reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart C - PROVIDER ASSESSMENTS › Section 140.80 - Hospital Provider Fund

Current through Register Vol. 48, No. 28, July 12, 2024
a) Purpose and
				Contents
1) The Hospital Provider Fund (Fund)
				was created in the State Treasury on February 3, 2004 (see
				305 ILCS
				5/5A-8). Interest earned by the Fund shall be credited
				to the Fund. The Fund shall not be used to replace any funds appropriated to
				the Medicaid program by the General Assembly.
2) The Fund is created for the purpose of
				receiving and disbursing monies in accordance with this Section and Article 5A
				of the Code.
3) The Fund shall
				consist of:
A) All monies collected or
				received by the Department under subsection (b);
B) All federal matching funds received by the
				Department as a result of expenditures made by the Department that are
				attributable to monies deposited in the Fund;
C) Any interest or penalty levied in
				conjunction with the administration of the Fund;
D) Monies transferred from another fund in
				the State treasury;
E) All other
				monies received for the Fund from any other source, including interest earned
				on those monies.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart C - PROVIDER ASSESSMENTS › Section 140.82 - Developmentally Disabled Care Provider Fund

Current through Register Vol. 48, No. 28, July 12, 2024
a) Purpose and Contents
1) The Developmentally Disabled Care Provider
				Fund was created in the State Treasury on July 1, 1992, July 14, 1993 and July
				1, 1995 (see
				305
				ILCS 5/5C-7 ). Interest earned by the Fund shall be
				credited to the Fund. The Fund shall not be used to replace any funds
				appropriated to the Medicaid program by the General Assembly.
2) The Fund is created for the purpose of
				receiving and disbursing monies in accordance with this Section and Sections
				5C-2 and 7 of the Code.
3) The Fund
				shall consist of:
A) All monies collected or
				received by the Department under subsection (b);
B) All federal matching funds received by the
				Department as a result of expenditures made by the Department that are
				attributable to monies deposited in the Fund;
C) Any interest or penalty levied in
				conjunction with the administration of the Fund;
D) All other monies received for the Fund
				from any other source, including interest earned thereon; and
E) All monies transferred from the Medicaid
				Developmentally Disabled Provider Participation Fee Trust Fund.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart C - PROVIDER ASSESSMENTS › Section 140.84 - Long Term Care Provider Fund

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Purpose and Contents
1) The Long Term Care
				Provider Fund was created in the State Treasury on July 1, 1992, July 14, 1993
				and July 1, 1995 (see Section 5B-8 of the Code). Interest earned by the Fund
				shall be credited to the Fund. The Fund shall not be used to replace any funds
				appropriated to the Medicaid program by the General Assembly.
2) The Fund is created for the purpose of
				receiving and disbursing monies in accordance with this Section and Sections
				5B-2 and 5B-8 of the Code.
3) The
				Fund shall consist of:
A) All monies collected
				or received by the Department under subsection (b);
B) All federal matching funds received by the
				Department as a result of expenditures made from the Fund;
C) Any interest or penalty levied in
				conjunction with the administration of the Fund;
D) All other monies received for the Fund
				from any other source, including interest earned thereon; and
E) All monies transferred from the Tobacco
				Products Tax Act [35 ILCS 143].
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart C - PROVIDER ASSESSMENTS › Section 140.86 - Supportive Living Facility Fund

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Purpose and Contents
1) The Supportive Living
				Facility Fund was created in the State Treasury on July 1, 2014 (see
				305 ILCS
				5/5G-35 ). Interest earned by the Fund shall be
				credited to the Fund. The Fund shall not be used to replace any funds
				appropriated to the Medicaid program by the General Assembly.
2) The Fund is created for the purpose of
				receiving and disbursing monies in accordance with this Section and Sections
				5G-10 and 35 of the Code.
3) The
				Fund shall consist of:
A) All monies
				collected or received by the Department under subsection (b);
B) All monies collected or received by the
				Department under subsection (j);
C)
				All federal matching funds received by the Department as a result of
				expenditures made by the Department that are attributable to monies deposited
				in the Fund;
D) Any interest or
				penalty levied in conjunction with the administration of the Fund;
E) All monies transferred from another fund
				in the State Treasury; and
F) All
				other monies received for the Fund from any other source, including interest
				earned on monies in the Fund.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart C - PROVIDER ASSESSMENTS › Section 140.88 - Managed Care Organization Provider Assessment

