reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.441 - Pharmacy Services Not Covered

Current through Register Vol. 48, No. 28, July 12, 2024
Items excluded from coverage include the following:
a) Drug products manufactured by drug
				manufacturers not meeting the rebate requirements of Section
				140.440(d);
b) Anorectic drugs or combinations including
				such drugs;
c) Biologicals and
				drugs available without charge from the Illinois Department of Public Health or
				other agencies;
d) Drugs for
				injection in a practitioner's office unless the cost of the drug per injection
				(excluding administration) exceeds $25.00;
e) Drugs that have been classified by the
				Food and Drug Administration (FDA) as ineffective or unsafe in a final
				order;
f) Drugs that the Food and
				Drug Administration has proposed in a notice of opportunity for hearing to
				withdraw labeled indications (pursuant to section 107(c)(3) of the Drug
				Amendments of 1962 ( P.L. 87-781 ) and section 505(e) of the Federal Food, Drug
				and Cosmetic Act (
				21 USC
				355(e) ) and any identical,
				related or similar drug products (determined by the FDA in accordance with
				21
				CFR 310.6 );
g) Items identified as Group Care Restricted
				Items (see Section
				140.449(b)
				) are not covered when provided to recipients living in licensed long-term care
				facilities;
h) Sickroom Needs and
				Medical Equipment Items are not covered as pharmacy items. A pharmacy that
				desires to provide the items must enroll as a provider of medical
				equipment;
i) Miscellaneous
				supplies that are stocked and dispensed by some pharmacies are not covered.
				These items include, but are not limited to, dental products, hair products,
				facial tissues, infant disposable diapers, sanitary pads, tampons, soap or
				other personal hygiene products, proprietary food supplements or substitutes,
				sugar or salt substitutes, household products, or infant formula for routine
				feeding; and
j) Effective July 1,
				2012, blood factor, when a patient has not had a comprehensive examination at a
				federally-funded Hemophilia Treatment Center during the 365 days preceding the
				date of service.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.443 - Filling of Prescriptions

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				prescription must contain the information required under Section 3(e) of the
				Pharmacy Practice Act of 1987 [
				225
				ILCS 85/3(e) ], 68 Ill. Adm. Code
				1330 and 42 USC 1936(i)(23) and also contain the prescriber's:
1) Drug Enforcement Administration (DEA)
				Number; or
2) National Provider
				Identifier (NPI); or
3) Medical
				Assistance Program Provider Number; or
4) Illinois State License Number.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.444 - Compounded Prescriptions

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Pharmacy charges for compounded prescriptions shall be billed at the per
				ingredient charge to the general public.
b) Reimbursement will be at the lower of the
				pharmacy's charge or the Department's maximum for each ingredient.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.445 - Prescribed Drugs

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective July
				15, 2019, for prescribed drugs, including prescription and over the counter
				drugs, the Department shall pay the lower of:
1) the pharmacy's usual and customary charge
				to the general public;
2) the
				Department's maximum price plus the established professional dispensing fee of
				$15.55 for drugs dispensed by Critical Access Pharmacies, as defined in this
				subsection, and $8.85 for drugs dispensed by non Critical Access Pharmacies.
				The Department shall pay only one dispensing fee per 30 or greater days' supply
				for those drugs dispensed in accordance with Section
				140.443(h).
				For purposes of this section, Critical Access Pharmacies are defined as
				pharmacies physically located within Illinois in counties with less than 50,000
				residents; and whose owner(s) do not have ownership or control interest in ten
				(10) or more pharmacies; and which are brick and mortar, meaning the pharmacy
				location is open to the public, recipients present at the pharmacy to fill
				prescriptions, and the majority of the pharmacy's business is not mail order
				based or through delivery to a residential facility and which is not
				owned/operated by a hospital or located within a hospital.;
3) The Department's maximum price is
				calculated as the lowest of:
A) Wholesale
				Acquisition Cost (WAC) minus 17.5 % for multiple source drugs; WAC minus 4.4 %
				for brand name drugs; or WAC minus 10% for blood clotting factor; or
B) National Average Drug Acquisition Cost, if
				available; or
C) the Federal upper
				limit as established under section 1927(e)(4) of the Social Security Act
				(42 USC
				1396r-8(e)(4)) ;
				or
D) the State upper
				limit.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.447 - Reimbursement

