Section 140.1  Incorporation By Reference

Any rules or regulations of an agency of the United States or of a nationally recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified, and do not include any later amendments or editions.

(Source:  Added at 9 Ill. Reg. 2697, effective February 22, 1985)

Section 140.2  Medical Assistance Programs

a)         Under the Medical Assistance Programs, the Department pays participating providers for necessary medical services, specified in Section 140.3 through 140.7 for:

1)         persons eligible for financial assistance under the Aid to the Aged, Blind or Disabled-State Supplemental Payment (AABD-SSP) and Temporary Assistance to Needy Families (TANF) programs (Medicaid-MAG);

2)         persons who would be eligible for financial assistance but who have resources in excess of the Department's eligibility standards and who have incurred medical expenses greater than the difference between their income and the Department's standards (Medicaid-MANG);

3)         individuals under age 18 who do not qualify for TANF/TANF-MANG and infants under age one year (see Section 140.7);

4)         pregnant women who would not be eligible for TANF/TANF-MANG if the child were born and who do not qualify as mandatory categorically needy (see Section 140.9);

5)         persons who are eligible for Title IV-E adoption assistance/foster care assistance from another State and who are living in Illinois;

6)         noncitizens who have an emergency medical condition (see 89 Ill. Adm. Code 120.310); however, payment is not included for care and services related to an organ transplant procedure;

7)         persons eligible for medical assistance under the Aid to the Aged, Blind or Disabled (AABD) program who reside in specified Supportive Living Facilities (SLFs), as described at 89 Ill. Adm. Code 146, Subpart B;

8)         persons eligible for FamilyCare as described in 89 Ill. Adm. Code 120.32;

9)         beginning January 1, 2014, persons eligible as ACA Adults as described in 89 Ill. Adm. Code 120.10(h); and

10)         beginning January 1, 2014, persons eligible as Former Foster Care as described in 89 Ill. Adm. Code 120.10(i).

b)         "Necessary medical care" is that which is generally recognized as standard medical care required because of disease, disability, infirmity or impairment.

c)         The Department may impose prior approval requirements, as specified by rule, to determine whether the medical care is necessary and eligible for payment from the Department in individual situations.  Such requirements shall be based on recommendations of technical and professional staff and advisory committees.

d)         When recipients are entitled to Medicare benefits, the Department shall assume responsibility for their deductible and coinsurance obligations, unless the recipients have income and/or resources available to meet these needs.  The total payment to a provider from both Medicare and the Department shall not exceed either the amount that Medicare determines to be a reasonable charge or the Department standard for the services provided, whichever is applicable.

e)         The Department shall pay for services and items not allowed by Medicare only if they are provided in accordance with Department policy for recipients not entitled to Medicare benefits.

f)         The Department may contract with qualified practitioners, hospitals and all other dispensers of medical services for the provision and reimbursement of any and all medical care or services as specified in the contract on a prepaid capitation basis (i.e., payment of a fixed amount per enrollee made in advance of the service); volume purchase basis (i.e., purchase of a volume of goods or services for a price specified in the contract); ambulatory visit basis (i.e., one comprehensive payment for each visit regardless of the services provided during that visit) or per discharge basis (i.e., one comprehensive payment per discharge regardless of the services provided during the stay).  Such contracts shall be based either on formally solicited competitive bid proposals or individually negotiated rates with providers willing to enter into special contractual arrangements with the State.

g)         The Department may require that recipients of medical assistance under any of the Department's programs exercise their freedom of choice by choosing to receive medical care under the traditional fee for service system or through a prepaid capitation plan or under one of the other alternative contractual arrangements described in subsection (f) of this Section.  The categories of recipients who may choose or be assigned to an alternative plan will be specified in the contract.  Recipients required to make such a choice will be notified in writing by the Department.  If a recipient does not choose to exercise his/her freedom of choice, the Department may assign that recipient to a prepaid plan.  Under such a plan, recipients would obtain certain medical services or supplies from a single source or limited source.  The Department will notify recipients in writing if they are assigned to a prepaid plan. Recipients enrolled in or assigned to a prepaid plan will receive written notification advising them of the services which they will receive from the plan.  Covered services not provided by the plan will be reimbursed by the Department on a fee for service basis.  Recipients will receive a medical eligibility card, which will apply to such services.

h)         The Department may enter into contracts for the provision of medical care on a prepaid capitation basis from a Health Maintenance Organization (HMO) whereby the recipient who chooses to receive medical care through an HMO must stay in the HMO for a certain period of time, not to exceed six months (the enrollment period).  Upon written notice, the recipient may choose to disenroll from such an HMO at any time within the first month of each enrollment period. The Department will send the recipient a notice at least 30 days prior to the end of the enrollment period, which gives the recipient a specified period of time in which to inform the Department if the recipient does not wish to re-enroll in the HMO for a new enrollment period.  The recipient may then disenroll at the end of the enrollment period only if the recipient responds to the notice and indicates in writing a choice to disenroll.  Failure to respond to the notice will result in automatic re-enrollment for a new enrollment period.  Recipients shall also be allowed to disenroll at any time for cause.

i)          The Department may enter into contracts for the provision of medical care on a prepaid capitation basis from a Health Maintenance Organization whereby the recipient who chooses to receive medical care through an HMO may choose to disenroll at any time, upon written notice.

j)          The Department shall pay for services under the Maternal and Child Health Program, a primary health care program for pregnant women and children (see Subpart G).

k)         Services covered for persons who are confined or detained as described in 89 Ill. Adm. Code 120.318(b) shall be limited as described in Section 140.10.

(Source:  Amended at 38 Ill. Reg. 12141, effective May 30, 2014)

Section 140.3  Covered Services Under Medical Assistance Programs

a)         As described in this Section, medical services shall be covered for:

1)         recipients of financial assistance under the AABD (Aid to the Aged, Blind or Disabled), TANF (Temporary Assistance to Needy Families), or Refugee/Entrant/Repatriate program;

2)         recipients of medical assistance only under the AABD program (AABD-MANG);

3)         recipients of medical assistance only under the TANF program (TANF-MANG);

4)         individuals under age 18 not eligible for TANF (see Section 140.7), pregnant women who would be eligible if the child were born and pregnant women and children under age eight who do not qualify as mandatory categorically needy (see Section 140.9);

5)         disabled persons under age 21 who may qualify for Medicaid or in-home care under the Illinois Home and Community-Based Services Waiver for Medically Fragile Technology Dependent Children;

6)         individuals 19 years of age or older eligible under the KidCare Parent Coverage Waiver described at 89 Ill. Adm. Code 120.32, except for services provided only through a waiver approved under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c));

7)         beginning January 1, 2014, ACA Adults as described in 89 Ill. Adm. Code 120.10(h).  Notwithstanding any rule to the contrary in Title 89, the services that shall be covered are services for which the Department obtains federal approval and receives federal matching funds; and

8)         beginning January 1, 2014, Former Foster Care as described in 89 Ill. Adm. Code 120.10(i).

b)         The following medical services shall be covered for recipients under age 21 who are included under subsection (a):

1)         Inpatient hospital services;

2)         Hospital outpatient and clinic services;

3)         Hospital emergency room visits.  The visit must be for the alleviation of severe pain or for immediate diagnosis and/or treatment of conditions or injuries that might result in disability or death if there is not immediate treatment;

4)         Encounter rate clinic visits;

5)         Physician services;

6)         Pharmacy services;

7)         Home health agency visits;

8)         Laboratory and x-ray services;

9)         Group care services;

10)         Family planning services and supplies;

11)         Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies;

12)         Transportation to secure medical services;

13)         EPSDT services pursuant to Section 140.485;

14)         Dental services;

15)         Chiropractic services;

16)         Podiatric services;

17)         Optical services and supplies;

18)         Subacute alcoholism and substance abuse services pursuant to Sections 140.390 through 140.396;

19)         Hospice services;

20)         Nursing care pursuant to Section 140.472;

21)         Nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting pursuant to 89 Ill. Adm. Code 146, Subpart D;

22)         Telehealth services pursuant to Section 140.403;

23)         Preventive services;

24)         Licensed Clinical Social Worker services;

25)         Licensed Clinical Psychologist services;

26)         Effective January 1, 2018, abortion services; and

27)         Effective January 1, 2022, coverage of routine patient cost for items and services in connection with participation in a qualified clinical trial, as defined in Section 1905(gg) of the Social Security Act.

c)         Effective July 1, 2012, the following medical services shall be covered for recipients age 21 or over who are included under subsection (a):

1)         Inpatient hospital services;

2)         Hospital outpatient and clinic services;

3)         Hospital emergency room visits.  The visit must be for the alleviation of severe pain or for immediate diagnosis and/or treatment of conditions or injuries that might result in disability or death if there is not immediate treatment;

4)         Encounter rate clinic visits;

5)         Physician services;

6)         Pharmacy services;

7)         Home health agency visits;

8)         Laboratory and x-ray services;

9)         Group care services;

10)         Family planning services and supplies;

11)         Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies;

12)         Transportation to secure medical services;

13)         Subacute alcoholism and substance abuse services pursuant to Sections 140.390 through 140.396;

14)         Hospice services;

15)         Dental services, pursuant to Section 140.420;

16)         Podiatric services, pursuant to Section 140.425 for individuals with a diagnosis of diabetes;

17)         Optical services and supplies;

18)         Telehealth services pursuant to Section 140.403;

19)         Preventive services;

20)         Licensed Clinical Social Worker services;

21)         Licensed Clinical Psychologist services;

22)         Effective January 1, 2018, abortion services; and

23)         Effective January 1, 2022, coverage of routine patient cost for items and services in connection with participation in a qualified clinical trial, as defined in Section 1905(gg) of the Social Security Act.

(Source:  Amended at 46 Ill. Reg. 18061, effective October 27, 2022)

Section 140.4  Covered Medical Services Under AFDC-MANG for non-pregnant persons who are 18 years of age or older (Repealed)

(Source:  Repealed at 9 Ill. Reg. 14684, effective September 13, 1985)

Section 140.5  Covered Medical Services Under General Assistance

This program is no longer in effect as of July 1, 2012.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.6  Medical Services Not Covered

The following services are not covered under the Department's medical assistance programs:

a)         Services available without charge;

b)         Services prohibited by State or federal law;

c)         Experimental procedures;

d)         Research oriented procedures; other than those described in Section 140.3(b)(27) and 140.3(c)(23);

e)         Medical examinations required for entrance into educational or vocational programs;

f)         Autopsy examinations;

g)         Artificial insemination;

h)         Medical or surgical procedures performed for cosmetic purposes;

i)          Medical or surgical transsexual treatment, for dates of service prior to April 1, 2015;

j)          Diagnostic and/or therapeutic procedures related to primary infertility/sterility;

k)         Subsequent treatment for venereal disease, when those services are available through State and/or local health agencies;

l)          Medical care provided by mail or telephone;

m)        Unkept appointments;

n)         Non-medically necessary items and services provided for the convenience of recipients and/or their families; and

o)         Preparation of routine records, forms and reports.

p)         Visits with persons other than a recipient, such as family members or group care facility staff.

(Source:  Amended at 49 Ill. Reg. 4026, effective March 20, 2025)

Section 140.7  Medical Assistance Provided to Individuals Under the Age of Eighteen Who Do Not Qualify for AFDC and Children Under Age Eight

a)         Individuals Under Age Eighteen (18)

1)         Medical assistance shall be provided to individuals under the age of eighteen who do not qualify for AFDC under the definition of dependent child as defined in 89 Ill. Adm. Code 101.20 and 112.60 through 112.64.  However, such individuals must meet the eligibility requirements and other provisions of 89 Ill. Adm. Code 112.10, 112.20, 112. Subparts C and D, 112.303, 112.304 and 112.307 through 112.309.

2)         If non-exempt countable income is equal to or less than the appropriate MANG (AFDC) standard the individual is eligible for payment of his/her allowable medical care costs.

3)         Persons whose income exceeds the appropriate MANG (AFDC) standard are eligible for medical assistance each month incurred or paid medical care costs equals the amount of excess non-exempt income over the standard.  When income exceeds the MANG (AFDC) standard, eligibility begins on the day in the month incurred or paid medical care costs equals excess monthly income.  Eligibility ends on the last day of the same month.

b)         Children Under Age Eight (8) Medical assistance shall be provided to children under age six (6) who do not qualify as mandatory categorically needy (Social Security Act (42 U.S.C. 1902(a)(10)(A)(i) and 1905(n)) and meet the eligibility requirements of 89 Ill. Adm. Code 120.11, 120.31 and 120.64.

(Source:  Amended at 15 Ill. Reg. 11176, effective August 1, 1991)

Section 140.8  Medical Assistance For Qualified Severely Impaired Individuals

Medical assistance shall be provided under the AABD program to a qualified severly impaired individual whose Supplemental Security Income (SSI) payment status is based on Section 1619 of the Social Security Act (the Act) (42 U.S.C. 1382h)) if he/she was eligible for Medicaid in the month prior to first becoming eligible under Section 1619 of the Act (see 89 Ill. Adm. Code 113:  Subparts B and C, and 89 Ill. Adm. Code 120.10 and 120.60).  A qualified severely impaired individual is any person under age 65 who received either SSI, State Supplemental Payment or special Section 1619(a) of the Act benefits and was eligible for Medicaid and who the Social Security Administration determines meets all of the following criteria:

a)         is blind or disabled under Title XVI of the Act (see 42 U.S.C. 1382c);

b)         meets all SSI requirements except for earned income;

c)         would be seriously inhibited by the lack of Medicaid coverage from continuing to work or obtaining employment; and

d)         has earnings insufficient to provide a reasonable equivalent of Medicaid, SSI and Title XX (42 U.S.C. 1397 et seq.) attendant care benefits that would be available if he/she did not work.

(Source:  Added at 12 Ill. Reg. 916, effective January 1, 1988)

Section 140.9  Medical Assistance for a Pregnant Woman Who Would Not Be Categorically Eligible for AFDC/AFDC-MANG if the Child Were Already Born Or Who Do Not Qualify As Mandatory Categorically Needy

a)         Pregnant Women Who Would Not Be Categorically Eligible for AFDC/AFDC‑MANG if the Child Were Already Born

1)         Medical assistance will be provided to applicants of any age who are pregnant and meet the asset standards of the AFDC medical assistance program and who would not be eligible for AFDC if the child were already born because:

A)        the father is not absent, and

B)        neither parent is incapacitated and the principal wage earner does not meet the Department's definition of unemployment (see 89 Ill. Adm. Code 112.64).

2)         Medical Assistance for up to sixty (60) days following the last day of pregnancy

A)        Medical assistance shall be provided for the woman and newborn child for 60 days following the last day of the pregnancy.  The sixty (60) day medical coverage continues through the last day of the calendar month in which the sixty (60) day period ends.

B)        In order for a pregnant woman to qualify for the extended sixty (60) day medical coverage, an AFDC MANG application must have been filed prior to the date the pregnancy ended.

b)         Pregnant Women Who Do Not Qualify As Mandatory Categorically Needy

1)         Medical assistance shall be provided to women of any age who do not qualify as mandatory categorically needy (Sections 1902(a)(10)(A)(i) and 1905(n) of the Social Security Act) and meet the eligibility requirements of 89 Ill. Adm. Code 120.11, 120.31 and 120.64).

2)         Medical Assistance shall be provided for the woman and newborn child(ren) for up to sixty (60) days following the last day of the pregnancy.  The sixty (60) day medical coverage continues through the last day of the calendar month in which the sixty (60) day period ends.