Current through Register Vol. 48, No. 28, July 12, 2024
a) Definitions
1) "Base Year" means the 12 month period from
				January 1, 2018 to December 31, 2018
2) "Department" means the Department of
				Healthcare and Family Services.
3)
				"Federal employee health benefit" means the program of health benefits plans,
				as defined in 5 U.S.C.
				8901, available to federal employees under
				5 U.S.C.
				8901 to
				8914.
4) "Fund" means the Healthcare Provider
				Relief Fund.
5) "Managed Care
				Organization" means an entity operating under a certificate of authority issued
				pursuant to the Health Maintenance Organization Act [215 ILCS 125
				] or as a Managed Care Community Network pursuant to Section 5-11 of the Public
				Aid Code [305 ILCS 5 ].
6) "Medicaid Managed Care Organization" or
				"Medicaid MCO" means a Managed Care Organization under contract with the
				Department to provide services to recipients of benefits in the Medical
				Assistance Program under Article V of the Public Aid Code, the Children's
				Health Insurance Program Act [215 ILCS 106 ], and the Covering
				ALL KIDS Health Insurance Act [215 ILCS 170 ]. It does not
				include contracts the same entity or an affiliated entity maintains for other
				business.
7) "Medicare" means the
				federal Medicare program established under Title XVIII of the Social Security
				Act.
8) "Member months" means the
				aggregate total number of months all individuals are enrolled for coverage in
				an MCO during the base year. Member months are determined by the Department for
				Medicaid MCOs based on enrollment data in its Medicaid Management Information
				System and by the Department of Insurance for other MCOs based on required
				filings with the Department of Insurance. Member months do not include months
				individuals are enrolled in a Limited Health Services Organization, including
				stand-alone dental or vision plans, a Medicare Advantage Plan, a Medicare
				Supplement Plan, a Medicaid-Medicare Alignment Initiative Plan pursuant to a
				Memorandum of Understanding between the Department and the federal Centers for
				Medicare and Medicaid Services or a Federal Employee Health Benefits
				Plan.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.400 - Payment to Practitioners

Current through Register Vol. 48, No. 28, July 12, 2024
a) This
				Section applies to physicians, dentists, Advanced Practice Registered Nurses
				(APRN) (see Section 140.435), optometrists,
				podiatrists, chiropractors, Licensed Clinical Psychologists (LCP) (see Section
				140.423) and Licensed Clinical
				Social Workers (LCSW) (see Section
				140.424).
1) Practitioners are required to bill the
				Medical Assistance Program at the same rate they charge patients paying their
				own bills and patients covered by other third party payers.
2) A practitioner may bill only for services
				the practitioner personally provides or that are provided, under the
				practitioner's supervision, or by the practitioner's staff, except as provided
				in subsection (f). An APRN, as described in Section 140.435, LCP, as described
				in Section 140.423, or LCSW, as described in Section 140.424, may bill only for
				the services the practitioner personally provided.
3) Payment will be made only in the
				practitioner's name or a Department approved alternate payee.
4) Except as described otherwise in this
				Section, payments will be made according to a schedule of statewide pricing
				screens established by the Department, except that LCP and LCSW will be
				reimbursed for covered services at 75% of the physician reimbursement rate.
				Covered services provided by qualifying providers under the Maternal and Child
				Health Program will be reimbursed at enhanced rates as described in subsection
				(b). The pricing screens are to be established based on consideration of the
				market value of the service. In considering the market value, the Department
				will examine the costs of operations and material. Input from advisory groups
				designated by statute, generally recognized provider interest groups and the
				general public will be taken into consideration in determining the allocation
				of available funds to rate adjustments. Increases in rates are contingent upon
				funds appropriated by the General Assembly. Reductions or increases may be
				affected by changes in the market place or changes in funding available for the
				Medical Assistance Program. Screens will be related to the average statewide
				charge. Except as described otherwise in this Section, the upper limit for
				services shall not exceed the lowest Medicare charge levels.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.402 - Copayments for Non-institutional Medical Services