Current through Register Vol. 48, No. 28, July 12, 2024
a) The calculation
				of average wholesale price in the determination of the Department's maximum
				price (Section
				140.445(b)
				) is made using the standard package size.
b) If a pharmacy gives discounts to the
				general public, it must provide the same to Public Aid recipients. If discounts
				are allowed only to a specific group of people, they shall be extended to a
				recipient if he or she is a member of the special discount group. Public Aid
				recipients can constitute a special group and receive a discount, but they
				cannot be excluded from a discount group just because they are
				recipients.
c) The Department will
				require pharmacies to complete hard copy (paper) claim forms for pharmacy
				services and attach a Prescribing Practitioner Name Identification Form. A
				separate hard copy (paper) claim form and Practitioner Name Identification Form
				is to be required for each recipient and prescribing practitioner.
d) The Department will authorize an exception
				for pharmacies, to the requirements of subsection (c) of this Section, by
				allowing pharmacy claims to be submitted with the prescribing practitioner's
				DEA number, Department Medical Assistance Program participating provider
				identification number or Social Security Number.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.448 - Returned Pharmacy Items

Current through Register Vol. 48, No. 28, July 12, 2024
The Department shall not pay for an unused pharmacy item
				  returned to the dispensing pharmacy by or on behalf of a recipient, due to a
				  change in prescription, death of a recipient, etc., when the item can be
				  accepted by the pharmacy in accordance with applicable Federal and State laws
				  and regulations.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.449 - Payment of Pharmacy Items

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				Department shall pay no more for charges submitted than the maximum permitted
				by federal regulations.
b)
				Explanation of Drug Restrictions
1) Group
				Care Restricted - The drug is available to all recipient categories except
				individuals residing in a nursing home.
2) The nursing home must provide the
				following listed drugs to resident recipients at no charge to the recipient:
Acetaminophen Drops 80mg/0.8ml
Acetaminophen Drops 120mg/2.5ml
Acetaminophen Elixir/Syrup 120mg/5ml
Acetaminophen Tab/Cap 325mg
Acetaminophen Tab/Cap 500mg
Acetaminophen Tab/Cap 650mg
Acetaminophen Tablet Chewable 80mg
Acetaminophen Tablet Chewable 120mg
Aspirin Tab Buffered 325mg
Aspirin Tab Buffered 600mg
Aspirin Tab EC 300mg
Aspirin Tab EC 600mg
Aspirin Tab Pediatric
Aspirin Tab 300mg
Aspirin Tab 600mg
Glucola Liquid
Milk of Magnesia Liquid
Milk of Magnesia Tablet
Zinc Oxide Ointment
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.450 - Record Requirements for Pharmacies

Current through Register Vol. 48, No. 28, July 12, 2024
a) Pharmacies shall retain the following
				basic records:
1) All original prescriptions
				for Public Aid recipients;
2) All
				invoices from all suppliers from which the pharmacy acquires goods for which
				charges are made to the Department; and
3) A method of verification of usual and
				customary charges to the general public; and
4) A signature log as described in subsection
				(c) of this Section.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.451 - Prospective Drug Review and Patient Counseling

Current through Register Vol. 48, No. 28, July 12, 2024
Each pharmacy must ensure that:
a) The requirements for patient counseling
				established by the Illinois Department of Professional Regulation at 68 Ill.
				Adm. Code 1330.65, including the requirements of confidentiality and
				documentation of refusal of offers of patient counseling by recipients, are met
				on a continuing basis.
b) Before
				each prescription is delivered to the recipient or the recipient's care giver,
				a pharmacist must ensure that a review of the recipient's drug therapy
				(prospective drug review or drug utilization evaluation) was performed using
				commonly accepted drug review criteria. The review must include screening to
				identify potential drug therapy problems of the following types:
1) Therapeutic duplication, including the
				prescribing and dispensing of two or more drugs from the same therapeutic class
				such that the combined daily dose puts the recipient at risk of an adverse
				medical result or incurs additional program costs without additional
				therapeutic benefit;
2)
				Drug-disease contraindication when there is the potential for, or the
				occurrence of, an undesirable alteration of the therapeutic effect of a given
				drug because of the presence of a disease condition known to the pharmacist or
				that may reasonably be expected to be known to the pharmacist, or an adverse
				effect of the drug on the patient's disease condition;
3) Adverse drug-drug interaction when there
				is the potential for, or occurrence of, a clinically significant adverse
				medical effect as the result of the recipient using two or more drugs
				together;
4) Perceived incorrect
				drug dosage or duration; and
5)
				Drug-allergy interactions.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.452 - Community-based Mental Health Providers Qualified for Payment