(Source:  Amended at 12 Ill. Reg. 19734, effective November 15, 1988)

Section 140.10  Medical Assistance Provided to Persons Confined or Detained by the Criminal Justice System

a)         The Department shall pay for certain medical services provided to the following groups of individuals who are confined or detained in county jails or other detention facilities in Illinois, that are not operated by the State, and who are eligible for, and enrolled in, medical assistance administered under Article V of the Illinois Public Aid Code [305 ILCS 5]:

1)         Individuals who, at the time of confinement or detention, were already enrolled for medical assistance.

2)         Individuals who, subsequent to their confinement or detention, were determined eligible and enrolled for medical assistance.

b)         Reimbursement of hospital inpatient services.  The Department will directly reimburse hospitals pursuant to 89 Ill. Adm. Code 147, 148 and 152 for inpatient hospital services provided to those covered under subsections (a)(1) and (2) of this Section.

c)         Reimbursement of other services:

1)         With respect to medical services provided to individuals described in subsection (a)(1), the Department shall reimburse the county or arresting authority (a unit of local government other than a county that employs peace officers who make the arrest) for a portion of the cost of medical services, other than hospital inpatient services, that are:

A)        Provided to the individual during his or her period of confinement or detention;

B)        Covered for the class of persons described in Section 5-2 of the Public Aid Code under which the individual is enrolled;

C)        Provided by medical providers that are enrolled with the Department to participate in the medical assistance program; and

D)        Provided pursuant to a county or arresting authority ordinance or resolution providing for reimbursement for the cost of medical services at the reimbursement levels established by the Department for medical assistance under Article V of the Public Aid Code.

2)         The county or arresting authority requesting reimbursement from the Department must submit the following documentation in a form and format specified by the Department:

A)        Information necessary to adjudicate a claim for each service provided, including, but not limited to:

i)          the name, birth date, Social Security number and recipient identification number of the individual receiving the medical service;

ii)         the name, address and provider number of the health care provider that provided the service;

iii)        the service provided, including applicable diagnosis, procedure and national drug codes; and

iv)        the provider charges and the amount paid by the county or arresting authority for the services.

B)        The date of confinement and, if applicable, the date of release or transfer to another criminal justice authority.

C)        Verification that the services claimed for reimbursement correspond to the services rendered.

D)        A copy of the ordinance or resolution providing for reimbursement for the cost of medical services at the reimbursement levels established by the Department for medical assistance pursuant to Article V of the Public Aid Code.

3)         The Department will adjudicate each claim applying its reimbursement rates and, to the extent that the cost of care for the individual exceeds $500 accumulated over the individual's period of confinement, will reimburse the county or arresting authority the amount in excess of $500.

(Source:  Amended at 35 Ill. Reg. 394, effective December 27, 2010)

Section 140.11  Enrollment Conditions for Medical Providers

a)         In order to enroll for participation, providers shall:

1)         Hold a valid, appropriate license where State law requires licensure of medical practitioners, agencies, institutions and other medical vendors.

2)         Be certified for participation in the Title XVIII Medicare program where federal or State rules and regulations require such certification for Title XIX participation.

3)         Be certified for Title XIX when federal or State rules and regulations so require.

4)         Provide enrollment information to the Department in the prescribed format, and notify the Department, in writing, immediately whenever there is a change in any such information which the provider has previously submitted.

5)         Provide disclosure, as requested by the Department, of all financial, beneficial, ownership, equity, surety, or other interests in any and all firms, corporations, partnerships, associations, business, enterprises, joint ventures, agencies, institutions or other legal entities providing any form of health care services to public aid recipients.

6)         Have a written provider agreement on file with the Department.

b)         Approval of a corporate entity such as a pharmacy, laboratory, durable medical equipment and supplies provider, medical transportation provider, nursing home or renal satellite facility, as a participant in the Medical Assistance Program, applies only to the entity's existing ownership, corporate structure and location; therefore, participation approval is not transferable.

c)         Except for children's hospitals described at 89 Ill. Adm. Code 148.25(d)(3)(B), hospitals providing inpatient care that are certified under a single Centers for Medicare and Medicaid Services certification number shall be enrolled as a single entity in the Medical Assistance Program.  A children's hospital must be separately enrolled from the general care hospital with which it is affiliated.

d)         Upon notification from the Illinois Department of Public Health of a change of ownership, the Department shall notify the prospective buyer of its obligation under Section 140.12(l) to assume liability for repayment to the Department for overpayments made to the current owner or operator.  Such notification shall inform the prospective buyer of all outstanding known liabilities due to the Department by the facility and of any known pending Department actions against the facility that may result in further liability. For long term care providers, when there is a change of ownership of a facility or a facility is leased to a new operator, the provider agreement shall be automatically assigned to the new owner or lessee. Such assigned agreement shall be subject to all conditions under which it was originally issued, including, but not limited to, any existing plans of correction, all requirements of participation as set forth in Section 140.12 or additional requirements imposed by the Department.

e)         For purposes of administrative efficiency, the Department may periodically require classes of providers to re-enroll in the Medical Assistance Program.  Under such re-enrollments, the Department shall request classes of providers to submit updated enrollment information.  Failure of a provider to submit such information within the requested time frames will result in the disenrollment of the provider from the Program.  Such disenrollment shall have no effect on the future eligibility of the provider to participate in the Program and is intended only for purposes of the Department’s efficient administration of the Program.  A disenrolled provider may reapply to the Program and all such re-applications must meet the requirements for enrollment.

f)         For purposes of this Section, a vendor whose investor ownership has changed by 50 percent or more from the date the vendor was initially approved for enrollment in the Medical Assistance Program shall be required to submit a new application for enrollment in the Medical Assistance Program.  All such applications must meet the requirements for enrollment.

g)         Anything in this Subpart B to the contrary notwithstanding, enrollment of a vendor is subject to a provisional period and shall be conditional for one year unless limited by the Department.  During the period of conditional enrollment, the Department may terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the Medical Assistance Program without cause.  Upon termination of a vendor under this subsection (g), the following individuals shall be barred from participation in the Medical Assistance Program:

1)         Individuals with management responsibility;

2)         All owners or partners in a partnership;

3)         All officers of a corporation or individuals owning, directly or indirectly, five percent or more of the shares of stock or other evidence of ownership in a corporation; or

4)         An owner of a sole proprietorship.

h)         Unless otherwise specified, the termination of eligibility or vendor disenrollment, as described in subsection (g) of this Section, and resulting barrments are not subject to the Department's hearing process. However, a disenrolled vendor may reapply without penalty.

(Source:  Amended at 38 Ill. Reg. 15081, effective July 2, 2014)

Section 140.12  Participation Requirements for Medical Providers

The provider shall agree to:

a)         Verify eligibility of recipients prior to providing each service;

b)         Allow recipients the choice of accepting or rejecting medical or surgical care or treatment;

c)         Provide supplies and services in full compliance with all applicable provisions of State and federal laws and regulations pertaining to nondiscrimination and equal employment opportunity including but not limited to:

1)         Full compliance with Title VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of race, color or national origin;

2)         Full compliance with Section 504 of the Rehabilitation Act of 1973 and 45 CFR 84, which prohibit discrimination on the basis of handicap; and

3)         Without discrimination on the basis of religious belief, political affiliation, sex, age or disability;

d)         Comply with the requirements of applicable federal and State laws and not engage in practices prohibited by such laws;

e)         Provide, and upon demand present documentation of, education of employees, contractors and agents regarding the federal False Claims Act (31 USC 3729‑3733) that complies with all requirements of 42 USC 1396a(a)(68).  Providers subject to this requirement include a governmental agency, organization, unit, corporation, partnership, or other business arrangement (including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists), whether for-profit or no‑for‑profit, that receives or makes payments totaling at least $5 million annually;

f)         Hold confidential, and use for authorized program purposes only, all Medical Assistance information regarding recipients;

g)         Furnish to the Department, in the form and manner requested by it, any information it requests regarding payments for providing goods or services, or in connection with the rendering of goods or services or supplies to recipients by the provider, his agent, employer or employee;

h)         Make charges for the provision of services and supplies to recipients in amounts not to exceed the provider's usual and customary charges and in the same quality and mode of delivery as are provided to the general public;

i)          Accept as payment in full the amounts established by the Department.

1)         If a provider accepts an individual eligible for medical assistance from the Department as a Medicaid recipient, such provider shall not bill, demand or otherwise seek reimbursement from that individual or from a financially responsible relative or representative of the individual for any service for which reimbursement would have been available from the Department if the provider had timely and properly billed the Department.  For purposes of this subsection, "accepts" shall be deemed to include:

A)        an affirmative representation to an individual that payment for services will be sought from the Department;

B)        an individual presents the provider with his or her medical card and the provider does not indicate that other payment arrangements will be necessary; or

C)        billing the Department for the covered medical service provided an eligible individual.

2)         If an eligible individual is entitled to medical assistance with respect to a service for which a third party is liable for payment, the provider furnishing the service may not seek to collect from the individual payment for that service if the total liability of the third party for that service is at least equal to the amount payable for that service by the Department.

j)          Accept assignment of Medicare benefits for public aid recipients eligible for Medicare, when payment for services to such persons is sought from the Department;

k)         Complete an MCH (Maternal and Child Health) Primary Care Provider Agreement in order to participate in the Maternal and Child Health Program (see Section 140.924(a)(1)(D)); and

l)          In the case of long term care providers, assume liability for repayment to the Department of any overpayment made to a facility regardless of whether the overpayment was incurred by a current owner or operator or by a previous owner or operator.  Liability of current and previous providers to the Department shall be joint and several.  Recoveries by the Department under this Section may be made pursuant to Sections 140.15 and 140.25.  A current or previous owner or lessee may request from the Department a list of all known outstanding liabilities due the Department by the facility and of any known pending Department actions against a facility that may result in further liability.  For purposes of this Section, "overpayment" shall include, but not be limited to:

1)         Amounts established by final administrative decisions pursuant to 89 Ill. Adm. Code 104;

2)         Overpayments resulting from advance C-13 payments made pursuant to Section 140.71;

3)         Liabilities resulting from nonpayment or delinquent payment of assessments pursuant to Sections 140.82, 140.84 and 140.94; and

4)         Amounts identified during past, pending or future audits that pertain to audit periods prior to a change in ownership and are conducted pursuant to Sections 140.30 and 140.590.  Liability of current owners or operators for amounts identified during such audits shall be as follows:

A)        For past audits (audits completed before changes in ownership), liability shall be the amount established by final administrative decision.

B)        For pending audits (audits initiated, but not completed prior to the change in ownership), liability shall be limited to the lesser of the amounts established by final administrative decision or two months of service revenue. Two months of service revenue is defined as the most recent two months of Medicaid patient days multiplied by the total Medicaid rate in effect on the date the new owner or operator is enrolled in the Program as a provider by the Department. The Medicaid rate in effect on the date of enrollment shall be used even if that rate is subsequently changed.

C)        For future audits (audits initiated after the change in ownership but pertaining to an audit period prior to a change in ownership), liability shall be limited as described in subsection (l)(4)(B) of this Section.

m)        A provider that is eligible to participate in the 340B federal Drug Pricing Program under section 340B of the federal Public Health Service Act (47 USC 201 et seq.), shall enroll in that program.  No entity participating in the federal Drug Pricing Program under section 340B of the federal Public Health Services Act may exclude Medicaid from their participation in that program. A provider enrolled in the 340B federal Drug Pricing Program must charge the Department no more than its actual acquisition cost for the drug product, plus the Department established dispensing fee.  This requirement is effective October 1, 2012 for 340B providers who own and/or operate a pharmacy that bills the Department for drugs, unless the 340B provider is a Hemophilia Treatment Center (HTC); July 1, 2013 for providers who are eligible to participate in the 340B program as HTCs; and January 1, 2013 for all other 340B-eligible providers who bill the Department for drugs.  Contract pharmacies are exempt from the requirements of this subsection (m).

(Source:  Amended at 38 Ill. Reg. 18462, effective August 19, 2014)

Section 140.13  Definitions

"Abuse".  For purposes of this Part and 89 Ill. Adm. Code 104, "abuse" means provider practices that are inconsistent with sound fiscal, business or medical practices and that result in an unnecessary cost to the Medical Assistance Program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  It also includes recipient practices that result in unnecessary cost to the Medical Assistance Program.  Abuse does not include diagnostic or therapeutic measures conducted primarily as a safeguard against possible vendor liability.

"Alternate Payee".  For purposes of this Part, "Alternate Payee" shall mean an entity that is registered as an alternate payee in the Medical Assistance Program.  An individual practitioner may designate payments due the practitioner be made to an alternate payee.

"Code".  For purposes of this Part, "Code" means the Public Aid Code [305 ILCS 5].

"Credible Allegation". For purposes of this Part, "credible allegation" includes an allegation from any source, including, but not limited to, fraud hotline complaints, claims data mining, patterns identified through provider audits, civil actions filed under the False Claims Act [740 ILCS 175], and law enforcement investigations.  An allegation is considered to be credible when it has indicia of reliability.

"Credible Evidence". For purposes of this Part, "credible evidence" shall mean evidence that reasonable people would agree as being trustworthy and reliable.

"Department Policy".  For purposes of this Part, "Department policy" shall mean the written requirements of the Department set forth in the Medical Assistance Program Handbooks, and the Department's written manuals, bulletins and releases.  It shall also include any additional policy statements transmitted in writing to a vendor.

"Entity".  For purposes of this Part, "entity" means any person, firm, corporation, partnership, association, agency, institution, or other legal organization.

"Fraud".  For purposes of this Part and 89 Ill. Adm. Code 104, "fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or herself or some other person.  It includes any act that constitutes fraud under applicable federal or State law.

"Harm".  For purposes of this Part and 89 Ill. Adm. Code 104, "harm" means physical, mental or monetary damage to recipients or to the Medical Assistance Program.

"Investor".  For purposes of this Part, "investor" shall mean any entity that owns (directly or indirectly) five percent or more of the shares of stock or other evidences of ownership of a vendor, or holds (directly or indirectly) five percent or more of the debt of a vendor, or owns and holds (directly or indirectly) three percent or more of the combined debt and equity of a vendor.

"Management Responsibility".  For purposes of this Part, a person with management responsibility includes a person vested with discretion or judgment who either alone or in conjunction with others, conducts, administers or oversees either the general concerns of the vendor or a portion of the vendor's concerns.  A person with management responsibility shall specifically include the pharmacist in a pharmacy, the medical director of a laboratory, the administrator of a hospital or nursing home, the dispatcher in a transportation vendor, dispatchers and all individuals in charge of day to day operations of a non-emergency transportation vendor, the person or persons responsible for preparation and submittal of billings for services to the Department, and the manager of a group practice, clinic or shared health facility.

"Non-Emergency Transportation Vendor".  For purposes of this Part, non-emergency transportation vendor shall mean any transportation provider identified in Section 140.490(a) other than those identified in Section 140.490(a)(1) and (a)(6).

"Technical or Other Advisor".  For purposes of this Part, "technical or other advisor" shall mean any entity that provides any form of advice to a vendor regarding the vendor's business or participation in the Medical Assistance Program in return for compensation, directly or indirectly, in any form.

"Vendor".  For purposes of this Part, "vendor" or "provider" shall mean a person, firm, corporation, association, agency, institution, or other legal entity that provides goods or services to a recipient or recipients, and is enrolled to participate in the Medical Assistance Program pursuant to 89 Ill. Adm. Code 140.11 and 140.12.

