes responding to requests for
				additional information from the Department or its designee, participating in
				the assessment and service planning process, and communicating with selected
				service providers. Participants that do not actively participate in treatment
				for a period exceeding 90 days may be disenrolled from services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart B - CHILDREN'S MENTAL HEALTH HOME AND COMMUNITY-BASED SERVICES › Section 141.200 - Participant Eligibility Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
To be determined eligible for the Children's Mental Health
				  Home and Community Based Services (CMH-HCBS), the individual seeking services
				  must meet all the following criteria:
a) Demonstrate and maintain residence in
				Illinois as defined in Section 2-10 of the Illinois Public Aid Code
				(305 ILCS
				5/2-10 );
b) Be eligible for comprehensive medical
				benefits under Illinois Medical Assistance Program pursuant to Article V of the
				Illinois Public Aid Code (305 ILCS 5 );
c) Be under the age of 21;
d) Demonstrate a Severe Emotional Disturbance
				(SED), as defined in 89 Ill. Adm. Code
				139.115(e)(1),
				or have been diagnosed with a Severe and Persistent Mental Illness (SPMI),
				based on the DSM-5; and
e)
				Demonstrate a degree of emotional and mental disturbance which substantially
				interferes with, or substantially limits, the individual's ability to function
				in the family, school, or community setting.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart B - CHILDREN'S MENTAL HEALTH HOME AND COMMUNITY-BASED SERVICES › Section 141.205 - Eligibility Determination Process

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Department will implement a
				standardized, assessment-based process for identifying individuals eligible to
				receive CMH-HCBS that includes the following:
1) An individual seeking community-based
				mental health services must first have an Integrated Assessment and Treatment
				Plan (IATP) completed by a qualified provider of their choice. IATP providers
				shall be required to upload IATP data into the Department's statewide IATP data
				system.
2) The Department shall
				apply a standardized stratification methodology against IATP data to identify
				individuals who meet the eligibility criteria outlined in Section
				141.200. The
				stratification methodology shall:
A) Utilize
				information from the individual's IATP to determine whether the individual
				meets the criteria outlined in Sections
				141.200(d)
				and
				141.200(e);
				and
B) Be published and maintained
				on the Department's website.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart B - CHILDREN'S MENTAL HEALTH HOME AND COMMUNITY-BASED SERVICES › Section 141.210 - Authorization Process for CMH-HCBS

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Individuals determined eligible for CMH-HCBS shall be authorized to receive
				services as detailed in Section
				141.220 for a period
				of 6 calendar months beginning on the first day of the calendar month following
				the eligibility determination or redetermination.
b) The Department will conduct a
				redetermination of eligibility utilizing the stratification methodology
				outlined in Section
				141.205(a)(2)
				prior to the end of the participant's 6-month eligibility period.
1) In order to conduct a redetermination of
				eligibility, a completed full re-assessment of the individual's IATP must be
				uploaded to the statewide IATP data portal at least 45 days prior to the end of
				the participant's 6-month eligibility period.
2) The Department or its agent shall notify
				participants in the instance a re-assessment of the individual's IATP has not
				been completed at least 45 days prior to the end of the participant's 6-month
				eligibility period.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart B - CHILDREN'S MENTAL HEALTH HOME AND COMMUNITY-BASED SERVICES › Section 141.215 - Service Reimbursement

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				CMH-HCBS services detailed in Section
				141.220 shall be
				eligible for reimbursement pursuant to the Department's published fee schedule
				when the services are rendered by a provider approved by the Department and
				are:
1) Recommended by a Licensed
				Practitioner of the Healing Arts (LPHA) in consultation with the participant's
				Child and Family Team (CFT), as applicable, on the participant's
				IATP;
2) Provided to a participant
				for the maximum reduction of mental disability and restoration to the best
				possible functional level;
3)
				Provided consistent with any service limitations, utilization controls, and
				prior authorizations established by the Department pursuant to 89 Ill. Adm.
				Code
				140.40
				or as detailed in this Part; and
4)
				Provided for the direct benefit of the participant, which may include support
				provided to immediate caregivers of the eligible participant.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart B - CHILDREN'S MENTAL HEALTH HOME AND COMMUNITY-BASED SERVICES › Section 141.220 - CMH-HCBS Services