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment will be made for community-based
				mental health services provided by providers enrolled in the Illinois Medical
				Assistance Program as:
1) A Community Mental
				Health Center. Community Mental Health Center shall mean an entity certified by
				the Department, or its agent, pursuant to 59 Ill. Adm. Code 132; or
2) A Behavioral Health Clinic, pursuant to
				Section
				140.499;
				or
3) An Independent Practitioner
				defined as:
A) A Licensed Clinical
				Psychologist, pursuant to 89 Ill. Adm. Code
				140.423(a);
B) A Licensed Clinical Social Worker,
				pursuant to 89 Ill. Code
				140.424(a);
				or
C) A psychiatrist, defined as a
				physician licensed under the Medical Practice Act of 1987 who has successfully
				completed a training program in psychiatry approved by the Accreditation
				Council for Graduate Medical Education (ACGME) or other training program
				identified as equivalent by the Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.454 - Types of Mental Health Services

Current through Register Vol. 48, No. 28, July 12, 2024
The specific types of mental health services for which
				  payment will be made are:
a) Mental
				health services meeting the standards in 89 Ill. Adm. Code
				140.453;
b) The screening and assessment authorized
				under 59 Ill. Adm. Code
				131.40 for
				individuals under 21 years of age;
c) The crisis intervention and stabilization
				services authorized under 59 Ill. Adm. Code
				131.50(a)
				provided during an individual's participation in the Screening, Assessment and
				Support Services program;
d)
				Subject to prior approval pursuant to Section
				140.40,
				case management services for individuals, identified through the screening
				process specified in Section
				140.642,
				transitioning from a nursing facility into residence in the community;
				and
e) Developmental testing for an
				infant and risk assessment screening for perinatal depression, for either the
				mother (prenatal or post-partum) or the infant, up to one year after
				delivery.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.455 - Payment for Mental Health Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) The amount approved for payment for mental
				health services described in Section
				140.454
				shall be based on the type and amount of service required by and actually
				delivered, and provided consistent with any service limitations, utilization
				controls, or prior approval processes established or authorized by the
				Department.
b) The payment amount
				for a service described in Section
				140.454(a) through
				(d) is determined in accordance with the rate
				methodologies outlined in the Department's published fee schedule, available at
https://www.illinois.gov/hfs/MedicalProviders/MedicaidReimbursement/Pages/CMHP.aspx
.
c) The payment amount for a service described
				in Section
				140.454(e)
				shall be at the rate of reimbursement paid to a physician for the same
				service.
d) Payment for services
				described in Section
				140.453(d)(1)
				and (3) is effective for dates of service on
				or after August 1, 2018.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.456 - Hearings

Current through Register Vol. 48, No. 28, July 12, 2024
The Department shall initiate administrative proceedings
				  pursuant to 89 Ill. Adm. Code 104, Subpart C, and Sections
				  140.13 through
				  140.19
				  to suspend or terminate the eligibility of providers of mental health services
				  to participate in the Illinois Medical Assistance Program when the provider has
				  failed to comply with:
a) 59 Ill. Adm.
				Code 132;
b) Sections
				140.452
				through
				140.455;
c) Section
				140.460;
d) Section 140.499 or Table O;
				and/or
e) Any of the grounds for
				suspension or termination set forth in Section
				140.16
				or Section
				140.17
				are present.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.457 - Therapy Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) For
				purposes of enrollment as a provider in the Medical Assistance Program, a
				physical, speech/language or occupational therapist must be licensed by the
				Illinois Department of Financial and Professional Regulation or equivalent
				licensing body in the therapist's state of practice.
b) Payment for therapy services shall be made
				to providers enrolled in the Illinois Medical Assistance Program as a physical
				therapist, an occupational therapist, a speech/language therapist, or a
				Community Health Agency.
c) Payment
				shall be made for physical, occupational, and speech/language therapy
				evaluation and treatment services that are:
1)
				Rendered by a licensed physical, occupational, or speech/language therapist or
				by a licensed therapy assistant operating under the licensed therapist's
				supervision in line with an established plan of care;
2) Ordered by a physician or other licensed
				practitioner of the healing arts (LPHA) operating within their scope of
				practice. For the purposes of this Section, an LPHA may include a licensed
				physical, occupational, or speech/language therapist as permitted pursuant to
				the therapist's respective practice act.
3) Medically necessary in accordance with a
				plan of care established by the rendering therapist or clinical fellow for the
				purpose of attaining maximum reduction of a disability and/or restoration of
				the individual to an acceptable functional level; and
4) Provided to children and adults with prior
				authorization, except prior authorization is not required for speech/language
				therapy services for children under age 21.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.458 - Prior Approval for Therapy Services