"Waste".  For purposes of this Part and 89 Ill. Adm. Code 104, "waste" means the unintentional misuse of medical assistance resources, resulting in unnecessary cost to the Medical Assistance Program.  Waste does not include diagnostic or therapeutic measures conducted primarily as a safeguard against possible vendor liability.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.14  Denial of Application to Participate in the Medical Assistance Program

a)         The Department may deny an application to participate in the Medical Assistance Program if the vendor has engaged in activities which constitute grounds for termination, suspension or exclusion under Section 140.16.  If the activities were engaged in prior to December 1, 1977, they may be used as the basis for denial of an application only if the vendor had actual or constructive knowledge of the requirements which applied to his conduct or activities.

b)         Denial of Application

1)         The Department may deny an application submitted by a vendor if:

A)        the vendor cannot reasonably be expected to meet the written requirements of the Department including those set forth in the Medical Assistance Program Handbooks and the Department's manuals, bulletins and releases; or

B)        the Department determines, after reviewing the activities that served as the basis for the earlier termination or barring, that the application should not be approved.  Factors to be considered by the Department in making this determination shall include:

i)          length of time the vendor has not participated in the Medical Assistance Program;

ii)         magnitude and severity of the activities that led to the binding administrative decision which served as the basis for the vendor's termination, barring or denied participation;

iii)        mitigating circumstances presented by the vendor;

iv)        whether the deficiencies that served as the basis for the vendor to be terminated, barred or denied participation are corrected;

v)         whether the vendor demonstrates a fitness to participate in the Medical Assistance Program; and

vi)        the extent to which any legally enforceable debts owed to the Department by the applicant or an entity in which the applicant or his or her nominee held a substantial ownership interest have been paid.

2)         These factors must be established by submission of documentary evidence in support of the application.

c)         The Department may deny an application of a previously terminated or barred applicant if the applicant, without special permission from the Department, has already become a vendor, an entity with management responsibility for a vendor, an incorporator, officer or member of the board of directors of a vendor, an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, an owner of a sole proprietorship vendor, a partner in a partnership vendor, a technical or other advisor to a vendor, or an investor in a vendor.

d)         Effective July 1, 2012, the Department shall deny an application to participate in the Medical Assistance Program of any person, firm, corporation, association, agency, institution or other legal entity:

1)         immediately, if the vendor is not properly licensed, certified or authorized;

2)         within 30 days after the date when the vendor's professional license, certification or other authorization has been refused renewal, restricted or revoked, suspended or otherwise terminated; or

3)         if the vendor has been convicted of a violation of the Public Aid Code, as provided in Article VIIIA of the Code.

e)         Effective July 1, 2012, the Department may deny the eligibility of any person, firm, corporation, association, agency, institution or other legal entity to participate as a vendor if, after reasonable notice and opportunity for a hearing, the Department finds:

1)         The applicant or any person with management responsibility for the applicant; an officer or member of the board of directors of an applicant; an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor applicant; an owner of a sole proprietorship applicant; a partner in a partnership applicant; or a technical or other advisor to an applicant has a debt owed to the Department, and no payment arrangements acceptable to the Department have been made by the applicant.

2)         The applicant or any person with management responsibility for the applicant; an officer or member of the board of directors of an applicant; an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor applicant; an owner of a sole proprietorship applicant; a partner in a partnership vendor applicant; or a technical or other advisor to an applicant, during a period of time when the conduct of that vendor resulted in a debt owed to the Department and no payment arrangements acceptable to the Department have been made by that vendor, was:

A)        a person with management responsibility;

B)        an officer or member of the board of directors of an applicant;

C)        an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor;

D)        an owner of a sole proprietorship;

E)        a partner in a partnership vendor; or

F)         a technical or other advisor to a vendor.

3)         There is a credible allegation, as defined in Section 140.13, of the use, transfer or lease of assets of any kind to an applicant from a current or prior vendor who has a debt owed to the Department, no payment arrangements acceptable to the Department have been made by that vendor or the vendor's alternate payee, and the applicant knows or should have known of the debt.

4)         There is a credible allegation of a transfer of management responsibilities, or direct or indirect ownership, to an applicant from a current or prior vendor who has debt owed to the Department, and no payment arrangements acceptable to the Department have been made by the vendor or the vendor's alternate payee, and the applicant knows or should have known of the debt.

5)         There is a credible allegation of the use, transfer or lease of assets of any kind to an applicant who is a spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, relative by marriage, nephew, cousin or other relative of a current or prior vendor who has a debt owed to the Department and no payment arrangements acceptable to the Department have been made.

6)         There is a credible allegation that the applicant's previous affiliations with a provider of medical services that has an uncollected debt, a provider that has been or is subject to a payment suspension under a federal health care program, or a provider that has been previously excluded from participation in the Medical Assistance Program, poses a risk of fraud, waste or abuse to the Department.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.15  Suspension and Denial of Payment, Recovery of Money and Penalties

a)         Effective July 1, 2012, theDepartment may suspend or deny payment, in whole or in part, to a vendor or the vendor's alternate payee if the payment would be improper or erroneous or would otherwise result in overpayment.  The Department may recover money improperly or erroneously paid, or overpayments (see subsection (b) of this Section for exception to recovery of money), made to a vendor or vendor's alternate payee, either by setoff (deducting from Department obligations to the vendor or the designated alternate payee), deductions from future billings or by requiring direct repayment. Payments may be suspended, denied or recovered from a vendor or alternate payee:

1)         for services rendered in violation of the Department's provider notices, statutes, rules and regulations;

2)         for services rendered in violation of the terms and conditions prescribed by the Department in its vendor agreement;

3)         for any vendor who fails to grant the Office of Inspector General of the Department timely access to full and complete records, including, but not limited to, records relating to recipients under the Medical Assistance Program for the most recent six years, in accordance with Section 140.28, and other information for the purpose of audits, investigations or other program integrity functions, after reasonable written request by the Inspector General; provided, however, that this subsection (a)(3) does not require vendors to make available the medical records of patients for whom services are not reimbursed under this Part or to provide access to medical records more than six years old;

4)         when the vendor has knowingly made, or caused to be made, any false statement or representation of a material fact in connection with the administration of the Medical Assistance Program;

5)         when the vendor previously rendered services while terminated, suspended or excluded from participation in the Medical Assistance Program or while terminated or excluded from participation in another state or federal medical assistance or health care program; or

6)         for ground ambulance services rendered as the result of improper or false certification.  Overpayments can be recovered from a vendor, including, but not limited to, from the discharging physician, the discharging facility, and the ground ambulance service provider.

b)         If a practitioner designates an alternate payee, the practitioner and the alternate payee shall be jointly and severally liable to the Department for payments made to the alternate payee.  Recoveries by the Department may be made against either party or both, at the Department's option.

c)         The Department shall not recoup from any long term care provider any amounts subsequently determined to be owed by a client due to an error in the initial determination of medical eligibility.

d)         Effective July 1, 2012, if  it is established through an administrative hearing that an overpayment resulted from a vendor or the designated alternate payee knowingly making, using, or causing to be made or used, a false record or statement to obtain payment or other benefit from the medical assistance program, in addition to any other penalties that may be prescribed by law:

1)         the Department may recover interest (based on criteria in 89 Ill. Adm. Code 104.206(d)(2)) on the amount of the overpayment or other benefit from the vendor or alternate payee at the rate of 5% per annum;

2)         the vendor or alternate payee shall be subject to civil penalties consisting of an amount not to exceed three times the amount of payment or other benefit resulting from each false record or statement; and

3)         the vendor or alternate payee shall be subject to payment of a penalty of $2,000 for each false record or statement for payment or other benefit.

e)         Effective July 1, 2012, for purposes of this Section, "knowingly" means that a vendor or alternate payee, with respect to information:

1)         has actual knowledge of the information;

2)         acts in deliberate ignorance of the truth or falsity of the information; or

3)         acts in reckless disregard of the truth or falsity of the information.  No proof of specific intent to defraud is required.

f)         If a vendor has the same taxpayer identification number (assigned under section 6109 of the Internal Revenue Code of 1986) as is assigned to a vendor with past-due financial obligations to the Department, the Department may make any necessary adjustments to payments to that vendor in order to satisfy any past-due obligations, regardless of whether the vendor is assigned a different billing number under the Medical Assistance Program.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.16  Termination, Suspension or Exclusion of a Vendor's Eligibility to Participate in the Medical Assistance Program

a)         The Department may terminate or suspend a vendor's eligibility to participate in the Medical Assistance Program, terminate or not renew a vendor's provider agreement, or exclude a person or entity from participation in the Medical Assistance Program, when it determines that, at any time:

1)         The vendor is not complying with the Department's policy or rules, or with the terms and conditions prescribed by the Department in any vendor agreement developed as a result of negotiations with the vendor category, or with the covenants contained in certifications bearing the vendor's signature on claims submitted to the Department by the vendor, or with restrictions on participation imposed pursuant to Section 140.32;

2)         The vendor, person or entity is not properly licensed, certified, authorized or otherwise qualified, or the vendor person's or entity's professional license, certificate or other authorization has not been renewed or has been restricted, revoked, suspended or otherwise terminated as determined by the appropriate licensing, certifying or authorizing agency.  The termination, suspension or exclusion shall be immediately effective;

3)         The vendor violates records requirements as set forth in statute or Department rules, provider handbooks or policies.

A)        The vendor has failed to keep or timely make available for inspection, audit or copying (including photocopying), after receiving a written request from the Department:

i)          records required to be maintained by the Department or necessary to fully and completely disclose the extent of the services or supplies provided; or

ii)         full and complete records required to be maintained by the Department regarding payments claimed for providing services.

B)        This subsection (a)(3) does not require vendors to make available medical records of patients for whom services are not reimbursed under the Illinois Public Aid Code;

4)         The vendor has failed to furnish any information requested by the Department regarding payments for providing goods or services, or has failed to furnish all information required by the Department in connection with the rendering of services or supplies to recipients of public assistance by the vendor or his or her agent, employer or employee;

5)         The vendor has knowingly made, or caused to be made, any false statement or representation of a material fact in connection with the administration of the Medical Assistance Program.  For purposes of this subsection (a)(5), statements or representations made "knowingly" shall include statements or representations made with actual knowledge that they were false as well as those statements made when the individual making the statement had knowledge of such facts or information as would cause one to be aware that the statements or representations were false when made;

6)         The vendor has submitted claims for services or supplies that were not rendered or delivered by that vendor;

7)         The vendor has furnished goods or services to a recipient that, when based upon competent medical judgment and evaluation, are determined to be:

A)        in excess of needs;

B)        harmful (for the purpose of this subsection (a)(7)(B), "harmful" goods or services cause actual harm as defined in Section 140.13 or place an individual at risk of harm, or of adverse side effects, that outweigh the medical benefits sought); or

C)        of grossly inferior quality;

8)         The vendor knew or should have known that a person with management responsibility for a vendor, an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, an investor in the vendor, a technical or other advisor of the vendor, an owner of a sole proprietorship that is a vendor, or a partner in a partnership that is a vendor was previously terminated, suspended, excluded or barred from participation in the Medical Assistance Program, or in another state or federal medical assistance or health care program;

9)         The vendor has a delinquent debt owed to the Department;

10)         The vendor engaged in practices prohibited by federal or State law or regulation.

A)        The vendor, a person with management responsibility for a vendor, an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor, an owner of a sole proprietorship that is a vendor, or a partner in a partnership that is a vendor, either:

i)          has engaged in practices prohibited by applicable federal or State law or regulation; or

ii)         was a person with management responsibility for a vendor at the time that the vendor engaged in practices prohibited by applicable federal or State law or regulation; or

iii)        was an officer, or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a vendor at the time the vendor engaged in practices prohibited by applicable federal or State law or regulation; or

iv)        was an owner of a sole proprietorship or partner of a partnership that was a vendor at the time the vendor engaged in practices prohibited by applicable federal or State law or regulation;

B)        For purposes of this subsection (a)(10), "applicable federal or State law or regulation" includes, but is not limited to, licensing or certification standards contained in State or federal law or regulations related to the Medical Assistance Program, any other licensing standards as they relate to the vendor's practice or business or any federal or State laws or regulations related to the Medical Assistance Program;

C)        For purposes of this subsection (a)(10), conviction or a plea of guilty to activities violative of applicable federal or State law or regulation shall be conclusive proof that those activities were engaged in;

11)         The vendor, a person with management responsibility for a vendor, an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, an owner of a sole proprietorship that is a vendor, or a partner in a partnership that is a vendor has been convicted in this or any other State, or in any Federal Court, of any offense not related to the Medical Assistance Program, if the offense constitutes grounds for disciplinary action under the licensing Act applicable to that individual or vendor;

12)         The vendor, a person with management responsibility for a vendor, an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor, an owner of a sole proprietorship that is a vendor, or partner in a partnership that is a vendor has been convicted in this or any other state, or in any Federal Court, of:

A)        murder;

B)        a Class X felony under the Illinois Criminal Code of 1961;

C)        sexual misconduct that may subject recipients to an undue risk of harm;

D)        a criminal offense that may subject recipients to an undue risk of harm;

E)        a crime of fraud or dishonesty;

F)         a crime involving a controlled substance;

G)        a misdemeanor relating to fraud, theft, embezzlement or breach of fiduciary responsibility; or

H)        other financial misconduct related to a health care program.

13)         The direct or indirect ownership of the terminated, suspended or excluded vendor (including the ownership of a vendor that is a sole proprietorship, a partner's interest in a vendor that is a partnership, or ownership of 5% or more of the shares of stock or other evidences of ownership in a corporate vendor) has been transferred by an individual to the individual's spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin or relative by marriage.

b)         The Department may suspend a vendor's eligibility to participate in the Medical Assistance Program if the vendor is not in compliance with State income tax requirements, child support payments in accordance with Article X of the Illinois Public Aid Code, or educational loans guaranteed by the Illinois Student Assistance Commission.  The vendor may prevent suspension of eligibility by payment of past-due amounts in full or by entering into payment arrangements acceptable to the appropriate State agency.

c)         The Department may terminate, suspend or exclude vendors who pose a risk of fraud, waste, abuse or harm, as defined in Section 140.13, from participation in the Medical Assistance Program.

(Source:  Amended at 38 Ill. Reg. 15081, effective July 2, 2014)

Section 140.17  Suspension of a Vendor's Eligibility to Participate in the Medical Assistance Program

In actions based on Section 140.16 in which the Notice states an intent to terminate, the final administrative decision may result in suspension for a specific time, which shall not exceed one year from the time of the final administrative decision, rather than termination, when the Department determines that:

a)         the seriousness and extent of the violations do not warrant termination; and

b)         the vendor had no prior history of violations of the Medical Assistance Program; and

c)         the lesser sanction of suspension will be sufficient to remedy the problem created by the vendor's violations.