Current through Register Vol. 48, No. 28, July 12, 2024
The following implements cost sharing in compliance with
				  42
				  USC 1396o (section 1916 of the Social
				  Security Act):
a) Each recipient, with
				the exception of those classes of recipients identified in subsection (d),
				shall be required to pay a copayment of $2.00 for generic legend drugs and
				over-the-counter drugs billed to the Department, and for other services, with
				the exception of those services identified in subsection (e), the nominal
				copayment amount as defined at
				42
				CFR 447.54. For dates of service beginning
				July 1, 2012 through March 31, 2013 the nominal copayment amount is $3.65.
				Beginning with dates of service on April 1, 2013 through August 31, 2019, the
				nominal copayment amount is $3.90.
				Beginning with dates of service on or after September 1, 2019, recipients will
				no longer be required to pay a copayment for medical assistance services.
				Specific copayment amounts are described and updated on the Department's Web
				site for the following non-institutional medical services:
1) Office visits to enrolled practitioners
				for services reimbursed under the Illinois Public Aid Code.
2) Each brand name legend drug billed to the
				Department.
3) Each encounter
				billed to the Department by an Encounter Rate Clinic (ERC), Federally Qualified
				Health Center (FQHC) or Rural Health Clinic (RHC), but excluding behavioral
				services provided by these facilities. For dates of service beginning July 1,
				2013 through August 31, 2019, copayments for behavioral health services
				provided by these facilities are no longer excluded and shall be required to be
				paid by recipients with the exception of those classes of recipients identified
				in subsection (d).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.403 - Telehealth Services

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Definitions
1) "Asynchronous Store and Forward
				Technology" means the transmission of a patient's medical information from an
				originating site to the provider at the distant site. The provider at the
				distant site can review the medical case without the patient being present. An
				asynchronous telecommunication system in single media format does not include
				telephone calls, images transmitted via facsimile machines and text messages
				without visualization of the patient (electronic mail). Photographs visualized
				by a telecommunication system must be specific to the patient' s medical
				condition and adequate for furnishing or confirming a diagnosis and/or
				treatment plan. Dermatological photographs (for example, a photograph of a skin
				lesion) may be considered to meet the requirement of a single media format
				under this provision.
2) "Distant
				Site" means the location at which the provider rendering the service is
				located.
3) "Encounter Clinic"
				means a Federally Qualified Health Center, Rural Health Clinic or Encounter
				Rate Clinic, as defined in 89 Ill. Adm. Code
				140.461.
4) "Facility Fee" means the reimbursement
				made to the following originating sites for the telehealth service: physician's
				office, podiatrist's office, local health departments, community mental health
				centers, licensed hospital outpatient departments as defined in 89 Ill. Adm.
				Code
				148.25(d)
				and substance abuse treatment centers licensed by the Department of Human
				Services-Division of Alcoholism and Substance Abuse (DASA).
5) "Interactive Telecommunication System"
				means multimedia communications equipment that includes, at a minimum, audio
				and video equipment permitting two-way, real-time interactive communication
				between the patient and the distant site provider. Telephones, facsimile
				machines, and electronic mail systems do not meet the definition of an
				interactive telecommunication system.
6) "Originating Site" means the location at
				which the participant receiving the service is located.
7) "Telecommunication System" means an
				asynchronous store and forward technology and/or an interactive
				telecommunication system that is used to transmit data between the originating
				and distant sites.
8) "Telehealth"
				means services provided via a telecommunication system.
9) "Telemedicine" means the use of a
				telecommunication system to provide medical services for the purpose of
				evaluation and treatment when the patient is at one medical provider location
				and the rendering provider is at another location.
10) "Telepsychiatry" means the use of a
				telecommunication system to provide psychiatric services for the purpose of
				evaluation and treatment when the patient is at one medical provider location
				and the rendering provider is at another location.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.405 - Non-Institutional Rate Reductions