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Effective July 1, 2012 through September 30, 2014, prior approval is required
				for the provision of services by an independent speech/language, physical or
				occupational therapist or by a community health agency, unless:
1) the individual is eligible for services
				under Medicare; or
2) the
				individual is under the age of 21.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.459 - Payment for Therapy Services

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Therapy services shall be paid at an all-inclusive rate that shall be the lower
				of the following. The rate shall not exceed the upper limits set in federal
				regulations at
				42
				CFR 447.321 (2012) and reimbursement is based
				upon the applicable modifier billed by the provider.
1) The provider's usual and customary charge
				for services.
2) The maximum
				reimbursement rate established by the Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.460 - Clinic Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) The
				following types of clinics are eligible to receive payment for clinic services:
1) Hospital-based organized
				clinics;
2) Encounter rate
				clinics;
3) Federally Qualified
				Health Centers (FQHC):
4) Rural
				health clinics; and
5) Maternal and
				Child Health Clinics.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.462 - Covered Services in Clinics

Current through Register Vol. 48, No. 28, July 12, 2024
Payment shall be made to clinics for the following types of
				  services when provided by, or under the direction of, a physician:
a) Hospital-Based Organized Clinics. Covered
				services are those described in 89 Ill. Adm. Code 148.
b) Encounter Rate Clinics
1) With respect to those encounter rate
				clinics that qualify as Maternal and Child Health providers, as described in
				Section
				140.924,
				covered services are those described in Section
				140.922.
2) With respect to all other encounter rate
				clinics, covered services are medical services that provide for the continuous
				health care needs of persons who elect to use this type of service, including
				dental services that will be billed as separate encounters for dates of service
				on or after January 1, 2011.
3)
				Group psychotherapy services must meet the guidelines set forth in Section
				140.413(a)(4)(C).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.463 - Clinic Service Payment

Current through Register Vol. 48, No. 28, July 12, 2024
a) Definitions
"Behavioral Health Services", for the purposes of this
				  Section, means services provided by a licensed clinical psychologist, licensed
				  clinical social worker or licensed clinical professional counselor.
"Center", for the purposes of this Section, means both a
				  federally qualified health center and a rural health clinic.
"Federally Qualified Health Center" or "FQHC" means a health
				  care provider that receives a grant under Section 330 of the Public Health
				  Service Act ( Public Law 78-410 ) (
				  42 USC
				  1395 x(aa)(3) ) or has been determined to
				  meet the requirements for receiving such a grant by the Health Resources and
				  Services Administration, U.S. Department of Health and Human Services.
"Rural Health Clinic" or "RHC" means a health care provider
				  that has been designated by the Public Health Service, U.S. Department of
				  Health and Human Services, or by the Governor, and approved by the Public
				  Health Service, in accordance with the Rural Health Clinics Act ( Public Law
				  95-210 ) (
				  42 USC
				  1395 x(aa)(2) ) to be an RHC.
b) Reimbursement
The Center will be reimbursed under a prospective payment
				  system for 100 percent of the average of the costs that are reasonable and
				  related to the cost of furnishing such services by the Center in accordance
				  with the provisions of federal law (
				  42 USC
				  1396 a(aa) ). Baseline payment rates will be
				  determined individually for each enrolled Center. Once determined, the baseline
				  payment rate will be adjusted annually using the Medicare Economic Index (MEI).
				  Payment for services provided on or after January 1, 2001, shall be made using
				  specific rates for each Center as specified in this Section.
1) Baseline Payment Rates
A) For each Center, the Department will
				calculate a baseline medical encounter rate and, for each Center that is
				enrolled with the Department to provide Behavioral Health Services or dental
				services, the Department will calculate a baseline Behavioral Health Services
				or dental encounter rate, using the methodology specified in this subsection
				(b).
i) The cost basis for the baseline rates
				shall be drawn from individual Center cost reports for Center fiscal years
				ending in 1999 and 2000 or, in the instance of a Center that did not operate
				during the entirety of those periods, cost reports that cover the portions of
				those periods during which the Center was in operation.
ii) Pending federal approval, for dates of
				service provided by an FQHC on or after January 1, 2006, the cost basis for the
				baseline rates shall be the greater of an encounter rate using the criteria
				under subsection (b)(1)(A)(i) of this Section, or the same criteria that uses
				the Center's cost reports ending in 2002 and 2003 in place of cost reports
				ending in 1999 and 2000.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.464 - Hospital-Based and Encounter Rate Clinic Payments