(Source:  Amended at 16 Ill. Reg. 17302, effective November 2, 1992)

Section 140.18  Effect of Termination, Suspension, Exclusion or Revocation on Persons Associated with Vendor

a)         Upon termination, suspension or exclusion of a vendor of goods or services from participation in the Medical Assistance Program, a person with management responsibility for such vendor during the time of any conduct that served as the basis for that vendor's termination, suspension or exclusion is barred from participation in the Medical Assistance Program.

b)         Upon termination, suspension or exclusion of a corporate vendor, the officers and persons owning, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in the vendor during the time of any conduct that served as the basis for that vendor's termination, suspension or exclusion are barred from participation in the Medical Assistance Program.

c)                  Upon termination, suspension or exclusion of a sole proprietorship or partnership, the owner or partners during the time of any conduct that served as the basis for that vendor's termination, suspension or exclusion are barred from participation in the Medical Assistance Program.

d)         Upon revocation of an alternate payee pursuant to Section 140.1005, the owners, officers, and individuals with management responsibility for the alternate payee during the time of any conduct that served as the basis for that alternate payee's revocation may be prohibited from participation as an owner, an officer, or an individual with management responsibility for an alternate payee in the Illinois Medical Assistance Program.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.19  Application to Participate or for Reinstatement Subsequent to Termination, Suspension, Exclusion or Barring

a)         A vendor that has been terminated, suspended or excluded from the Medical Assistance Program may not apply to participate for at least one year after the date of the final administrative decision terminating, suspending or excluding eligibility, except that, if a vendor has been terminated, suspended or excluded based on a conviction of a violation of Article VIIIA of the Public Aid Code or a conviction of a felony based on fraud or a willful misrepresentation related to subsection (a)(1), (2) or (3), the vendor shall be barred from participation for five years or for the length of the vendor's sentence for that conviction, whichever is longer.

1)         The Medical Assistance Program under Article V of the Public Aid Code;

2)         A federal or another state's medical assistance or health care program; or

3)         The provision of health care services.

b)         After one year, a vendor who has been terminated, suspended or excluded for any reason, other than for the reasons in subsections (a)(1) through (3), may apply for reinstatement to the Medical Assistance Program. If a vendor's application for reinstatement is denied by the Department, he or she shall be barred from again applying for reinstatement for one year after the date of the final administrative decision denying his or her application for reinstatement.

c)         A vendor whose termination, suspension or exclusion from participation in the Illinois Medical Assistance Program under Article V was based solely on an action by a governmental entity other than the Department may, upon reinstatement by that governmental entity or upon reversal of the termination, suspension or exclusion from participation in the Medical Assistance Program.  Upon proper application for rescission, the vendor may be deemed eligible by the Director if the vendor meets the requirements for eligibility under the Public Aid Code.

d)         At the end of a period of suspension, a vendor that has been suspended from the Medical Assistance Program shall be reinstated upon completion of the necessary enrollment forms and execution of a new vendor agreement unless it is determined that such vendor has not corrected the deficiencies upon which the suspension was based.  If the deficiencies have not been corrected, the vendor shall, after notice and hearing, be terminated. The notice in any termination action based on this Section shall notify the vendor of the deficiencies not corrected.

e)         An individual barred pursuant to Section 140.18 can apply to participate in the Medical Assistance Program.  If an individual's application is denied by the Department or if he or she is denied special permission under Section 140.32, he or she shall be barred from again applying for one year after the date of the final administrative decision denying his or her application or special permission.

f)         If a vendor has been terminated, suspended or excluded and reinstated to the Medical Assistance Program and the vendor is terminated, suspended or excluded a second or subsequent time from the Medical Assistance Program, the vendor shall be barred from participation for at least two years, except that, if a vendor has been terminated, suspended or excluded a second time based on a conviction of a violation of Article VIIIA of the Public Aid Code or a conviction of a felony based on fraud or a willful misrepresentation related to subsection (a)(1), (2) or (3), the vendor shall be barred from participation for life.

g)         At the end of two years, a vendor who has been terminated, suspended or excluded for any reason, other than for the reasons in subsections (a)(1) through (3), may apply for reinstatement to the Medical Assistance Program.  If a vendor's application for reinstatement is denied by the Department, he or she shall be barred from again applying for reinstatement for two years after the date of the final administrative decision denying his or her application for reinstatement.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.20  Submittal of Claims

a)         When claims for payment are submitted to the Department, providers shall:

1)         Use Department designated billing forms or electronic format for submittal of charges; and

2)         Certify that:

A)        They have personally rendered the services and provided the items for which charges are being made;

B)        Payment has not been received, or that only partial payment has been received;

C)        The charge made for each item constitutes the complete charge;

D)        They have not, and will not, accept additional payment for any item from any person or persons;

E)        They will not make additional charges to, nor accept additional payment from, any persons if the charges they present are reduced by the Department to conform to Department standards; and

F)         Starting June 1, 2019, in the case of providers of medical equipment, supplies, prosthetic devices and orthotic devices, the provider is accredited by a healthcare accrediting body approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department under Section 140.475(g). 

b)         Statement of Certification

1)         All billing statements shall contain a certification statement that must remain unaltered, and must be legibly signed and dated in ink by the provider, his or her designated alternate payee, or his or her authorized representative.  A rubber stamp or facsimile signature is not acceptable.

2)         An "authorized representative" may only be a trusted employee over whom the provider has direct supervision on a daily basis and who is personally responsible on a daily basis to the provider.  The representative must be specifically designated and must sign the provider's name and his or her own initials on each certification statement.

3)         An alternate payee must be specifically designated by the provider and must sign the provider's name and alternate payee's authorized representative's initials on each certification statement.

c)         Effective July 1, 2012, to be eligible for payment consideration, a provider's vendor-payment claim or bill, either as an initial or resubmitted claim following prior rejection, that can be processed without obtaining additional information from the provider of the service or from a third party, must be received by the Department, or its fiscal intermediary, no later than 180 days after the date on which medical goods or services were provided, with the following exceptions:

1)         The Department must receive a claim after disposition by Medicare or its fiscal intermediary no later than 24 months after the date on which medical goods or services were provided.

2)         In the case of a provider whose enrollment is in process by the Department, the 180-day period shall not begin until the date on the written notice from the Department that the provider enrollment is complete.

3)         In the case of errors attributable to the Department or any of its claims processing intermediaries that result in an inability to receive, process or adjudicate a claim, the 180-day period shall not begin until the provider has been notified of the error.

4)         In the case of a provider for whom the Department initiates the monthly billing process.

5)         For claims for rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible.

6)         For claims for which the Department is not the primary payer, claims must be submitted to the Department within 180 days after the final adjudication by the primary payer.

A)        For purpose of this subsection (c)(6), a primary payer is a payer that can reasonably be expected to make payments within 120 days after the date of service; for example, other medical insurance or a group health plan, when the patient is the insured party.  Primary payer does not include payers who are not reasonably expected to pay within 120 days; for example, liability insurance and workers' compensation, when the patient is not the insured party.

B)        During the 180 day period beginning November 15, 2014, providers may submit claims and request a time override from the Department for claims with dates of service on and after July 1, 2012 not filed because of the provider's belief that it could file after final adjudication by an insurer when the patient was not the insured party.  A provider asking for such a time override shall also provide a copy of the request for time override to the Department's Bureau of Collections, with a written notification to the Bureau indicating the names and addresses of other parties, insurers or attorneys involved in attempting to recover, defend or settle possible damages to the patient that resulted in the services provided.  Failure to provide the required information to the Bureau shall result in a denial of the request for time override.

7)         In the case of long term care facilities, admission documents shall be submitted as provided in Section 140.513. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal.  Once an admission transaction has been completed, the Department will generate a monthly billing statement (remittance advice) for the services rendered to the admitted Medicaid eligible resident from date of admission through date of discharge.  Any disputes regarding payment for services provided from the date of admission through date of completion of the admission transaction must be submitted to the Department for Payment Review Request (HFS Form 3725) no later than 180 days after the date of completion of the admission transaction.  For any disputes regarding payment for services rendered after the date of completion of the admission transaction, the Payment Review Request must be submitted to the Department within 180 days after the:

A)        date of the remittance advice that initially shows the adjudication for the date or dates of service that are disputed;

B)        date of the remittance advice that rejects a previously adjudicated claim, if rejection is the basis for the disputed payment; or

C)        date of the remittance advice that adjusts a previously adjudicated claim, if the adjustment is the basis for the disputed payment.

8)         For hospital inpatient claims, the 180 days is measured from the date of discharge.

9)         Per Public Act 98-104, in the case of a provider operated by a unit of local government with a population exceeding 3,000,000, when local government funds finance federal participation for claims payment, a claim must be received by the Department or its fiscal intermediary no later than one year after the date on which medical goods or services were provided.

d)         Claims that are not submitted and received in compliance with the foregoing requirements will not be eligible for payment under the Department's Medical Assistance Program, and the State shall have no liability for payment of the claim.

(Source:  Amended at 42 Ill. Reg. 4829, effective March 1, 2018)

Section 140.21  Reimbursement for QMB Eligible Medical Assistance Recipients and QMB Eligible Only Recipients and Individuals Who Are Entitled to Medicare Part A or Part B and Are Eligible for Some Form of Medicaid Benefits

a)         In order to be qualified to receive reimbursement for services provided to QMB (Qualified Medicare Beneficiary) eligible medical assistance recipients, QMB eligible only recipients (see 89 Ill. Adm. Code 120.72), or individuals who are entitled to Medicare Part A or Part B and are eligible for some form of Medicaid benefits, providers must be enrolled in the Medical Assistance Program.  Providers must also accept assignment of Medicare benefits for QMB eligible medical assistance recipients and individuals who are entitled to Medicare Part A or Part B and are eligible for some form of Medicaid benefits, when payment for services to such persons is sought from the Department.

b)         For Medicaid covered services, the Department will reimburse qualified providers who render services to QMB eligible medical assistance recipients, QMB eligible only recipients and individuals who are entitled to Medicare Part A or Part B and are eligible for some form of Medicaid benefits in accordance with Department standards for the service(s) provided, with the following exception: for drugs and medical supplies provided by a pharmacy or Durable Medical Equipment (DME) provider, and reimbursed by Medicare, the Department's liability for deductible and coinsurance amounts shall be at the full Medicare rate.  For individuals enrolled in the SeniorCare Program, the provisions in this subsection (b) will apply to services provided on or after October 16, 2002. 

c)         For services approved by Medicare but not covered by Medicaid, the maximum allowable rate payable to qualified providers who render services to QMB eligible medical assistance recipients and recipients who are QMB eligible only is 80 percent of full Medicare rate when determining the Department's liability for deductible and coinsurance amounts.

d)         Licensed and Medicare certified nursing facilities that enroll for the sole purpose of receiving payment for services to QMB eligible only residents of the facility, then disenroll, are not subject to the provisions found in Section 140.506 governing voluntary withdrawal from the Medical Assistance Program.

(Source:  Amended at 27 Ill. Reg. 4364, effective February 24, 2003)

Section 140.22  Magnetic Tape Billings (Repealed)

(Source:  Repealed at 25 Ill. Reg. 3897, effective March 1, 2001)

Section 140.23  Payment Of Claims

a)         The Department shall pay only for those services and supplies that:

1)         Meet the U.S. Department of Health, Education and Welfare's definition of medical service (42 U.S.C. 1396d);

2)         Can be paid by vendor payment; and

3)         Are specified in the individual rules governing particular types of medical services provided.

b)         Except as provided in subsection (d), the Department shall make payment only after services have been rendered.

c)         Payment shall be made only to a provider who:

1)         Participates in the Medical Assistance Program; and

2)         Except as provided in subsections (d) and (e), is the actual provider of service.

d)         The Department may contract with qualified practitioners, hospitals and all other dispensers of medical services for the provision and reimbursement as specified in the contract of any and all medical care or services on a prepaid capitation, volume purchase, ambulatory visit or per discharge basis.  Such contracts shall be based either on formally solicited competitive bid proposals or individually negotiated rates with providers willing to enter into special contractual arrangements with the State.  Payments shall be made in advance of services under prepaid capitation arrangements.  The Department shall not pay a provider for services provided to recipient enrolled in a HMO or other plan as specified above when the service is one which the HMO or plan has contracted to provide.

e)         The Department will make payment to a provider for services provided by a substitute physician when the substitute physician is performing the duties of a qualified attending physician, and all of the following conditions are met:

1)         The attending physician is ill, on vacation, or otherwise unavailable because of an emergency situation;

2)         The substitute physician is a Doctor of Medicine (M.D.) or Osteopathy (D.O.) who holds a license to practice medicine in all its branches;

3)         The substitute physician is not terminated, suspended, barred or otherwise excluded from participation or has not voluntarily withdrawn from the Medical Assistance Program as part of a settlement agreement; and

4)         The substitution does not exceed 14 days for a single incident and up to a maximum of 90 days per year for the attending physician. If the substitute period extends beyond the 14 days per single incident, the substitute physician must enroll with the Department.

(Source:  Amended at 47 Ill. Reg. 16385, effective November 3, 2023)

Section 140.24  Payment Procedures

a)         Payment of valid claims will be made by a State warrant (check) issued through the Office of the State Comptroller.

b)         All providers of medical services must designate a payee when enrolling in the Department's Medical Assistance Program.

1)         Providers enrolled as business entities are limited to one payee.  A business entity is defined as any firm, corporation, partnership, agency, institution or other legal organization organized for the purpose of providing medically related professional services.  A provider enrolled as a business entity may designate the corporate or partnership name as the payee.  The mailing address for the payee must be the provider's service address, the designated address of the provider's corporate or partnership office, or a designated address that will accept and forward the remittance advice to the business entity.

2)         Providers enrolled as individual practitioners are allowed to have more than one payee.  An individual practitioner is defined as an individual person licensed by an authorized State agency to provide medical services.  Payment may be mailed to an individual practitioner at one of the following addresses that will accept and forward the remittance advice to the individual practitioner:

A)        The provider's service address; or

B)        The provider's residence; or

C)        The provider's designated address; or

D)        The address of the provider's designated alternate payee pursuant to subsection (d) of this Section; or

E)        The address of the entity specified according to an arrangement under Section 140.27(c) or (d).

3)         A long term care facility and its corporate or partnership owner may request the facility's warrant be sent directly to the business office address of the corporate or partnership owner.  After approval is given, the warrant will be issued in the name of the facility or corporate name doing business under the facility name, but sent to the business office address of the corporate or partnership owner rather than the facility.

c)         Individual practitioners may request the Department to designate an alternate payee for the practitioner.  The Department may permit a request if the Department determines that the designation is consistent with the provision of medical services to eligible recipients.  The alternate payee must meet the registration conditions for, and be registered as an alternate payee pursuant to, 89 Ill. Adm. Code 140.1001.  Additionally, the individual practitioner must meet the following conditions:

1)         The individual practitioner must have a contractual/salary arrangement with a hospital or a hospital affiliate, as defined by the Hospital Licensing Act [210 ILCS 85], that requires fees to be turned over to the hospital or hospital affiliate; or

2)         The individual practitioner must have a contractual/salary arrangement with a professional school that requires fees to be turned over to the professional school.  A professional school is defined as a college or university offering a degree to qualify individuals for licensure to perform medical services; or

3)         The individual practitioner must have a contractual/salary arrangement with or be employed by a practitioner owned group practice that requires fees to be turned over to the practitioner owned group practice.  The practitioner owned group practice must be owned by three or more full‑time licensed individual practitioners who are eligible to participate in the Medical Assistance Program; or

4)         The individual practitioner must have a contractual/salary arrangement with a partnership that requires fees to be turned over to the partnership.  The partnership must be solely-owned by two or more practitioners who are eligible to participate in the Medical Assistance Program; or

5)         The individual practitioner must have a contractual/salary arrangement or be employed by a governmental entity that requires fees to be turned over to the governmental entity; or

6)         The individual practitioner must have a contractual/salary arrangement with a community mental health agency that requires fees to be turned over to the community mental health agency.  The community mental health agency must be certified by the Department of Human Services under 59 Ill. Adm. Code 132 and be enrolled as a provider in the Medical Assistance Program; or

7)         The individual practitioner must have a contractual/salary arrangement or be employed by a Federally Qualified Health Center, Rural Health Center or Encounter Rate Clinic that requires fees to be turned over to the center or clinic.  The center or clinic must be enrolled as a provider in the Medical Assistance Program; or

8)         The individual practitioner must have a contractual/salary arrangement with a corporation registered with the Illinois Secretary of State's Office to do business in the State of Illinois that requires fees to be turned over to the corporation; or

9)         The individual practitioner must have a contractual/salary arrangement as a condition of employment with an individual practitioner "employer" that requires fees to be turned over to the employer.  The employer must be eligible to participate in the Medical Assistance Program. An individual practitioner may designate an employer who is a physician licensed under the Medical Practice Act of 1987 [225 ILCS 60] if the practitioner is an advanced practice nurse licensed under the Nurse Practice Act [225 ILCS 65].

d)         The Department will not permit the designation of a payee or alternate payee that appoints, employs, or contracts with any person as an owner, officer, director, or individual with management or advisory responsibility who is terminated, suspended, or barred or has voluntarily withdrawn as a result of a settlement agreement, from any state or federal healthcare program.

e)         If a practitioner designates an alternate payee, the practitioner and the alternate payee shall be jointly and severally liable to the Department for payments made to the alternate payee.