Current through Register Vol. 48, No. 28, July 12, 2024
Notwithstanding any provisions to the contrary in this Part,
				  effective for dates of service on or after July 1, 2012, reimbursement rates
				  and other payments to non-institutional providers shall be reduced by an
				  additional 2.7 % from the rates or payments that were otherwise in effect on
				  June 30. 2012, except that the reductions shall not apply to:
a) Rates or payments for physician services,
				dental services, services reimbursed through an encounter rate, services
				provided under the Medicaid Rehabilitation Option of the Illinois Title XIX
				State Plan.
b) Rates or payments,
				or the portion thereof, paid to a provider that is operated by a unit of local
				government or State University that provides some or all of the non-federal
				share of the services.
c) Pharmacy
				services, which are reduced pursuant to Sections
				140.414
				and
				140.445.
d) Notwithstanding any other provision to the
				contrary in this Part, federally approved rates or payments for services
				related to a public health emergency that:
1)
				Appear on the Department's public health emergency published fee schedule;
				and
2) Meet the date of service
				specifications on the Department's public health emergency published fee
				schedule.
3) The Department's
				public health emergency published fee schedule shall remain in place until the
				Department determines the rates or payments described under this subsection (d)
				are no longer necessary to address a public health emergency, for reasons
				including, but not limited to: the establishment, termination, or modification
				of any applicable federal or State disaster declaration, Executive Orders of
				the Governor, or disaster-related flexibilities granted by federal
				agencies.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.410 - Physicians' Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment
				shall be made only to physicians licensed to practice medicine in all its
				branches.
b) The restrictions and
				limitations which shall apply to physician participation include the following:
1) Interns are not eligible to
				participate;
2) Residents are
				eligible to participate where, by terms of their contract with the hospital,
				they are permitted to and do bill private patients and collect and retain the
				payments received for their services;
3) Hospital based specialists who are
				salaried, with the cost of their services included in the hospital
				reimbursement costs, are eligible to participate when their contractual
				arrangment with the hospital provides for them to make their own charges for
				professional services and they do, in fact, bill private patients and collect
				and retain payments made;
4)
				Physicians holding non-teaching administrative or staff positions in hospitals
				and/or medical schools are eligible to participate to the extent that they
				maintain a private practice and bill private patients and collect and retain
				payments made; and
5) Teaching
				physicians who provide direct patient care are eligible to participate if the
				salaries paid them by hospitals or other institutions do not include a
				component for treatment services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.411 - Covered Services By Physicians

Current through Register Vol. 48, No. 28, July 12, 2024
The Department shall pay physicians for the provision of
				  services not otherwise excluded which are:
a) Essential for the diagnosis and treatment
				of a disease or injury;
b) Included
				in the Physicians' Current Procedural Terminology (CPT) fourth edition,
				published by the American Medical Association; and
c) Provided by the physician or by a member
				of the physician's staff under the physician's direct supervision.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.412 - Services Not Covered By Physicians

Current through Register Vol. 48, No. 28, July 12, 2024
Services for which medical necessity is not clearly
				  established are not covered in the Medical Assistance Program. Additionally,
				  the following services are specifically excluded from coverage and payment
				  cannot be made by the Department for the provision of these services.
a) Experimental medical or surgical
				services.
b) Acupuncture.
c) Investigational and research oriented
				procedures.
d) Artificial
				insemination.
e) Services
				prohibited by Illinois or Federal statute.
f) Services provided in Federal or State
				institutions.
g) Medical care
				provided by mail or telephone.
h)
				Unkept appointments.
i) Autopsy
				examinations.
j) Preparation of
				routine records, forms and reports.
k) Cosmetic procedures, medical or surgical,
				where projected results do not relieve a physical or functional
				handicap.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.413 - Limitation on Physician Services

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				When provided in accordance with the specified limitations and requirements,
				the Department shall pay for the following services:
1) Termination of Pregnancy. All abortion
				service claims must be accompanied by an HFS 2390 Abortion Payment Application.
				The Department will pay for abortion services when:
A) The pregnancy results from rape or
				incest;
B) In the physician's
				professional judgment, the pregnancy threatens the life of the mother;
				or
C) The service is performed for
				any other reason.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.414 - Requirements for Prescriptions and Dispensing of Pharmacy Items - Prescibers

Current through Register Vol. 48, No. 28, July 12, 2024
For the purpose of this Section, "prescriber" shall mean any
				  person who, within the scope of his or her professional licensing requirements,
				  may prescribe or dispense drugs.
a)
				Prescriptions
1) A prescriber may prescribe
				any pharmacy item, not otherwise excluded, that, in the prescriber's
				professional judgment, is essential for the diagnosis or accepted treatment of
				a recipient's present symptoms. The Department may require prior approval of
				any drug except as outlined in Section
				140.442(a)(9).
2) A prescriber shall:
A) Use a tamper-resistant prescription form,
				as defined at Section
				140.443(b)(2),
				for non-electronic prescriptions. Non-electronic prescriptions are defined at
				Section
				140.443(b)(1).
				In addition, the prescriber shall ensure the prescription form is compliant
				with 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
B)
				Enter on the form all data elements 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), as well as one of the following data elements
				identifying the prescriber:
i) Drug
				Enforcement Administration (DEA) Number; or
ii) National Provider Indentifier (NPI);
				or
iii) Medical Assistance Program
				Provider Number; or
iv) Illinois
				State License Number.
3) The prescriber shall not charge for
				writing a prescription.
4) Items
				that shall not be prescribed are listed in Section
				140.441.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.416 - Optometric Services and Materials