Current through Register Vol. 48, No. 28, July 12, 2024
a) Hospital-based organized clinics, as
				described in Section
				140.461(a),
				shall be paid in accordance with 89 Ill. Adm. Code
				148.140.
b) Encounter Rate Clinics
Encounter rate clinics, as described at Section
				  140.461(b),
				  providing comprehensive health care for infants and women, including but not
				  limited to prenatal and postnatal care, will be reimbursed under a per
				  encounter rate system based upon 85% of the average of the costs of furnishing
				  those services. Baseline payment rates will be determined individually for each
				  encounter rate clinic. Once determined, the baseline payment rate will be
				  adjusted annually using the Medicare Economic Index (MEI) beginning January 1,
				  2015. Payment for services provided on or after October 1, 2014 shall be made
				  using specific rates for each clinic as specified in this Section.
1) Baseline Payment Rates
A) For each clinic, the Department will
				calculate a baseline medical encounter rate and, for dental services, the
				Department will calculate a baseline dental encounter rate, using the
				methodology specified in subsection (b)(1)(B).
B) The cost basis for the baseline rates
				shall be based upon allowable costs reported by the clinic that are determined
				by the Department to be reasonable, efficient and related to the cost of
				furnishing the services by the clinic and drawn from individual clinic cost
				reports for clinic fiscal years ending in 2012 and 2013.
C) The Department shall supply and the clinic
				shall submit a cost report for the years specified in subsection (b)(1)(B) for
				the purpose of determining the average cost per encounter for both medical and
				dental services. Clinics shall also furnish audited financial statements for
				each fiscal year specified in subsection (b)(1)(B).
D) The baseline payment rates for a clinic
				shall be the average (arithmetic mean) of the annual costs per encounter,
				calculated separately for each of the fiscal years for which cost report data
				must be submitted and multiplied by a cost factor of .85.
E) Encounter rate clinic claims submitted to
				the Department must identify all services provided during the
				encounter.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.465 - Adaptive Behavior Support Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment for Adaptive Behavior Support
				(ABS) Services.
1) Payment for ABS services
				shall be made to providers enrolled in the Illinois Medical Assistance Program
				as:
A) A Behavioral Health Clinic (BHC),
				pursuant to Section 140.499; or
B) An independently enrolled ABS Clinician,
				as defined in subsection (b)(1).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.467 - Independent Clinics

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment for
				all other Medicaid covered services provided by an independent clinic will be
				made on a fee-for-service basis, that is, the lower of charges or the
				Department's established maximum for the service, not to exceed the lowest
				Medicare reimbursement levels.
b)
				Payments to independent clinics will be subject to a two-way reconciliation of
				payments to reasonable costs.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.469 - Hospice

Current through Register Vol. 48, No. 28, July 12, 2024
a) Hospice is a
				continuum of palliative and supportive care, directed and coordinated by a team
				of professionals and volunteer workers who provide care to terminally ill
				persons to:
1) reduce or abate pain or other
				symptoms of mental or physical distress; and
2) meet the special needs arising out of the
				stresses of terminal illness, dying or bereavement.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.470 - Eligible Home Health Care, Nursing and Public Health Providers

Current through Register Vol. 48, No. 28, July 12, 2024
Effective July 1, 2012:
a) The following classes of providers may
				enroll with the Department as home health care providers:
1) A Medicare-certified home health agency
				licensed by the Department of Public Health;
2) A home nursing agency licensed by the
				Department of Public Health;
3) A
				self-employed nurse licensed by the Department of Financial and Professional
				Regulation as a registered nurse as defined by the Nurse Practice Act [225 ILCS
				65 ], when there is no home health agency in the area available to provide
				needed services; or
4) A health
				department certified by the Department of Public Health.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.472 - Home Health Care Services