(Source:  Amended at 38 Ill. Reg. 4330, effective January 29, 2014)

Section 140.25  Overpayment or Underpayment of Claims

a)         When the Department, the provider, or the designated alternate payee has determined that an overpayment has been made, the provider or the alternate payee shall reimburse the Department for the overpayment.  The Department shall recover overpayments made to or on behalf of a provider that result from improper billing practices.  Recovery may occur by setoff, crediting against future billings or requiring direct repayment to the Department.

b)         When a provider believes it has received an underpayment for services, it may request Department review.  The request must be received by the Department within 12 months after the date payment was authorized.  If the review reveals an underpayment was made, the Department shall pay the additional amount due.  If the review reveals an overpayment was made, the provider, or the designated alternate payee, shall refund the amount of the overpayment.

c)         When a provider operated by a unit of local government with a population exceeding 3,000,000, when local government funds finance federal participation for claims payment, believes it has received an underpayment for services, it may submit an adjustment to void and re-bill the claim.  The request must be received within one year after the date payment was authorized.

d)         For underpayments, the Department will not adjust claims received beyond the applicable timeframes identified in subsections (b) and (c). The review procedures provided for in this Section may not be used to submit any new or corrected information that was required to be submitted by a specific date in order to qualify for a payment or payment adjustment.

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)

Section 140.26  Payment to Factors Prohibited

a)         Payment for any care or service furnished to an individual by a provider will not be made to or through a factor, either directly or by virtue of a power of attorney given by the provider to the factor.  In addition, transfers by providers to a factor of any claims for reimbursement or receivables under the Medical Assistance Program, either by assignment, sale or otherwise is expressly prohibited.  This prohibition shall include, but not be limited to, the following:

1)         Transfer of such claims or receivables to a nonrelated entity, i.e., an organization in which the provider is neither an officer nor an owner, which has given the provider an unsecured loan,

2)         Transfer of accounts for such claims or receivables, or

3)         The use of such claims or receivables by a provider as collateral for a loan, except as allowed under Section 140.27 ("Assignment of Vendor Payments").

b)         For purposes of these Rules, "factor" shall mean an organization, i.e., collection agency or service bureau which, or an individual who, advances money to a provider for his accounts receivable which the provider has assigned or sold, or otherwise transferred, including transfer through the use of power of attorney, to this organization or individual.  The organization or individual receives an added fee receivable in return for the advanced money.

(Source:  Amended at 8 Ill. Reg. 22097, effective October 24, 1984)

Section 140.27  Assignment of Vendor Payments

a)         Except as provided in this Section, vendor payments and the right to receive such payments are absolutely inalienable by assignment, sale, attachment, garnishment or otherwise.

b)         A medical vendor may use his or her right to receive vendor payments as collateral for loans from banks, credit unions, and savings and loan associations chartered under or trust companies issued certificates of authority under Chapter 205 of the Illinois Compiled Statutes, provided that such arrangements:

1)         shall not require the Department to issue the payment directly to any person or entity other than the vendor; and

2)         shall not constitute any activities prohibited by the provisions of 42 U.S.C.A. 1396(a)(32) (1983) and Section 140.26 ("Payment to Factors Prohibited").

c)         A medical vendor or other vendor or service provider may assign, reassign, sell, pledge or grant a security interest in any such financial aid, vendor payment or money payments of grants he or she has a right to receive to the Illinois Health Facilities Authority in connection with any financing program undertaken by that Authority, or to the Illinois Development Finance Authority in connection with any financing program undertaken by that Authority.  Each Authority may utilize an agent or trustee accepting, accomplishing, effectuating or realizing upon any such assignment, reassignment, sale, pledge or grant on such Authority's behalf; and such arrangements may provide that the Department shall issue the payment directly to the Illinois Health Facilities Authority, Illinois Development Finance Authority or to any such agent or trustee.

d)         A medical vendor that is a governmental entity or is exempt from income reporting under Section 1.6041-3(c) of the federal income tax regulations [26 CFR 1.6041-3(c)] and that provides Healthy Kids Program services under Section 140.485(d) may assign its interest in payment from the Department to a local school district with which the provider has an arrangement to provide such services.  Under such assignment, with Department approval, payment will be made directly to the school district.

(Source:  Amended at 19 Ill. Reg. 13019, effective September 5, 1995)

Section 140.28  Record Requirements for Medical Providers

a)         Providers shall maintain in the regular course of business the following:

1)         Any and all business records that may indicate financial arrangements between the provider and other providers in the program or other entities, or that are necessary to determine compliance with federal and State requirements, including but not limited to:

A)        business ledgers of all transactions,

B)        records of all payments received, including cash,

C)        records of all payments made, including cash,

D)        corporate papers, including stock record books and minute books,

E)        records of all arrangements and payments related in any way to the leasing of real estate or personal property, including any equipment,

F)         records of all accounts receivable and payable; and

2)         Any and all professional records that relate to the quality of care given by the provider or that document the care for which payment is claimed, including but not limited to:

A)        medical records for applicants and recipients of public assistance. This rule does not require a provider to keep or make available medical records for persons who are not applicants or recipients and for whom no claim to the Department for payment is made.

B)        other professional records required to be maintained by applicable federal or State law or regulations.

b)         The business and professional records required to be maintained shall be kept in accordance with accepted business and accounting practice and shall be legible.  Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period the records must be retained until the audit is completed and every exception resolved.  This provision is not to be construed as a statute of limitations.  However, the Department will not deny, suspend or terminate a provider pursuant to Sections 140.14 through 140.19 solely because the provider has failed to keep records for more than 3 years.

c)         All records required to be maintained shall be available for inspection, audit and copying (including photocopying) by authorized Department personnel during normal business hours.  Department personnel shall make all attempts to examine such records without interfering with the professional activities of the provider.

d)                 The provider's business and professional records for at least 12 previous calendar months shall be maintained and available for inspection by authorized Department personnel on the premises of the provider. Department personnel shall make requests in writing to inspect records more than 12 months old at least 2 days in advance of the date they must be produced.

e)         The provider is responsible to furnish records to the Department.  If records are maintained by a designated alternate payee or another entity, the provider remains responsible for obtaining those records and furnishing them to the Department.

(Source:  Amended at 38 Ill. Reg. 4330, effective January 29, 2014)

Section 140.30  Audits

a)         Effective July 1, 2012, whether pre-payment or post-payment, all services for which charges are made to the Department are subject to audit.  During a review audit, the provider shall furnish to the Department or to its authorized representative, pertinent information regarding claims for payment.  If records are maintained by a designated alternate payee, it is the provider's responsibility to obtain the records and furnish them to the Department.  Should an audit reveal that incorrect payments were made, or that the provider's records do not support the payments that were made, or should the provider or designated alternate payee fail to furnish records to support payments that were made, the provider or designated alternate payee shall make restitution.

b)         The Department's procedure for auditing providers may involve the use of sampling and extrapolation.  Under such a procedure, the Department selects a statistically valid sample of the cases for which the provider or designated alternate payee received payment for the audit period in question and audits the provider's records for those cases.  All incorrect payments determined by an audit of the cases in the sample are then totaled and extrapolated to the entire universe of cases for which the provider or designated alternate payee has been paid during the audit period.  The provider or designated alternate payee shall be required to pay the Department the entire extrapolated amount of incorrect payments calculated under this procedure after notice and opportunity for hearing pursuant to 89 Ill. Adm. Code 104.210.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.31  Emergency Services Audits

a)         All emergency services for which charges are made to the Department and are provided to a recipient who does not require admission as an inpatient are subject to audit.

b)         An emergency services audit shall be limited to a review of records related to services rendered within three years of the date the hospital is notified that the audit will be initiated.  The Department shall notify the hospital of an audit at least four calendar weeks before the audit occurs, unless the hospital and the Department agree to schedule the audit at an earlier date.  The hospital's business and professional records for at least 12 previous calendar months shall be maintained and available for inspection by authorized Department personnel on the premises of the hospital.  Department personnel shall make requests in writing to inspect records more than 12 months old at least two business days in advance of the date they must be produced.  These records required to be maintained shall be kept in accordance with accepted business and accounting practice and shall be legible.  Such records must be retained for a period of not less than three years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period the records must be retained until the audit is completed and every exception resolved by settlement or by the Director's final decision.

c)         All records required to be maintained shall be available for inspection by authorized Department personnel during normal business hours.  Department personnel shall make all attempts to examine such records without interfering with the professional activities of the hospital.  The hospital shall make legible copies of those records requested by the Department upon completion of its inspection, and tender said copied records to the Department within two weeks after such request is made unless this time is extended by mutual consent.  Additionally, if the hospital locates records that were unavailable during the audit, that data shall be submitted to the Department within 30 days after completion of the audit conducted on the hospital's premises, and that data shall be utilized in generating the audit findings. The determination that an emergency medical condition exists shall be based solely upon the review of the legible information contained in those medical records supplied by the hospital during the audit.

d)         Authorized Department personnel shall meet with the chief executive officer of the hospital, or a person designated by the chief executive officer, upon arrival at the hospital to conduct the audit and at the conclusion of the audit.  The purpose of the pre-audit meeting shall be to inform the hospital of the scope of the audit.  The purpose of the post-audit meeting shall be to provide an opportunity for the auditors to discuss their preliminary findings with the chief executive officer, or a person designated by the chief executive officer.  More detailed audit findings shall be provided in writing to the hospital within 120 days after the date on which the audit conducted on the hospital premises was completed.

e)         The final determination of whether an emergency room visit was for the alleviation of severe pain or for the immediate diagnosis and/or treatment of conditions or injuries which might result in disability or death if there is not immediate treatment shall be based upon the symptoms and condition of the recipient at the time the recipient is initially examined by the hospital's emergency department physician and not upon the final determination of the recipient's actual medical condition (see Sections 140.3 and 140.5 of this Part).

f)         When the purpose of the audit is to determine the appropriateness of the emergency services provided, any final determination that would result in a denial of or reduction in payment to the hospital shall be based on the opinion of a physician licensed to practice medicine in all of its branches who is board certified in emergency medicine or by the appropriate health care professionals under the supervision of the physician.

g)         The Department or its designated review agent in cases where the Department seeks to recover an extrapolated amount, shall use statistically valid sampling techniques when conducting audits as provided by Section 140.30 of this Part.

h)         This Section shall not apply to any audits initiated prior to July 1, 1992.

(Source:  Added at 16 Ill. Reg. 19879, effective December 7, 1992)

Section 140.32  Prohibition on Participation, and Special Permission for Participation

a)         Prohibition on Participation by Terminated, Suspended, Excluded or Barred Entities

1)         Upon being terminated, suspended, excluded or barred, and while the disability from Medical Assistance Program participation remains in effect, an entity:

A)        Cannot be a vendor, assume management responsibility for a vendor, own (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership of a corporate vendor, become an owner of a sole proprietorship that is a vendor, become a partner of a vendor or become an officer of a corporate vendor;

B)        Cannot be an employer of a vendor; a person with management responsibility for an employer of a vendor; an officer of an employer of a vendor; an entity owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in an employer of a vendor; an owner of a sole proprietorship that employs a vendor; or a partner of a partnership that employs a vendor;

C)        Cannot order goods or services from a vendor when payment for such goods or services will be made in whole or in part by the Department;

D)        Cannot render goods or services as an employee of a vendor or as an independent contractor with a vendor for which payment will be made in whole or in part by the Department;

E)        Cannot, directly or indirectly, serve as a technical or other advisor to a vendor;

F)         Cannot, directly or indirectly, be an incorporator or member of the board of directors of a vendor;

G)        Cannot, directly or indirectly, be an investor in a vendor; and

H)        Cannot own (directly or indirectly) a 5% or greater interest in any premises or equipment leased by a vendor.

2)         An individual who is terminated or barred from participation in the Medical Assistance Program cannot transfer the direct or indirect ownership of a vendor (including the ownership of a vendor that is a sole proprietorship, a partner's interest in a vendor that is a partnership, or ownership of 5% or more of the shares of stock or other evidences of ownership in a vendor) to the individual's spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin, or relative by marriage.

3)         Effective July 1, 2012, a person who owns, directly or indirectly, 5% or more of the shares of stock or other evidences of ownership in a corporate or limited liability company vendor who owes a debt to the Department, if that vendor has not made payment arrangements acceptable to the Department, shall not transfer his or her ownership interest in that vendor, or vendor assets of any kind, to his or her spouse, child, brother, sister, parent, grandparent, grandchild, uncle, aunt, niece, nephew, cousin or relative by marriage.

4)         After the provision of written notice to the affected parties, the Department may deny payment for goods or services rendered or ordered by an entity that violates the provisions of subsection (a)(1)(A), (B), (C) or (D). The Department may also pursue the imposition of all criminal and civil penalties as may be available and necessary.

5)         Whenever an entity violates the provisions of subsection (a)(1)(E), (F), (G) or (H) the Department may refer the matter for filing of an appropriate civil suit by the Attorney General or the State's Attorney to recover all benefits obtained improperly as well as treble damages or $10,000.00 for each such violation whichever amount is greater, in accordance with Section 11-27 of the Public Aid Code.

b)         Special Permission for Continuation or Reinstatement of Medical Assistance Program Participation for Barred Entities

1)         Any entity barred pursuant to Section 140.18 may seek special permission to continue participation in the Medical Assistance Program or for reinstatement in the Program.

2)         Special permission shall be granted only if the entity seeking such action demonstrates to the Department that it had no part in, and no knowledge of, the conduct which led to the decision to terminate upon which the barring was based or that it had no part in, and notified the Department as soon as it gained knowledge of, the conduct.

3)         In deciding whether to authorize the continued participation by, or reinstatement of, an entity that meets the conditions of this subsection (b) the Director shall consider the following factors:

A)        Whether the entity requesting special permission demonstrates a fitness to participate in the Medical Assistance Program;

B)        The extent to which any legally enforceable debts owed to the Department by the applicant or an entity in which the applicant or his nominee held a substantial ownership interest have been paid;

C)        Any other circumstances reasonably related to the issue of whether the special permission should be granted.

4)         Any entity that seeks special permission to continue or reinstate benefits shall submit a written request to the Director.  Upon receipt of such a request, the Director or his designee shall review the request and any supporting documentation which accompanies it, and shall notify the entity of the decision within 60 days after receipt of the request, where practicable.  In reviewing the request, the Director may require the entity to appear before and cooperate with a peer review committee of the Department.