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment for optometric services and
				materials shall be made to physicians, optometrists, opticians and optical
				companies.
b) Payment shall be made
				for the following optometric services and materials:
1) An eye examination by a physician or an
				optometrist for the purpose of determining the condition of the eye including
				the refractive state.
2) Frame
				repairs, contact lenses, artificial eyes and low vision devices provided by
				physicians, optometrists, opticians and optical companies.
3) Dispensing of optical materials.
4) Lenses, frame parts and frames provided by
				the Department of Corrections (DOC) laboratory.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.417 - Limitations on Optometric Services

Current through Register Vol. 48, No. 28, July 12, 2024
Payment for the following optometric services and materials
				  shall be made subject to the following limitations:
a) Payment shall be made for single vision
				lenses only when the following conditions are met:
1) The power is at least 0.75 diopters in
				either the sphere or cylinder component; or
2) The difference between the old and new
				prescription is at least 0.75 diopters in either the sphere or cylinder
				component.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.418 - Department of Corrections Laboratory

Current through Register Vol. 48, No. 28, July 12, 2024
All lenses, frames and frame parts shall be obtained from the
				  Department of Corrections (DOC) laboratory and, upon receipt of federal
				  approval of an amendment to the Illinois Title XIX State Plan, a vendor or
				  vendors procured by the Chicago Public Schools (CPS) to manufacture eyeglasses
				  for individuals enrolled in a school within the CPS system. DOC shall not
				  engage in "office" services, such as examinations or dispensing of eyeglasses
				  to recipients. Individual optical suppliers shall continue to provide
				  examinations, frame repairs, contact lenses, artificial eyes and low vision
				  devices, as well as dispensing of eyeglasses obtained from the DOC laboratory
				  or CPS vendor. CPS shall ensure that its vendor or vendors are enrolled as
				  providers in the Medical Assistance Program and, as applicable, in a managed
				  care entity (MCE) serving individuals enrolled in a school within the CPS
				  system. Claims for services provided by DOC or CPS' vendor or vendors shall be
				  submitted to the Department of Healthcare and Family Services (Department) or
				  the MCE in which the individual is enrolled for payment and shall be reimbursed
				  at the Department's or the MCE's established rates or rate methodologies for
				  eyeglasses.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.420 - Dental Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1, 2014,
				  except as otherwise specified in this Section:
a) Except as outlined in subsection (b),
				payment for dental services shall be made only to enrolled licensed
				dentists.
b) Payment for oral
				health screening and fluoride varnish services shall be made to enrolled
				licensed dentists, and physicians or advance practice registered nurses (APRNs)
				who are trained and approved to provide oral health screening and fluoride
				varnish services.
c) Payment for
				comprehensive orthodontic care shall be made only to a dentist licensed for
				provision of those services.
d)
				Except as specified in subsections (e) and (f), payment shall be made for
				allowable dental services specified in Table D that are:
1) Necessary to relieve pain or infection,
				preserve teeth, or restore adequate dental function;
2) Diagnostic, preventive, or restorative
				services, endodontics, prosthodontics, orthodontics or oral surgery included in
				the Department's Schedule of Dental Procedures (see Table D); and
3) Performed by the dentist or under the
				direct supervision of the dentist, or for oral health screening and fluoride
				varnish services, performed by or under the direct supervision of an enrolled
				licensed dentist, physician or APRN.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.421 - Limitations on Dental Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2018:
a) The Department shall impose
				prior approval requirements to determine the medical necessity of dental
				services listed in this Section. Prior approval is required for:
1) Crowns;
2) Partial Pulpotomy;
3) Periodontal services, except full mouth
				debridement for diagnostic purposes;
4) Apexification and
				recalcification;
5)
				Apicoectomy;
6) Dentures, partial
				dentures and denture relines;
7)
				Maxillofacial prosthetics;
8)
				Prosthodontics;
9) Removal of
				impacted teeth;
10) Surgical
				removal of residual roots;