Current through Register Vol. 48, No. 28, July 12, 2024
The services and items for which payment can be made
				  are:
a) Intermittent skilled nursing
				in the home for the purpose of completing an assessment, evaluation or
				administration.
b) Shift nursing
				care in the home for the purpose of caring for a participant under 21 years of
				age who has extensive medical needs and requires ongoing skilled nursing
				care.
c) Home health
				aide.
d) Therapy services:
				Effective July 1, 2012 through September 30, 2014, speech, occupational and
				physical therapy services are limited to a maximum of 20 visits per State
				fiscal year for participants who are age 21 and over. For services provided on
				and after October 1, 2014, these services require prior approval by the
				Department for participants age 21 and over. For services on or after July 1,
				2015, these services shall require prior approval by the Department for
				participants under age 21.
e)
				Medical equipment and supplies described in Section
				140.475.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.473 - Prior Approval for Home Health Care Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Prior approval is required for the
				provision of home health services described in Section
				140.472.
				The decision to approve or deny a request for prior approval will be made
				within 21 days after the date the request is received or within 21 days after
				receipt of additional information, whichever occurs later. Prior approval is
				also required for participants needing more than one skilled nursing visit per
				day.
b) Prior approval is required
				for the provision of all home health services to terminally ill participants
				covered under the Transitional Assistance Program and the Family and Children
				Assistance Program.
c) Effective
				July 1, 2012, prior approval is not required for intermittent skilled nursing
				services provided by a home health agency provider for participants within the
				first 60 days after discharge from an acute care or rehabilitation hospital
				when services are initiated within 14 days after discharge.
d) Prior approval is required for all in-home
				shift nursing for individuals who are under 21 years of age or who receive
				services under the Illinois Home and Community-Based Services Waiver for
				Persons who are Medically Fragile, Technology Dependent (MFTD Waiver). The
				decision to approve or deny a request for prior approval will be made within 21
				days after the date the request is received or within 21 days after receipt of
				additional information, whichever occurs later. Review of services for
				individuals eligible for in-home shift nursing under the MFTD Waiver will be
				made in accordance with 89 Ill. Adm. Code
				120.530.
e) Approval will be granted when, in the
				judgment of a consulting physician and subject to the review of the
				professional staff of the Department, the services are medically necessary and
				appropriate to meet the participant's medical needs.
f) Medical equipment and supplies are subject
				to the prior approval requirements outlined in Sections
				140.40
				and
				140.478.
				Documentation of the face-to-face encounter described in Section
				140.475(g)
				must be submitted with the prior approval.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.474 - Payment for Home Health Care Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective July 1, 2012, except for
				services described in subsection (b), home health agencies will be paid an all
				inclusive, per visit rate that shall be the lowest of the:
1) Agency's usual and customary charge for
				the service;
2) Agency's Medicare
				rate; or
3) Department's maximum
				allowable rate of as identified in the Home Health Fee Schedule (see the
				Department's website). Beginning with the State fiscal year 2002, the maximum
				allowable rate may be adjusted annually in consideration of the appropriation
				of funds by the General Assembly.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.475 - Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment for the
				provision of medical equipment, supplies, prosthetic devices and orthotic
				devices shall be made only to participating providers who are licensed or
				exempt from licensure under any licensure Act, including but not limited to the
				Home Medical Equipment and Services Provider License Act [ 225 ILCS 51
				].
b) Payment for medical
				equipment, supplies, prosthetic devices and orthotic devices shall be made:
1) when:
A)
				they are essential to enable a client to remain at home or to function in the
				community;
B) the client's
				physician has recommended in writing to the Department or in a patient care
				plan that the supplies or equipment be provided and that they are medically
				necessary; and
C) the Department
				has approved payment based on consideration of:
i) the client's medical condition;
ii) the benefits the item is expected to
				effect;
iii) the client's ability
				to adjust to and to use the item recommended; and
iv) in the case of a communication device,
				whether the device will increase the client's potential for full participation
				in health care by assisting in cause and effect awareness, or training physical
				movements or improving the client's understanding and comprehension of his or
				her health needs and responsibilities; or
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.476 - Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices for Which Payment Will Not Be Made