5)         An entity may request special permission only once.  An entity that has been denied special permission may not apply for readmission under Section 140.14 for one year after the final decision to deny special permission.  An entity that has been denied readmission under Section 140.14 or has an application under Section 140.14 pending with the Department may not apply for special permission.

6)         Whenever a barred entity is readmitted to the Medical Assistance Program pursuant to this Section, the Director may make the vendor's continued participation contingent upon compliance with specified restrictions, including, but not limited to:

A)        Limiting the participation by the entity as to the location, type, volume or category of goods or services to be provided;

B)        Requiring that the entity obtain continuing education, or additional licenses or authorizations; and

C)        Any other terms or conditions which may be appropriate or required under the circumstances.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.33  Publication of List of Sanctioned Entities

a)         The Department shall publish a list of every entity that is currently terminated, suspended or barred from participation in the Medical Assistance Program and shall include every alternate payee that has been revoked, and every entity prohibited from participating with an alternate payee.  The list may also include entities that have voluntarily withdrawn from participation in the Medical Assistance Program as a result of a settlement agreement.  The list shall also include the period of suspension.  The list shall be supplemented with additions and deletions each month, if any.  The list shall be published on the Office of the Inspector General's (OIG) website at www.state.il.us/agency/oig.

b)         The Department shall, upon request, mail the list and supplements, without charge, to associations and societies of vendors in the Medical Assistance Program, including their affiliates and components.  Societies and associations of vendors and other entities that wish to receive the list are responsible for providing the Department with a current mailing address.

c)         An entity may file a request, in writing or via e-mail, for a list of any adverse actions against a particular entity that are not currently in effect.  Inquiries may be directed to the OIG at 404 North Fifth Street, Springfield, Illinois 62702, or at Oigwebmaster@illinois.gov. The Department shall respond to such a request within ten days after receiving it.

(Source:  Amended at 31 Ill. Reg. 2413, effective January 19, 2007)

Section 140.35  False Reporting and Other Fraudulent Activities

a)         Providers are subject to Section 12-13.1 of the Illinois Public Aid Code, pertaining to penalties for vendor fraud and kickbacks.

b)         Providers are also subject to Section 1909 (42 U.S.C. 1396h) of the Social Security Act that prohibits kickbacks, false reporting and other fraudulent activities, and provides for fines and imprisonment for persons who engage in such activities.

(Source:  Amended at 47 Ill. Reg. 3738, effective March 1, 2023)

Section 140.40  Prior Approval for Medical Services or Items

a)         The Department may impose prior approval requirements as specified by rule, to determine the essentialness of medical care provided in individual situations.  Such requirements shall be based on recommendations of technical and professional staff and advisory committees.

b)         In general, in order for prior approval to be granted, items and services must be:

1)         non-experimental,

2)         appropriate to the client's needs,

3)         necessary to avoid institutional care, and

4)         medically necessary to preserve health, alleviate sickness, or correct a handicapping condition.

c)         Providers are responsible for requesting prior approval for medical services or items.  Prior approval requests must include at a minimum:

1)         patient name,

2)         recipient number,

3)         patient age, address, and whether or not the patient resides in a group care facility,

4)         identification of the practitioner prescribing or ordering the item or service,

5)         diagnosis,

6)         description of item or service,

7)         treatment plan,

8)         how long the service or item will be needed, and

9)         purchase or rental cost.

d)         To the extent possible, the request should show how the item or service is expected to correct or help the condition, and why the requested treatment plan is better than any other plan commonly used to deal with similar diagnoses or conditions.  Anything unique to the medical condition or living arrangement affecting the choice of a recommended treatment plan or item should be explained.

e)         A written notice of disposition of the request for prior approval will be sent to the client within the time limits prescribed below.  If the notice of disposition is not sent within the applicable time limit, prior approval will be granted automatically.  Oral notification will be given only when a request for medical transportation is approved.

(Source:  Amended at 22 Ill. Reg. 19898, effective October 30, 1998)

Section 140.41  Prior Approval in Cases of Emergency

a)         In cases of emergency, the provider may request prior approval by telephoning the office that gives such approval.  "Emergency" is defined as a condition or situation which threatens the recipient's life or may cause permanent damage, or requires services which, in the opinion of the attending physician, are needed to relieve immediate pain and suffering. If a recipient's condition is so severe that his or her life is endangered and there is not enough time to seek approval by telephone or the service is needed during non-working hours, the service may be provided before obtaining prior approval.

b)         When emergency approval is obtained by telephone, or the service is provided before obtaining approval under the above circumstances, the provider must still submit a written request in order to receive approval to bill for the services provided.

Section 140.42  Limitation on Prior Approval

The Department will not give prior approval for an item or service if a less expensive item or service is appropriate to meet the client needs. The Department will not approve purchase of equipment if the client already has equipment which is adequate and sufficient to meet the client's needs. The Department will not approve the purchase of equipment if the Department already owns such equipment and will make it available for the client to use.

Section 140.43  Post Approval for Items or Services When Prior Approval Cannot Be Obtained

a)         Post approval may be requested for items or services provided during Department nonworking hours, or nonworking hours of its agents, whichever is applicable, or when a life threatening condition exists and there is no time to call for approval.

b)         To be eligible for approval consideration, the requirements for prior approval must be met and post approval requests must be received by the Department or its agents, whichever is applicable, no later than 90 days after the date services or goods are provided.  Exceptions to this requirement will be permitted only in the following circumstances:

1)         The Department or the Department of Human Services has received the patient's Medical Assistance application, but approval of the application has not been issued, as of the date of service.  In such a case, the post approval request must be received no later than 90 days after the date of the Department's Notice of Decision, approving the patient's application.

2)         The patient did not inform the provider of his/her eligibility for Medical Assistance.  In such a case, the post approval request must be received no later than six months after the date of service, but will be considered for payment only if there is attached to the request a copy of the provider's dated, private pay bill or collection correspondence, which was addressed and mailed to the patient each month following the date of service.

3)         A request for payment was submitted to a third party billing within six months following the date of service.  In such a case, a post approval request must be received by the Department no later than 90 days after the date of final adjudication by the third party.

(Source:  Amended at 28 Ill. Reg. 4958, effective March 3, 2004)

Section 140.44  Withholding of Payments Due to Fraud or Misrepresentation

a)         Effective July 1, 2012, payments on pending and subsequently submitted bills may be withheld, in whole or in part, to a provider or alternate payee, when there is credible evidence from State or federal law enforcement or federal oversight agencies or from the results of a preliminary Department audit that the circumstances giving rise to the need for a withholding of payments may involve fraud or willful misrepresentation under the Illinois Medical Assistance Program.  Payments may be withheld without first notifying the provider or alternate payee of its intention to withhold the payments.

b)         The Department must send notice of its withholding within 5 days after taking that action. The notice must set forth the general allegations as to the nature of the withholding, but need not disclose any specific information concerning the ongoing investigation. The notice must also state the following:

1)         The payments are being withheld in accordance with Section 12-4.25(K) of the Public Aid Code.

2)         The withholding is for a temporary period; the notice shall cite the circumstances under which withholding will be terminated.

3)         When appropriate, the type of claim for which withholding is effective.

4)         The provider or alternate payee has the right to submit written evidence for reconsideration of the withholding of payments by the Department.

5)         A written request may be made to the Department for full or partial release of withheld payments and the request may be made at any time after the Department first withholds the payments.

c)         All withholding of payment actions under this Section shall be temporary and shall not continue after any of the following:

1)         The Department or the prosecuting authorities determine that there is insufficient evidence of fraud or willful misrepresentation by the provider or alternate payee.

2)         Legal proceedings related to the provider's or alternate payee's alleged fraud, willful misrepresentation, or violations of Article V of the Illinois Public Aid Code or violations of 89 Ill. Adm. Code:  Chapter I are completed. If the Department commences an administrative proceeding that seeks the termination of the provider or revocation of the alternate payee, withholding will continue in conformance with 89 Ill. Adm. Code 104.272.

3)         The withholding of payments for a period of 3 years.

d)         The provider or alternate payee request for reconsideration of payment withholding, or request for full or partial release of payments withheld, must be in writing, set out the reasons for the request, and be sent to the Department's Office of Inspector General at 2200 Churchill Road, A-1, Springfield, Illinois 62702, or by e-mail to HFS.OIGWebmaster@illinois.gov.  The request may include documentation that the allegations of fraud or willful misrepresentation involving the Medical Assistance Program did not take place.

e)         Partial or full release of payments on pending and subsequently submitted bills may be granted, at the discretion of the Inspector General of the Department, when it is in the best interest of the recipients of medical assistance. This may include, but not be limited to, access to medical services for recipients or the potential movement of patients from long term care settings. 

(Source:  Amended at 42 Ill. Reg. 14383, effective July 23, 2018)

Section 140.45  Withholding of Payments Upon Provider Audit, Quality of Care Review, Credible Allegation of Fraud or Failure to Cooperate

a)         Effective July 1, 2012, the Department may withhold payments, in whole or in part, to a provider or alternate payee upon:

1)         initiation of an audit;

2)         quality of care review;

3)         investigation in which there is a credible allegation of fraud; or

4)         the provider or alternate payee is demonstrating a clear failure to cooperate with the Department, giving rise to the need for a withholding of payments.

b)         The Department may withhold payments without first notifying the provider or alternate payee of its intention to withhold payments.

c)         A provider or alternate payee may request a hearing or a reconsideration of payment withholding, and the Department must grant the request.

d)         The Department must send notice of its withholding of payments within five days after taking the action.  The notice shall:

1)         Set forth the general allegation as to the nature of the withholding action; however, the notice need not disclose any specific information concerning an ongoing investigation.

2)         State that payments are being withheld in accordance with Section 12‑4.25(K-5) of the Code.

3)         State that the withholding is for a temporary period, as specified in subsection (g), and cite the circumstances under which withholding will be terminated.

4)         Specify, when appropriate, which type or types of claims are withheld.

5)         Inform the provider or alternate payee of the right to request a hearing or a reconsideration of the withholding by the Department, including the ability to submit written evidence.

6)         Inform the provider or alternate payee that a written request may be made to the Department for a hearing or reconsideration for the full or partial release of withheld payments and that such requests may be made at any time after the Department first withholds payments.

e)         A provider or alternate payee may request reconsideration of payment withholding for the purpose of a full or partial release of payments withheld pursuant to Section 12-4.25(K-5) of the Code.  The provider or alternate payee shall submit a written request for reconsideration and the reasons for the reconsideration to the Department's Inspector General at:

Office of Inspector General

404 North Fifth Street

Springfield, Illinois 62706 

Or by e-mail to: HFS.OIGWebmaster@illinois.gov.

1)         The request may include documentation to contest a credible allegation of fraud or failure to cooperate with the Department.

2)         Partial or full release of payments on pending and subsequently submitted bills may be granted, at the discretion of the Inspector General, when it is in the best interest of Medical Assistance Program recipients.  Factors in this decision may include, but are not limited to, recipients' access to medical services or the potential transport of patients from long term care settings.

f)         A provider or alternate payee may request a hearing on the issue of a withholding of payments pursuant to Section 12-4.25(K-5) of the Code.  The only issue at hearing will be whether a partial or full release of funds is properly based on the following factors:

1)         Whether there is a credible allegation of fraud;

2)         Whether the provider or alternate payee demonstrated a clear failure to cooperate with the Department, giving rise to the need for a withholding of payments;

3)         Whether a release is in the best interest of the recipients of medical assistance based on access to medical services for recipients; and

4)         The potential movement of patients from long term care settings.

g)         All withholding of payment actions under this Section shall be temporary and shall not continue after either of the following:

1)         The Department determines that there is insufficient evidence of fraud, or the provider or alternate payee demonstrates clear cooperation with the Department, as determined by the Department, so that the circumstances do not give rise to the need for withholding of payments; or

2)         the withholding of payments has lasted for a period in excess of three years.

(Source:  Added at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.55  Electronic Data Interchange Service

a)         Definitions

As used in this Section, unless the context requires otherwise:

1)         "Batch Mode" is any request other than a "real time mode" request. The Department will respond to a "batch mode" request within 24 hours.

2)         "Medical Provider" is a provider of medical services who is enrolled with the Department to render services under any healthcare program administered by the Department.

3)         "Real Time Mode" is a request for eligibility verification for a single individual, or a request for claims status for a specific claim from a trading partner, to which the Department will respond as immediately as possible.

4)         "Recipient" is an individual eligible to receive services through any healthcare program administered by the Department.

5)         "Subscriber" is a medical provider or the agent of a medical provider who executes a contract with a trading partner to participate in the EDI service.

6)         "Trading Partner" is an entity that has successfully completed the EDI trading partner application process and executed an agreement with the Department to utilize the Department's EDI service.

b)         Electronic Data Interchange (EDI) Service

A new Electronic Data Interchange process will offer a HIPAA compliant means for trading partners to verify recipient eligibility (real time and batch mode), submit medical claims (batch mode only) and check medical claim status (real time and batch mode).  This information will be made available to medical providers through Department approved trading partners.  Trading partners are responsible for marketing the EDI service to medical providers.  Direct access to the EDI service will be made available through Department prescribed methods.  Only Department approved trading partners and their subscribing medical providers are authorized to access information provided through the EDI service, except as may be approved through subsection (e)(4).

c)         Recipient Eligibility Verification (REV) System Contract Termination

The REV system (see Section 5-1.2 of the Public Aid Code) offered on-line Medicaid eligibility information and claims history information to subscribers through REV contractors.  All REV vendor contracts that have not been terminated are terminated effective June 30, 2013.  Any REV vendor who had a contract with the Department that has terminated must apply to become a trading partner under subsection (d).

d)         Eligibility Requirements for Trading Partners

In order to be qualified to participate in the service, a trading partner must:

1)         Submit a Department prescribed application to the Department and execute an agreement with the Department. The agreement will establish the amount of reimbursement the trading partner will pay to the Department for real time mode and batch mode requests.  The agreement will also provide that the provider or trading partner will execute a written contract with each subscriber prior to any exchange of data with that subscriber;

2)         Agree to access data through one or more high speed data transmission circuits determined by the Department to be compatible with current technology and operating needs.  Current compatible high speed data transmission circuits shall be identified as part of the information provided to applicants who request the application from the Department.  Updates to technology, operating needs or transmission circuits will be provided to existing trading partners via electronic communication at least 30 days before usage is required;

3)         Treat all information, including information relating to recipients and medical providers obtained under the agreement with the Department as confidential information pursuant to the Public Aid Code [305 ILCS 5] and federal regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) (42 CFR 160, 162 and 164);

4)         Provide data to subscribers through a system designed to be flexible to meet each subscriber's needs as well as meeting the following specific requirements:

A)        Support various means of telecommunication that are commonly available for use by the subscriber; and

B)        Be compatible with the State of Illinois Department of Central Management Services' current electronic communication protocols;

5)         Certify that it is neither an individual nor an organization that:

A)        Furnishes statements or bills and receives payment in the name of medical providers; or

B)        Advances money to a medical provider for accounts receivable that the medical provider has assigned, sold or transferred to the individual or organization for an added fee or a deduction of the portion of the accounts receivable.

e)         Subscriber Contracts

The trading partner must agree that all contracts with subscribers provide that:

1)         Access to the system shall be restricted to the sole purpose of verification of medical assistance eligibility, submission of medical claims, and providing claims history information when a subscriber is requesting payment information for medical services rendered to a recipient;

2)         The subscriber indemnifies and holds harmless the State, its agents and employees from any and all claims by the subscriber or any recipient who is aggrieved by the actions of any party under the contract;

3)         The subscriber is an enrolled medical provider or the medical provider's agent;

4)         A third party who is not qualified as a subscriber may be granted access to the EDI service through a trading partner only with prior approval of the Department;

5)         All information, including information relating to recipients and providers obtained by the subscriber, through performance under contract with the contractor, is treated as confidential information pursuant to the Public Aid Code [305 ILCS 5] and federal regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) (42 CFR 160, 162 and 164); and

6)         The subscriber will certify that neither it, nor any employees, partners, officers or shareholders of the subscriber, are currently barred, suspended or terminated from participation in the Medicaid or Medicare program, nor are any of the above currently under sanction for, or serving a sentence for, conviction of any Medicaid or Medicare program offenses.

f)         Charges for EDI Services

1)         Reimbursement rates for real time mode and batch mode requests from a trading partner will be established in the agreement between the trading partner and the Department.