11)
				Surgical exposure to aid eruption;
12) Alveoloplasty;
13) Incision and drainage of
				abscess;
14) Removal of cysts or
				tumors;
15) Frenulectomy;
16) Orthodontics. Effective January 1, 2017,
				medically necessary orthodontic treatment is approved only for patients under
				the age of 21 and is defined as:
A) treatment
				necessary to correct a condition that scores 28 points or more on the
				Handicapping Labio-Lingual Deviation Index (HLD); or
B) treatment necessary to correct the
				following conditions:
i) Cleft
				palate;
ii) Deep impinging bite
				with signs of tissue damage, not just touching palate;
iii) Anterior crossbite with gingival
				recession;
iv) Severe traumatic
				deviation (i.e., accidents, tumors, etc.; attach description); and
v) Effective January 1, 2019, impacted
				maxillary central incisor;
17) General anesthesia, conscious sedation or
				deep sedation;
18) Therapeutic drug
				injection;
19) Other drugs and
				medicaments;
20) Unspecified
				miscellaneous adjunctive general services or procedures;
21) Dental services not listed in Table
				D.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.423 - Licensed Clinical Psychologist Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) For purposes of enrollment in the Medical
				Assistance Program, a Licensed Clinical Psychologist (LCP) means a person who
				is licensed and is legally authorized under State law or rule to practice as a
				Licensed Clinical Psychologist, pursuant to the Clinical Psychologist Licensing
				Act [ 225 ILCS 15 ] and implementing rules (68 Ill. Adm. Code 1400).
b) Effective with dates of service January 1,
				2017 and after, payment shall be made to LCPs for the following services:
1) Psychological and neuropsychological
				testing;
2) Diagnostic
				evaluation;
3) Therapeutic services
				provided in the office, home or community setting:
A) Individual psychotherapy; or
B) Family or group psychotherapy for which
				the purpose is the treatment of the patient. Group psychotherapy services must
				meet the guidelines set forth in Section
				140.462(c)(2) and
				(d)(2).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.424 - Licensed Clinical Social Worker Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) For purposes of enrollment in the Medical
				Assistance Program, a Licensed Clinical Social Worker (LCSW) means a person who
				is licensed and is legally authorized under State law or rule to practice as a
				Licensed Clinical Social Worker, pursuant to the Clinical Social Work and
				Social Work Practice Act [ 225 ILCS 20 ] and implementing rules (68 Ill. Adm.
				Code 1470).
b) Effective with dates
				of service January 1, 2017 and after, payment shall be made to LCSWs for the
				following services:
1) Diagnostic evaluation;
				and
2) Therapeutic services
				provided in the office, home or community setting:
A) Individual psychotherapy; or
B) Family or group psychotherapy for which
				the purpose is the treatment of the patient. Group psychotherapy services must
				meet the guidelines set forth in Section
				140.462(c)(2) and
				(d)(2).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.425 - Podiatry Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment
				for podiatry services shall be made only to licensed podiatrists.
b) Effective July 1, 2012 through September
				30, 2014, payment shall be made for those podiatric services provided to
				recipients under the age of 21 or recipients age 21 and over who have been
				diagnosed with diabetes as defined in the International Classification of
				Diseases, 9th Revision.
c) Payment shall be made for the following:
1) Effective July 1, 2012 through September
				30, 2014, payment shall be made for those podiatric services that are:
A) Limited to recipients under the age of 21
				or recipients age 21 and over who have been diagnosed with diabetes as defined
				in the International Classification of Diseases.
B) Essential for the diagnosis and treatment
				of conditions of the feet and ankles.
C) Listed in the Current Procedural
				Terminology (CPT) fourth edition published by the American Medical Association
				or Healthcare Common Procedure Coding System (HCPCS) Level II, for podiatric
				office visits, diagnostic radiology, pathology, or orthomechanical procedures
				included in the Department's schedule of podiatric services as itemized in
				Table F.
D) Performed by the
				podiatrist or under the direct supervision of the podiatrist.
E) Routine foot care services (trimming of
				nails, treatment of calluses, corns, and similar services) when a participant
				is under active treatment for diabetes mellitus.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.426 - Limitations on Podiatry Services