Current through Register Vol. 48, No. 28, July 12, 2024
Individuals determined eligible for CMH-HCBS shall be
				  eligible to receive the services listed within this section, as medically
				  necessary.
a) Care Coordination and
				Support (CCS). CCS is an evidence-informed, structured approach to care
				coordination that adheres to required procedures for participant and family
				engagement, individualized care planning, identifying and utilizing strengths
				and natural supports while monitoring progress and fidelity to the required
				process. CCS includes a broad set of activities designed to assess, plan, and
				monitor the service needs of the participant and family and includes, but is
				not limited to: engagement and outreach; organization and facilitation of a
				CFT; review and update of the individual's IATP; Crisis Assessment, Safety and
				Prevention Planning, and Response (CASPR); coordination and consultation with
				providers and formal and informal supports involved in the participant's care;
				and, referral, linkage, and follow-up.
1) CCS
				shall be provided at two intensity levels - CCS: High-Fidelity Wraparound
				(CCSW) and CCS: Intensive (CCSI).
A) Care
				Coordination and Support: High-Fidelity Wraparound (CCSW). CCSW shall be
				delivered in accordance with the evidence-based practice of High-Fidelity
				Wraparound. CCSW Care Coordinators shall not exceed an average Care Coordinator
				to participant caseload of 1:10, with no more than 12 participants on a
				caseload at one time. CCSW shall include facilitation of at least one CFT
				meeting a minimum of every 30 days, or more often as appropriate to each
				participant's needs, as well as frequent in-person and phone
				contacts.
B) Care Coordination and
				Support: Intensive (CCSI). CCSI shall be delivered in accordance with the
				principles of High-Fidelity Wraparound. CCSI Care Coordinators shall not exceed
				an average Care Coordinator to participant caseload of 1:25, with no more than
				30 participants on a caseload at one time. CCSI shall include facilitation of
				at least one CFT meeting a minimum of every 60 days, or more often as
				appropriate to each participant's needs, as well as frequent in-person and
				phone contacts.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart B - CHILDREN'S MENTAL HEALTH HOME AND COMMUNITY-BASED SERVICES › Section 141.230 - Service Planning

Current through Register Vol. 48, No. 28, July 12, 2024
a) When an
				individual is determined eligible for CMH-HCBS, they shall be assigned to a
				designated Care Coordination and Support Organization (CCSO) to initiate
				service planning. Participants shall have free choice of CCSO providers,
				including the ability to switch CCSO providers at any time.
b) Child and Family Teams. CCSOs shall
				convene a CFT for each participant receiving CCS. The CFT shall include the
				participant, the participant's primary caregiver and family members as
				appropriate, the CCSO, and should seek to include additional formal and
				informal supports involved in the participant and family's lives.
1) The CFT shall meet on a regular basis,
				consistent with the Department's provider handbook for CCSOs available on the
				Department's website and pursuant to the requirements of CCS services outlined
				in Section
				141.220(a).
2) Participants shall have full choice in
				determining the members of their CFT.
3) The CFT, utilizing a consensus based
				process facilitated by the CCSO, shall support participants and families in
				achieving their identified goals through the ongoing identification of the
				participant and family's strengths and needs, the development of a
				strengths-based service plan, and regular review of the participant and
				family's progress towards meeting their goals.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 141 - SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES › Subpart B - CHILDREN'S MENTAL HEALTH HOME AND COMMUNITY-BASED SERVICES › Section 141.240 - CMH-HCBS Provider Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a) Care
				Coordination and Support Organizations (CCSO). Providers approved to provide
				CCS services shall be referred to as CCSOs. CCSOs must:
1) Obtain and maintain CCS program approval
				pursuant to Section 141.240(b).
2)
				Provide cost reporting information upon request to the Department in a manner
				and format specified by the Department.
3) Not provide other non-waiver HCBS services
				defined in this Part, unless the Department has determined the provider is the
				sole provider willing and qualified to provide such services within the
				provider's Service Area and that the provider has established sufficient
				separations and independence between its direct service delivery and CCS
				services to ensure that conflict of interest standards are met.
4) Maintain, or establish prior to the
				delivery of any CCS services, Medicaid Rehabilitation Option (MRO) Crisis
				Services Program Approval pursuant to 89 Ill. Adm. Code 140.Table
				N.(c)(4).
5) Provide the Department
				with a minimum of 90 days written notice in the instance that the provider is
				unable or unwilling to continue providing services.