2)         Charges to the subscribers are made in accordance with the fee schedule and provisions specified in the contract between the trading partner and subscriber.

(Source:  Amended at 38 Ill. Reg. 4330, effective January 29, 2014)

Section 140.71  Reimbursement for Medical Services Through the Use of a C-13 Invoice Voucher Advance Payment and Expedited Payments

a)         C-13 Invoice Voucher Advance Payments

1)         The C-13 invoice voucher, when used as an advanced payment, is an exception to the regular reimbursement process.  It may be issued only under extraordinary circumstances to qualified providers of medical assistance services.  C-13 advance payments will be made only to a hospital organized under the University of Illinois Hospital Act, subject to approval by the Director, or to qualified providers who meet the following requirements:

A)        are enrolled with the Department;

B)        have experienced an emergency which necessitates C-13 advance payments. Emergency in this instance is defined as a circumstance under which withholding of the advance payment would impose severe and irreparable harm to the clients served.  Circumstances which may create such emergencies include, but are not limited to, the following:

i)          agency system errors (either automated system or clerical) which have precluded payments, or which have caused erroneous payments such that the provider's ability to provide further services to clients is severely impaired; or

ii)         cash flow problems encountered by a provider or group of providers which are unrelated to agency technical system problems.  These situations include problems which are exclusively those of the providers or problems related to State cash flow which result in delayed payments and extensive financial problems to a provider, adversely impacting on the ability to promptly serve the clients;

C)        serve a significant number of clients under the Medical Assistance Program.  Significant in this instance means:

i)          for long term care facilities, 80 percent or more of their residents must be eligible for public assistance;

ii)         for long term care facilities enrolled in the Exceptional Care Program, four or more residents receiving exceptional care;

iii)        for hospitals, the hospital must qualify as a disproportionate share hospital as described in 89 Ill. Adm. Code 148.120 or receive Medicaid Percentage Adjustment payments as described in 89 Ill. Adm. Code 148.122;

iv)        for practitioners and other medical providers, 50 percent or more of their patient revenue must be generated through Medicaid reimbursement;

v)         for sole source pharmacies in a community which are not within a 25-mile radius of another pharmacy, the provisions of this Section may be waived;

vi)        for government-owned facilities, this subsection (a)(1)(C) may be waived if the cash flow criterion under subsection (a)(1)(B)(ii) is met; and

vii)       for providers who have filed for Chapter 11 bankruptcy, this subsection (a)(1)(C) may be waived if the cash flow criterion under subsection (a)(1)(B)(ii) are met;

D)        sign an agreement with the Department which specifies the terms of advance payment and subsequent repayment.  The agreement will contain the following provisions:

i)          specific reasons for advanced payments;

ii)         specific amount agreed to be advanced;

iii)        specific date to begin recoupment; and

iv)        method of recoupment (percentage of payable amount of each Medicaid Management Information System (MMIS) voucher, specific amount per month, a warrant intercept, or a combination of the three recovery methods).

2)         Determination of amount of payment to be issued shall be based on anticipated future payments as determined by the Department.

3)         Approval Process

A)        In order to obtain C-13 advance payments, providers must submit their request in writing (telefacsimile and email requests are acceptable) to the appropriate Bureau Chief within the Division of Medical Programs.  The request must include:

i)          an explanation of the circumstances creating the need for the advance payments;

ii)         supportive documentation to substantiate the emergency nature of the request and risk of irreparable harm to the clients; and

iii)        specification of the amount of the advance required.

B)        An agreement will be issued to the provider for all approved requests. The agreement must be signed by the administrator, owner, chief executive officer or other authorized representative and be received by the Department prior to release of the warrant.

C)        C-13 advance payments shall be authorized for the provider following approval by the Administrator of the Division of Medical Programs or designee.  Once all requirements of this subsection (a)(3) are met, the Administrator will authorize payment within seven days.

4)         Recoupment

A)        Health care entities other than individual practitioners shall be required to sign an agreement stating that, should the entity be sold, the new owners will be made aware of the liability and will assume responsibility for repaying the debt to the Department according to the original agreement.

B)        All providers shall sign an agreement specifying the terms of recoupment.  An agreed percentage of the total payment to the provider for services rendered shall be deducted from future payments until the debt is repaid.  For providers who are properly certified, licensed or otherwise qualified under appropriate State and federal requirements, the recoupment period shall not exceed six months from the month in which payment is authorized.  For those providers enrolled but not in good standing (e.g., decertification termination hearing or other adverse action is pending), recoupment will be made from the next available payments owed the provider.

C)        In the event that the provider fails to comply with the recoupment terms of the agreement, the remaining balance of any advance payment shall be immediately recouped from claims being processed by the Department.  If such claims are insufficient for complete recovery, the remaining balance will become immediately due and payable by check to the Illinois Department of Public Aid.  Failure by the provider to remit such check will result in the Department pursuing other collection methods.

5)         Prior Agreements

The terms of any agreement signed between the provider and the Department prior to the adoption of this Section or prior to any amendment to this Section will remain in effect, notwithstanding the provisions of this Section.

b)         Expedited Claims Payments

1)         Expedited claims payments are issued through the regular MMIS payment process and represent an acceleration of the regular payment schedule.  They may be issued only under extraordinary circumstances to qualified providers of medical assistance services.  Reimbursement through the expedited process will be made only to a hospital qualified and participating under the Long Term Acute Care Hospital Quality Improvement Transfer Program Act [210 ILCS 155], a hospital organized under the University of Illinois Hospital Act, subject to approval by the Director, or to qualified providers who meet the following requirements:

A)        are enrolled with the Department;

B)        have experienced an emergency which necessitates expedited payments. Emergency in this instance is defined as a circumstance under which withholding of the expedited payment would impose severe and irreparable harm to the clients served.  Circumstances which may create such emergencies include, but are not limited to, the following:

i)          agency system errors (either automated system or clerical) that have precluded payments, or that have caused erroneous payments such that the provider's ability to provide further services to the clients is severely impaired;

ii)         cash flow problems encountered by a provider or group of providers which are unrelated to Department technical system problems.  These situations include problems which are exclusively those of the providers (i.e., provider billing system problems) or problems related to State cash flow which result in delayed payments and extensive financial problems to a provider adversely impacting on the ability to serve the clients;

C)        serve a significant number of clients under the Medical Assistance Program.  Significant in this instance means:

i)          for long term care facilities, 80 percent or more of their residents must be eligible for public assistance;

ii)         for long term care facilities enrolled in the Exceptional Care Program, four or more residents receiving exceptional care;

iii)        for hospitals, the hospitals must qualify as a disproportionate share hospital as described in 89 Ill. Adm. Code 148.120 or receive Medicaid Percentage Adjustment payments as described in 89 Ill. Adm. Code 148.122;

iv)        for practitioners and other medical providers, 50 percent or more of their patient revenue must be generated through Medicaid reimbursement;

v)         for sole source pharmacies in a community that are not within a 25-mile radius of another pharmacy, the provisions of this Section may be waived;

vi)        for government-owned facilities, this subsection (b)(1)(C) may be waived if the cash flow criteria under subsection (a)(1)(B)(ii) are met; and

vii)       for providers who have filed for Chapter 11 bankruptcy, subsection (b)(1)(C) may be waived if the cash flow criteria under subsection (b)(1)(B)(ii) are met.

2)         Reimbursement will be based upon the amount of claims determined payable and be made for a period specified by the Department.

3)         Approval Process 

A)        In order to qualify for expedited payments, providers must submit their request in writing (telefacsimile and email requests are acceptable) to the appropriate Bureau Chief within the Division of Medical Programs.  The request must include:

i)          an explanation of the need for the expedited payments; and

ii)         supportive documentation to substantiate the emergency nature of the request.

B)        Expedited payments shall be authorized for the provider following approval by the Administrator of the Division of Medical Programs or designee.

C)        The Department will periodically review the need for any continued expedited payments.

4)         Prior Agreements

The terms of any agreement signed between the provider and the Department prior to the adoption of this Section or prior to any amendment to this Section will remain in effect, notwithstanding the provisions of this Section.

(Source:  Amended at 38 Ill. Reg. 15081, effective July 2, 2014)

Section 140.72  Drug Manual (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 141 at 8 Ill. Reg. 16354)

Section 140.73  Drug Manual Updates (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 141 at 8 Ill. Reg. 16354)

Section 140.74  Resolution of Claims Related to Inaccurate or Updated Enrollment Information

a)         Payment shall be made for a medically necessary covered service when payment is initially denied due to inaccurate or updated enrollment information on the date of service when the provider:

1)         Submits documentation to the entity responsible for payment pursuant to subsection (c) that the provider verified the client's enrollment on the date of service by using the Recipient Eligibility Verification Program (REV), the Medical Electronic Data Interchange (MEDI), or any other electronic system that the Department designates for electronic enrollment verification; and

2)         Meets all other requirements for providing the medically necessary covered service on the date of service.

b)         In order to receive payment for the medically necessary covered service rendered, the provider must also meet the following:

1)         For services that required prior authorization, the provider must submit documentation to the entity responsible for payment pursuant to subsection (c) that the prior authorization request was approved by the previous entity to which the client was identified as being enrolled pursuant to subsection (a). For services that did not require prior authorization, the provider must provide proof that no prior authorization was required by the previous entity.

A)        The MCO responsible for payment pursuant to subsection (c) must accept the approved prior authorization made by the previous entity and may not impose any further prior authorization or similar requirements.

B)        For services that did not require prior authorization from the previous entity, the MCO responsible for payment pursuant to subsection (c) may not impose any further prior authorization or similar requirements.

2)         The provider must supply evidence of claim denial or rejection and supporting documentation of enrollment to the entity responsible for payment pursuant to subsection (c).

3)         The approved prior authorization request from the previous entity, or proof that no prior authorization was required by the previous entity, and initial or resubmitted claim must be received by the entity responsible for payment pursuant to subsection (c) within the appropriate timely filing period. The timely filing period shall begin on the date on the payment voucher/remittance advice that informs the provider that the claim is denied or rejected and extend for a period of 180 days.

c)         The MCO in which the client is enrolled on the date of service is responsible for payment.

d)         Payment by the responsible MCO will be made as follows:

1)         In-network managed care providers shall receive the payor's contracted rate that was in effect on the date of service.

2)         Out-of-network and fee-for-service providers shall receive, at a minimum, the fee-for-service rate, plus any add-ons, that was in effect on the date of service.

3)         A payment penalty reduction is not permissible.

e)         For the purposes of this Section, documentation may include, but is not limited to:

1)         REV eligibility batch file or screen print, MEDI eligibility batch file or screen print, or other eligibility statement from the electronic enrollment verification system designated by the Department and used to verify the client's eligibility on the date of service. For long term care providers, if the batch report or screen image is dated on or after the first day that the Department opens access to the enrollment verification system for purposes of verifying the client's eligibility for the covered service, it shall be accepted as the date of service verification.

2)         Previous entity's policy as contained in a provider manual, provider notice, provider contract, policy memorandum, or other entity-created document that indicates that no prior authorization was required for the services rendered, or the previous entity's prior authorization approval;

3)         Initial claim or resubmitted claim; and

4)         Payment voucher/remittance advice or explanation of benefits (EOB) that informs the provider that the previous entity denied or rejected the claim.

(Source:  Added at 41 Ill. Reg. 10950, effective August 9, 2017)

Section 140.75  Managed Care − Disputed Provider Claims Resolution Process

a)         The Department will maintain an electronic provider complaint portal through which a disputed claim between a provider and an MCO is documented, monitored, and resolved. A disputed claim is a determination made by an MCO that denies in whole or in part a claim for reimbursement to a provider for services rendered by the provider to an enrollee of the MCO with which the provider disagrees. 

b)         A provider or its billing agent may submit to the Department's provider complaint portal a disputed claim only after filing with the MCO's internal provider dispute resolution process, as described in this subsection (b).  Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy.

1)         The provider's submission to the portal must include the date the disputed claims were filed with the MCO's internal provider dispute resolution process and the corresponding MCO-provided tracking number.

2)         Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the provider complaint portal no sooner than 30 calendar days after submitting to the MCO's internal process and not later than 30 calendar days after the unsatisfactory resolution of the internal MCO process or 60 calendar days after submitting the dispute to the MCO internal process. 

c)         The Department, within 10 business days after a provider's disputed claims submission to the provider complaint portal, will present the disputed claims to the MCO for resolution. 

d)         The MCO, within 30 calendar days after receiving the disputed claims from the Department's provider complaint portal, will develop a written proposal to resolve the disputed claims, which shall be electronically transmitted to the provider and uploaded to the provider complaint portal, unless an extension is granted pursuant to subsection (e), resulting in an MCO having 60 calendar days to develop a written proposal. 

1)         In the event the MCO requires additional information from the provider to review the disputed claims, the MCO must request the additional information from the provider within 5 business days after receiving the disputed claims from the Department's provider complaint portal, unless the MCO requests an extension within this 5 business day timeframe and is granted an extension pursuant to subsection (e).  When an MCO is granted an extension, the MCO must request the additional information from the provider within 5 business days after receiving the extension.

2)         When additional information is requested from the provider by the MCO within the timeframes described in subsection (d)(1), the provider has 5 business days to respond with the requested information, unless the provider requests an extension within this 5 business day response timeframe and is granted an extension pursuant to subsection (e). When a provider is granted an extension, the provider must respond with the requested information within 5 business days after receiving the extension.  Failure to timely provide the information will result in the disputed claims being closed.

e)         During the disputed claims resolution process described in subsection (d), the MCO or the provider may request, through the provider complaint portal, that the Department authorize a single 30 calendar day extension.  The MCO or the provider may submit an extension request during the timeframes established in subsection (d).  An extension request, made by either the MCO or the provider, that occurs after the timelines in subsection (d) must be made no later than 7 calendar days prior to the end of the initial 30 calendar day period.  Approval of the extension is at the Department's discretion.  An approved extension adds 30 calendar days to the initial 30 calendar day period, for a total of 60 calendar days within which the MCO must develop a written proposal to address the disputed claims.

f)         A provider that disagrees with the MCO's written proposal or does not receive the MCO's written proposal within the required timeframe has 30 calendar days to request that the Department review the disputed claims and render a final decision.  

1)         Within 30 calendar days after a provider's request for Department review, both the MCO and the provider shall deliver all relevant information to the Department, including contact information for knowledgeable personnel. 