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Payment for an initial visit shall be made only one time for an individual
				patient to determine whether foot care is required and covered by the
				Department's program. In partnership or group practices, it is allowed only one
				time collectively for all podiatrists in the group.
b) Payment for blood work by the "dipstick"
				method shall be made only when a colorimetric instrument is used for evaluation
				of the results.
c) Payment for
				orthomechanics, multiple surgical procedures or surgical procedures within a
				six (6) month period following original surgery shall be made only when the
				podiatrist obtains prior approval from the Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.428 - Chiropractic Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment
				shall be made only to chiropractors.
b) Payment shall be made for only one
				chiropractic service: manual manipulation of the spine to correct a subluxation
				of the spine which has resulted in a neuromusculoskeletal condition for which
				the manipulation is an appropriate treatment.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.430 - Independent Clinical Laboratory Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment for clinical laboratory services
				may be made to a laboratory that is independent both of a physician's practice
				and of a hospital.
b) In order to
				participate in the Medical Assistance Program, the independent laboratory must
				be licensed and certified for participation in the Medicare program. Approval
				for participation in the program is not transferrable and shall only apply to
				the location and the owner specified on the laboratory's enrollment
				application.
c) Payment shall be
				made for only those laboratory services that have been ordered in writing by
				the referring practitioner as being essential to diagnosis and treatment. The
				practitioner must include the diagnosis or condition on the written
				request.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.431 - Services Not Covered by Independent Clinical Laboratories

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment shall not be made for any service
				that a clinical laboratory is not Medicare certified to provide.
b) Payment shall not be made for the
				following clinical laboratory services:
1)
				Any test which has not been performed on the laboratory's premises, by the
				laboratory's staff, using the laboratory's equipment and supplies.
2) The collection and handling of specimens
				obtained for referral to another laboratory.
3) Laboratory tests that are available
				without charge from other sources, including the Illinois Department of Public
				Health. The Department will pay, however, for throat cultures when the
				referring physician determines use of a Department of Public Health laboratory
				would result in delay in diagnosis and treatment.
4) Sensitivity studies when a culture shows
				no growth or when a growth is identified as beta hemolytic
				streptococcus.
5) Tests ordered for
				Healthy Kids screening purposes.
6)
				Tests and study of specimens referred as a result of an autopsy
				examination.
7) Laboratory services
				provided to recipients eligible for Medicare Part B benefits when the Medicare
				intermediary determines that the services are not medically
				necessary.
8) Laboratory services
				when not specifically required by the condition for which the recipient is
				being treated.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.432 - Limitations on Independent Clinical Laboratory Services

Current through Register Vol. 48, No. 28, July 12, 2024
The Department shall pay for the following services only when
				  they are provided in accordance with the limitations specified:
a) Vitamin B-12 testing - only in those cases
				in which a completed blood count has shown a macrocytic hormochromic anemia and
				a high lactic dehydrogenase.
b)
				Home Visits - only when the recipient's attending physician indicates on the
				order that the recipient is physically unable to travel to the laboratory and
				if it is the custom of the laboratory to charge the general public a home visit
				fee in addition to the fee for the laboratory service.
c) Routine, multi-channel (battery) tests -
				only those instances where the tests performed are consistent with the
				recipient's diagnosis and/or conditions.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.433 - Payment for Clinical Laboratory Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment for allowable laboratory services
				includes payment for collection and handling of specimens by laboratory
				personnel, use of laboratory equipment and supplies, and the written report of
				test results to the referring practitioner.
b) Payment for allowable laboratory services
				provided to recipients who are not eligible for Medicare Part B benefits is
				based on the laboratory's usual and customary charges within the limitations
				established by the Department (see Section
				140.400 ).
c) For recipients eligible for Medicare Part
				B Coverage, payment is made on deductible and coinsurance amounts up to the
				limitations established by the Department for the service.
d) Payment for three or more blood
				chemistries performed on the same specimen is made on a basis related to the
				use of automated equipment.
e) When
				the laboratory performs profile testing, it must bill the Department by
				profile. The Department considers two or more thyroid tests performed on the
				same specimen to be profile testing.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.434 - Record Requirements for Independent Clinical Laboratories