Current through Register Vol. 48, No. 28, July 12, 2024
Payment shall not be made for:
a) Items or repair of items for residents of
				long term care facilities, when such items are:
1) Durable medical equipment or supplies
				required by an individual in a long term care facility that are commonly used
				in patient care and considered as a part of the per diem reimbursement paid by
				the Department. Such items include, but are not limited to the following:
A) Equipment: Canes, crutches, standard
				wheelchairs, walkers, commodes, beds, mattresses, belts, cradles, trapeze bars,
				patient lifts, bedpans, urinals, suction equipment, supplies, hypothermia
				units, apnea monitors, and equipment necessary for the administration of
				oxygen.
B) Supplies: Catheters,
				urinary drainage bags, first aid supplies, dressings, soaps, irrigation
				supplies, drinking tubes, and other supplies necessary to provide patient
				care.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.477 - Limitations on Equipment, Prosthetic Devices and Orthotic Devices

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective July
				1, 2012, prior approval for the purchase, repair or rental of certain medical
				equipment, prosthetic devices and orthotic devices is required except when:
1) The client is a Medicare beneficiary and
				the item requested has been reimbursed under the Medicare program; or
2) The item is being loaned pending repair or
				replacement of the recipient's own item.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.478 - Prior Approval for Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices

Current through Register Vol. 48, No. 28, July 12, 2024
a) The following
				time frames shall be adhered to by the Department when prior approval is
				required for medical equipment, prosthetic devices and orthotic devices (see
				also Section
				140.40
				):
1) Decisions to approve or deny a request
				for prior approval of life-sustaining respiratory supplies and equipment will
				be made within 30 days after the date of receipt of the request by the
				Department. Prior approval is not required for such items for the first 30 days
				of service.
2) Decisions to approve
				or deny requests for artificial limbs and braces shall be made within 21 days
				after the date of receipt of the request by the Department.
3) Decisions to approve or deny requests for
				standard wheelchairs and hospital beds shall be made within 21 days after the
				date of receipt of the request by the Department.
4) Decisions to approve or deny requests for
				hearing aids, communication devices, custom molded shoes, shoe corrections,
				orthopedic shoes used in conjunction with a brace, and custom wheelchairs,
				shall be made within 30 days after the date of receipt of the request by the
				Department.
5) Decisions to approve
				or deny requests for medical supplies costing less than $100 shall be made
				within 21 days after the date of receipt of the requests by the
				Department.
6) Decisions to approve
				or deny requests for medical supplies costing more than $100 shall be made
				within 30 days after the date of receipt of the request by the
				Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.479 - Limitations, Medical Supplies

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Reimbursement for medical supplies will be limited to the quantity indicated by
				the ordering practitioner or to the quantity specified in the Department's
				prior approval, whichever is less. Once the total quantity specified by the
				ordering practitioner has been provided or the period of time shown on the
				approval request has elapsed, a new written order must be obtained.
b) A new written order must be obtained from
				the physician no less often than every 12 months, even for supplies needed for
				an ongoing chronic condition.
c)
				Prior approval for the purchase of medical supplies is required except when:
1) The client is a Medicare beneficiary and
				the item requested has been reimbursed under the Medicare program; or
2) Items are being dispensed, per physician
				order, in amounts less than the normal maximum allowable quantity limits
				established by the Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.480 - Equipment Rental Limitations

Current through Register Vol. 48, No. 28, July 12, 2024
Total cumulative rental costs must not exceed the usual
				  retail price of the medical equipment except for durable equipment used for
				  respiratory care. When total cumulative rental costs exceed the purchase price,
				  the Department considers the equipment paid for in full and the property of the
				  Department. Some durable medical equipment items used for respiratory care are
				  covered on a rental or lease basis only. Rental charges must be terminated
				  after the recipient's need for the equipment ceases to exist.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.481 - Payment for Medical Equipment, Supplies, Prosthetic Devices and Hearing Aids

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment for
				Medical Equipment. Medical equipment is durable, reusable equipment such as
				hospital beds, canes, walkers, etc. Payment for medical equipment is made for
				covered items or services at the lesser of the provider's charge or the maximum
				allowable rate established by the Department's fee schedule. The Department
				will review the maximum allowable rates at least annually. Beginning March 1,
				2018, the Department's maximum allowable rates for new items or services shall
				be calculated based on the Medicare DMEPOS fee schedule rate for the year the
				procedure code is first established on the Department's fee schedule, minus 6
				percent. The Medicare DMEPOS Fee Schedule is a list of payment amounts for
				durable medical equipment, prosthetics, orthotics, and supplies published by
				the Centers for Medicare and Medicaid Services; it is available at
				https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.
				When more than one rate is listed for a single item on the DMEPOS Fee Schedule
				(e.g., rural and nonrural rates), the Department will base its maximum
				allowable rate for that item on the highest Illinois rate listed. If there is
				no rate established on the Department's fee schedule, the maximum allowable
				rate established for each item or service shall be the least of:
1) The average suggested retail price derived
				from available medical supply catalogs and/or providers' price lists;
				or
2) The wholesale price, defined
				effective July 1, 2013 as actual acquisition cost including all discounts,
				derived from available medical supply catalogs and/or providers' price lists
				for each item plus 50 percent; or
3) The Medicare allowable rate for covered
				Medicare items or services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.482 - Family Planning Services