Current through Register Vol. 48, No. 28, July 12, 2024
a) In addition to
				the record requirements specified in Section
				140.28,
				independent clinical laboratories must comply with the administrative rules of
				the Illinois Department of Public Health governing the maintenance of medical
				records that are found at 77 Ill. Adm. Code 450, Illinois Clinical Laboratories
				Code.
b) The basic records that
				must be retained include, but are not limited to:
1) All original orders from practitioners for
				laboratory services for Public Aid recipients.
2) All copies of reports to referring
				practitioners.
3) Records that
				verify usual and customary charges to the general public.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.435 - Advanced Practice Registered Nurse Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) For purposes of enrollment in the Medical
				Assistance Program, an advanced practice registered nurse (APRN) means a person
				who is licensed as a registered professional nurse, holds a valid license in
				the state of practice and is legally authorized under state law or rule to
				practice as an advanced practice registered nurse, so long as that practice is
				not in conflict with the Nurse Practice Act [225 ILCS 65 ], the Medical
				Practice Act of 1987 [225 ILCS 60 ] and the administrative rules implementing
				the Nurse Practice Act (68 Ill. Adm. Code 1300) and the Medical Practice Act of
				1987 (68 Ill. Adm. Code 1285). Categories of APRNs include:
1) Certified Registered Nurse Anesthetist
				(CRNA);
2) Certified Nurse Midwife
				(CNM);
3) Certified Nurse
				Practitioner (CNP); and
4) Clinical
				Nurse Specialist (CNS).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.436 - Limitations on Advanced Practice Registered Nurse Services

Current through Register Vol. 48, No. 28, July 12, 2024
The following will not be reimbursed, unless specifically
				  authorized by rule during a Public Health Emergency:
a) Nursing services provided in the role of
				physician assistant;
b) Mileage to
				and from place of service;
c)
				Consultations between APRNs or between an APRN and a physician; or
d) Group psychotherapy or
				telepsychiatry.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.438 - Diagnostic Imaging Services

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Payment for diagnostic and imaging services may be made to the following
				providers that are independent of both a physician's office and a hospital:
1) Imaging Centers that are distinct entities
				operating primarily for the purpose of providing diagnostic imaging
				services.
2) Mammography Screening
				Centers.
3) Portable X-ray
				Facilities.
4) Independent
				Diagnostic Testing Facilities (IDTFs) that are a fixed location, a mobile
				entity, or an individual non-physician practitioner.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.439 - Critical Access Care Pharmacy Payment

Current through Register Vol. 48, No. 28, July 12, 2024
a) To be eligible to receive a Critical
				Access Care Pharmacy Payment (CAP Payment), a pharmacy provider must:
1) Attest to meeting all the following
				criteria for the entire previous fiscal quarter:
A) Pharmacy is physically located within
				Illinois;
B) Pharmacy is 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;
C) Pharmacy owners have an ownership or
				control interest in fewer than 10 pharmacies; and
D) Pharmacy is located in a county with fewer
				than 50,000 residents, or is located in a county with 50,000 or more residents
				and in an area within Illinois that is designated as a Medically Underserved
				Area by the Health Resources & Services Administration (HRSA), an agency of
				the U.S. Department of Health and Human Services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart D - PAYMENT FOR NON-INSTITUTIONAL SERVICES › Section 140.440 - Pharmacy Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment
				shall be made only to pharmacies.
b) The following conditions apply to pharmacy
				participation:
1) The pharmacy must hold a
				current Drug Enforcement Administration (DEA) registration issued by the United
				States Drug Enforcement Administration (see 21 CFR 1301 et seq.), as well as a
				current controlled substances license issued by the Illinois Department of
				Financial and Professional Regulation (see Controlled Substances Act [720 ILCS
				570]) prior to enrolling with the Department.
2) Licensed Pharmacy Requirements
A) A licensed pharmacy located in and/or
				administratively associated with a group practice or long-term facility must:
i) provide the same scope of general pharmacy
				and professional services as a pharmacy not so affiliated; and
ii) be retail in nature, open and accessible
				to the general public.
B)
				The pharmacy shall not limit prescriptions filled to those written by
				practitioners connected with the group or facility for persons receiving care
				or services from the group or facility.
3) A hospital pharmacy that provides
				pharmaceutical services and supplies for inpatients, outpatient clinic patients
				and emergency room patients of the hospital may not enroll as a participating
				pharmacy unless licensed to provide pharmaceutical services to the general
				public (Division 5 license).
4)
				Effective August 1, 2012, in order to dispense blood factor, a pharmacy must
				sign a standards of care agreement with the Department.
5) A pharmacy billing the Department for
				340B-purchased drugs shall charge the Department no more than its actual
				acquisition cost (AAC) for the drug product plus the Department's established
				dispensing fee, unless the Department has calculated an allowable amount
				specific to 340B-purchased drugs for that drug. In that case, the pharmacy may
				bill the Department its usual and customary charges. For a pharmacy provider
				owned or operated by a Hemophilia Treatment Center, this requirement does not
				become effective until July 1, 2013.