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Payment shall be made for the provision of Family Planning services only to
				providers who are enrolled to participate in the Medical Assistance
				Program.
b) Family Planning
				services consisting of contraceptive devices and birth control methods shall be
				available without regard to age, sex or marital status.
c) Payment shall be made for preliminary
				physician examinations, annual examinations, professional services when
				problems are indicated, laboratory tests, contraceptive devices, supplies and
				surgical sterilization procedures.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.483 - Limitations on Family Planning Services

Current through Register Vol. 48, No. 28, July 12, 2024
Payment for sterilization procedures shall be made only under
				  the following conditions:
a) When
				informed consent as defined under Federal regulations for the Medicaid program
				( 42 CFR 441.250 -
				441.259 )
				is given and a consent form acceptable under Federal regulations is properly
				signed and witnessed by the patient, a witness, and the surgeon not less than
				30 days or more than 180 days or in cases of premature delivery or emergency
				abdominal surgery not less than 72 hours prior to completion of the surgical
				procedure. In the case of premature delivery, the informed consent must have
				been given at least 30 days before the expected date of delivery.
b) The patient must have attained the age 21
				years.
c) The patient must be
				mentally competent to render consent for sterilization procedure.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.484 - Payment for Family Planning Services

Current through Register Vol. 48, No. 28, July 12, 2024
Payment for the specific service or procedure provided shall
				  be made at the usual and customary charge, not to exceed the rates or fees
				  established under the provision of the Department reimbursement schedule,
				  pursuant to the Department's Section
				  140.400. The
				  reimbursement schedule may be obtained by contacting the Bureau of Provider
				  Services, Illinois Department of Public Aid, 931 East Washington, Springfield,
				  Illinois.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.485 - Healthy Kids Program

Current through Register Vol. 48, No. 28, July 12, 2024
a) Program
				Description
1) The Healthy Kids Program is
				the Early and Periodic Screening, Diagnosis and Treatment Program mandated by
				the Social Security Act (see
				42 USC
				1396 a(43), 1396d(4)(B) (Supp. 1987)). The
				goals of the program are to:
A) improve the
				health status of Medicaid-eligible children ages birth through 20 years through
				the provision of preventive medical care and early diagnosis and treatment of
				conditions threatening the child's health;
B) reduce the long term costs of medical care
				to eligible children; and
C)
				effective for dates of service on or after July 1, 2014, comply with the
				evidence-based practices detailed in the American Academy of Pediatrics Bright
				Futures Guidelines for Health Supervision of Infants, Children and Adolescents,
				Third Edition (2008), American Academy of Pediatrics, 141 Northwest Point
				Blvd., Elk Grove Village IL 60007,
http://brightfutures.aap.org
.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.486 - Illinois Healthy Women

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Benefit coverage under Illinois Healthy Women is available to women meeting the
				eligibility requirements set forth in 89 Ill. Adm. Code
				120.540.
b) Covered medical services under Illinois
				Healthy Women are limited to the following reproductive health and family
				planning services:
1) Physical examination
				and health history for family planning purposes;
2) Brief and intermediate follow-up office
				visits related to family planning;
3) Pap smears, at least annually, or as
				medically indicated;
4) Necessary
				family planning or women's health related lab and diagnostic tests;
5) Birth control drugs and devices, including
				the inserting, implanting or injecting of a birth control drug and removing of
				a birth control device;
6)
				Sterilization services, pursuant to Section
				140.483;
7) Testing and treatment for sexually
				transmitted infections (STIs) diagnosed during a family planning
				visit;
8) Testing for HIV, when
				ordered by a physician during a family planning visit;
9) Generic prenatal vitamins, or generic
				multi-vitamins with folic acid, or folic acid; and
10) Mammograms, when ordered by a physician
				during a family planning visit.