2)         Within 30 calendar days after the timeframe established in subsection (f)(1), the Department shall provide a written decision on the disputed claims that reflects, and is consistent with, applicable contract terms, written Department policies and procedures, and State and federal statute and regulations.

3)         The decision of the Department is final. Disputes between MCOs and providers presented to the Department for resolution are not contested cases and do not confer any right to an administrative hearing.

(Source:  Added at 44 Ill. Reg. 4616, effective March 3, 2020)

Section 140.76  Hospital Managed Care Utilization Review Standardization and Transparency Practices

a)         Definitions. As used in this Section:

"Administrative days" means hospital long term care days as defined in 89 Ill. Adm. Code 148.50(c)(1).

"Adverse benefit determination" means the denial or limited authorization of a service authorization request for coverage of a health care service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; the reduction, suspension, or termination of a previously authorized health care service; or the denial, in whole or in part, of payment for a service (unrelated to whether the claim is submitted timely or properly coded).

"Enrollee" means any person who is eligible for medical assistance under the Public Aid Code, is not eligible for or enrolled in Medicare, and is enrolled in a managed care organization.

"Generally accepted standards of care" for a health care service means standards of care and clinical practice that are generally recognized by health care clinicians practicing in relevant clinical specialties for the illness, injury, or condition or its symptoms and comorbidities. Valid, evidence-based sources reflecting generally accepted standards of care include peer-reviewed scientific studies and medical literature, recommendations of nonprofit health care provider professional associations and specialty societies, including, but not limited to, enrollee placement criteria and clinical practice guidelines, recommendations of federal government agencies, and drug labeling approved by the United States Food and Drug Administration.

"Health care service" means any medical or behavioral health service covered under the medical assistance program that is subject to review under a service authorization program, except for durable medical equipment as described in 89 Ill. Adm. Code 140.475 and pharmacy services as described in 89 Ill. Adm. Code 140.440. [305 ILCS 5/5-30.1(a)]

"Managed care organization" or "MCO" means any entity that contracts with the Department to provide health care services to enrollees where payment for services is made on a capitated basis. For purposes of this Section, MCOs shall also mean an MCO's utilization review department, a peer review organization, a quality improvement organization, or a utilization review organization (URO) that contracts with an MCO to administer a service authorization program and make service authorization determinations. For purposes of this Section, MCO does not mean an entity that contracts with the Department to provide health care services to Medicare-eligible enrollees where payment is made on a capitated basis.

"Medically necessary" or "medical necessity" means that a service addresses the specific needs of an enrollee for the purpose of:

screening, preventing, diagnosing, managing, or treating an illness, injury, or condition and disorder that results in health impairments and/or disability or its symptoms and comorbidities;

minimizing the progression of an illness, injury, or condition or its symptoms and comorbidities;

achieving age-appropriate growth and development;

attaining, maintaining, or regaining functional capacity; and

is provided in a manner that is:

in accordance with generally accepted standards of care;

clinically appropriate in terms of type, frequency, extent, site, and duration; and

not primarily for the economic benefit of the MCO or for the convenience of the enrollee or provider.

"Provider" means a facility or individual who is enrolled in the medical assistance program and licensed or otherwise authorized to order, prescribe, refer, or render health care services in this State.

"Service authorization determination" means a decision made by a service authorization program in advance of, concurrent to, or after the provision of a health care service to approve, change the level of care, partially deny, deny, or otherwise limit coverage and reimbursement for a health care service upon review of a service authorization request. [305 ILCS 5/5-30.1(a)]

"Service authorization program" means any utilization review, utilization management, peer review, quality review, or other medical management activity conducted by an MCO including but not limited to, prior authorization, prior approval, pre-certification, concurrent review, retrospective review, or certification of admission, of health care services provided in an inpatient or outpatient hospital setting. [305 ILCS 5/5-30.1(a)]  Unless otherwise specifically stated in this Section, "inpatient hospital setting" means as defined in 89 Ill. Adm. Code 148.25 (b)(1). "Outpatient hospital setting" means as defined in 89 Ill. Adm. Code 148.25 (b)(2).

"Service authorization request" means a request submitted by a provider to a service authorization program for a service authorization determination.

b)         This Section is effective for dates of service or admission on and after July 1, 2025, except for subsection (d) which shall be effective September 2, 2025.

c)         An MCO shall provide documents to the Department showing compliance with this Section as requested by the Department. The MCO shall provide all documents deemed necessary by the Department and within the timeframes requested by the Department. Nothing in this Section shall be construed to alleviate each MCO's obligations to notify providers of changes in policies and procedures as required by the Department in its contracts with the MCOs. Where the MCO contract language is inconsistent or in conflict with this Section, the MCO shall follow the requirements set forth in this Section.

d)         Publication Guidelines for Hospital Service Authorization Programs.

1)         Each MCO shall clearly publish on the home page of its public-facing website or provide a link on the home page to policies and procedures specific to Illinois for its service authorization programs. The website must be readily accessible to enrollees, in-network providers and out-of-network providers, and members of the public without requiring an individual to create any account or enter any credentials to access it. The policies and procedures shall be conspicuously posted on the website, detailed, written in easily understandable language, and readily available to the provider at the point of care.

2)         The website shall minimally include all the following:

A)        A complete list of health care services included in each service authorization program.

B)        For each health care service referenced in subsection (d)(2)(A), the MCO must:

i)          Categorize the health care service by in-network and out-of-network.

ii)         Categorize the health care service by type of service authorization program.

iii)        Include all MCO-specific payment and clinical review criteria, guidelines, and policies that are used instead of or to supplement nationally recognized decision support criteria.

iv)        Include any proprietary, nationally recognized decision support criteria on its secure provider portal. 

v)         Include a list of commonly used service authorization program terms and their definitions, as approved by the Department.

vi)        Identify the date the service authorization program requirement became effective in Illinois; the date the requirement was listed on the MCO's Illinois-specific website; the effective date of any removal, termination, or revision of service authorization program requirements; and a summary of and rationale for the terminations, removals, and revisions.

C)        Policies and procedures for requesting approval of administrative days.

D)        A clear outline of the process for a provider to request an appeal of an adverse benefit determination on behalf of an enrollee, including all timelines and required forms.

E)        A clear outline of the process for an enrollee, or provider on behalf of an enrollee, to request a review by an external independent entity of an adverse benefit determination, except for Home and Community-Based Services (HCBS) waiver service determinations.

F)         Access to standard electronic service authorization requests.

G)        If an MCO intends either to implement a new requirement or restrict or amend an existing requirement, the MCO shall update its website and provide contracted providers written notice no less than 60 days prior to implementation. The written notice may be provided in an electronic format, including email or facsimile, if the provider has agreed in advance to receive notices electronically.

e)         Procedures Covered in the Inpatient Hospital Setting.

1)         This subsection (e) shall not apply to behavioral health and substance use disorder health care services and health care services rendered in "psychiatric hospitals" defined in 89 Ill. Adm. Code 148.25 (d)(1); "rehabilitation hospitals" defined in 89 Ill. Adm. Code 148.25 (d)(2); and "long-term acute care hospitals" defined in 89 Ill. Adm. Code 148.25 (d)(4). (See 215 ILCS 5/532(e), 370c and 370c.1)

2)         For a health care service listed on the HFS Inpatient Only (IPO) list, as published by the Department on November 19, 2025, at https://hfs.illinois.gov/medicalproviders/cc/managedcareprogrampolicies.html, service authorization programs must approve the level of care as requested by the provider on the service authorization request and provide reimbursement under the applicable payment methodology as billed by the provider. In enrollee-specific cases where the provider determines that it is clinically appropriate and safe for such procedure to be performed in an outpatient hospital setting, and the provider bills the service as outpatient hospital level of care, the MCO must reimburse under the applicable outpatient hospital payment methodology.

f)          Hospital Administrative Forms Used in Enrollee Appeal Process.

1)         Each MCO must use the standard appointment of representative (AOR) form, both paper and electronic, as published by the Department. The MCOs shall allow the form to be signed prior to the rendering of the determination on the service authorization request for the health care service.

2)         MCOs shall allow alternatives to the standardized AOR form if the alternative is a separate and distinct document from the general consent to treatment form and contains all elements included in the standardized AOR form. Alternatives may include, but are not limited to, electronic medical record-generated forms.

g)         Limitations on Second or Subsequent Medical Necessity Reviews for Health Care Services in a Hospital Setting.

1)         Nothing in this Section supersedes or waives requirements regarding behavioral health and substance use disorder health care services necessary to comply with applicable federal or state law, federal regulation, federal grant requirements, any State or federal consent decrees or court orders, or applicable case law.

2)         Health care services authorized by a service authorization program that have been or are in the process of being rendered shall not be subject to a second or subsequent medical necessity review to revoke or further limit, condition, or restrict an approval received, or reduce or recover payment for a service which the service authorization program previously determined was medically necessary. Nothing in this subsection prevents a service authorization program from requiring authorization for health care services beyond the scope of the initial approval. Nothing in subsection (g)(2) supersedes subsection (g)(5).

3)         The MCO shall not deny a claim due to readmission policies for approved, planned readmissions. Each MCO shall update its payment systems to allow providers to indicate on the institutional claim that an admission was planned and allow a claim for a planned readmission to bypass any edits that would cause a denial of a claim due to readmission policies.

4)         Nothing in this subsection (g) shall prevent an MCO from requiring a provider to submit a timely, complete, and properly coded claim. The MCO shall not be liable for payments for individuals who are not enrollees of the MCO at the time the health care service is rendered.

5)         Nothing in this subsection (g) shall prevent an MCO from denying payments or recovering overpayments based on fraud, waste, or abuse. The MCO and the Department shall continue to implement and enforce any program integrity safeguards mandated by state or federal law, regulations, and policies including but not limited to 305 ILCS 5/12-13.1 and Title 42, Chapter IV, Subchapter C, Part 438, Subpart H of the Code of Federal Regulations and Title 42, Chapter IV, Subchapter F, Part 455 of the Code of Federal Regulations. The MCO or Department may require documentation, including documentation of medical necessity, in cases where the MCO or the Department is investigating fraud, waste, or abuse. When a service authorization program has approved an inpatient hospital level of care as medically necessary, and that service meets medical necessity based on nationally recognized decision support criteria, an MCO shall not subsequently classify that service as waste if it subsequently determines that the enrollee could have been treated in the hospital outpatient setting.

h)         Standardization of Peer-to-Peer Processes and Timelines in the Hospital Setting

1)         Each MCO shall adhere to the requirements of this subsection for peer-to-peer reviews for health care services that are subject to its service authorization programs.

2)         Providers may request a peer-to-peer review within 10 calendar days of receipt of the MCO's notice of intent to make an adverse determination, request for further documentation, or notice of adverse benefit determination. MCOs shall make exceptions to this timeframe on a case-by-case basis to accommodate unique, provider-specific circumstances. A peer-to-peer review request shall not alter the grievance and appeals rights of enrollees.

3)         MCOs may request peer-to-peer reviews but shall not automatically require peer-to-peer reviews as part of its service authorization program.

4)         Nothing in this subsection (h) alters the timeframes in subsection (j) for MCOs to make service authorization determinations. If compliance with these timeframes results in a determination being made after a peer-to-peer is scheduled but before the peer-to-peer occurs, the MCO shall not be out of compliance with subsection (h)(2).

5)         MCOs shall respond to a request for a peer-to-peer review within one business day of receipt of the request confirming the date and time of the peer-to-peer review and instructions for facilitating the review.

6)         Unless otherwise agreed to by the MCO and provider, the MCO shall hold a peer-to-peer review within three business days of the receipt of the request.

7)         In cases where an MCO fails to attend a scheduled peer-to-peer review or otherwise is unable to hold a peer-to-peer review within three business days of the receipt of the request, the MCO must treat all post-denial actions, including, but not limited to, appeals as when the provider submits the appeal or other post-denial action as urgent.

8)         MCOs shall allow both in-network and out-of-network providers to schedule and request a peer-to-peer review telephonically or in writing by electronic means, facsimile, and web-based secure functionality.  MCOs must also allow in-network providers to request and schedule a peer-to-peer review through the provider portal.

9)         When scheduling a peer-to-peer review, MCOs shall allow the providers to minimally offer three dates and times for the review from which the MCO will select a date and time.

10)       Peer-to-peer reviews shall be held in a manner most efficient to meet the needs of the enrollee and may be in-person, telephonic, or web based as agreed to by the provider and MCO. MCOs must use physicians who are in the same or similar specialty as a physician who typically manages the medical condition or disease.

11)       MCOs shall allow providers to submit additional clinical documentation which shall be considered during the peer-to-peer review. If requested by the provider, the MCO shall accept the documentation in lieu of the peer-to-peer review.

12)       If the MCO modifies its original intent to make an adverse determination or modifies an adverse benefit determination prior to the date of the peer-to-peer review, the MCO shall notify the provider of its decision before the date of the peer-to-peer review to allow the provider the option to cancel the review. The MCOs shall follow the notification provisions set forth in subsection (h)(13).

13)       MCO Notification of Peer-to-Peer Decisions.

A)        The MCO may verbally notify the provider of its decision during or after the peer-to-peer review. However, the MCO must issue a written decision to the provider submitting the service authorization request within 24 hours of the date and time of the peer-to-peer review.

B)        The written notice shall be issued by electronic means, facsimile, portal, or web-based secure functionality.

C)        The written notice shall minimally include the following:

i)          Date notice is issued.

ii)         Identification of the health care service.

iii)        The effective date of the decision.

iv)        Plain language instructions on a provider's right to appeal an adverse benefit determination on behalf of an enrollee in accordance with the procedures outlined in subsection (f); the right of the provider to submit a service authorization dispute of the medical necessity denial and the process, and the circumstances, under which an external independent review may be requested, consistent with Department policy.

v)         For service authorization determinations not wholly in favor of the enrollee, such as denials, limits, conditions, or restrictions of a health care service, a detailed basis for the determination with any data used to explain the decision, including:

•           The principal reason(s) for the determination, including, if applicable, a statement that the determination was based on a failure to submit specified medical records.

•           Additional documentation necessary for reconsideration or to support an appeal of an adverse benefit determination.

•           The clinical basis for the determination.

•           A description of the sources, including citations, that were used in making the determination.

•           The professional specialty of the individual who made the determination.

i)          Standard Criteria for Admission to a Long-Term Acute Care Hospital.

1)         Except for (i)(11), this subsection applies only to service authorization requests for initial admissions to a long-term acute care hospital (LTACH), as defined in 89 Ill. Adm. Code 148.25 (d)(4), from a discharging hospital.

2)         The service authorization program shall make medical necessity determinations in a manner that is no more restrictive than that used by the Department, including quantitative and non-quantitative treatment limits, as indicated in federal and State laws and regulations.

3)         Each service authorization program shall determine medical necessity for initial admission to an LTACH based on nationally recognized decision support criteria, except as outlined in subsection (i)(4) and (i)(5). If an MCO purchases or licenses service authorization program LTACH review criteria, the MCO shall, before using the criteria, verify and document that the criteria were developed in accordance with this subsection.

4)         In cases where the enrollee's condition does not specifically meet nationally recognized decision support criteria, service authorization programs must consider all clinical factors and make enrollee-specific determinations on a case-by-case basis, which may include approving service authorization requests for LTACH level of care when an enrollee's individual needs support approval.

5)         In cases where a multidisciplinary team at the discharging hospital determines and documents that the enrollee is appropriate for and will benefit from care in an LTACH and a lower level of care will not meet the enrollee's clinical needs, the service authorization program shall not deny a service authorization request for initial admission to an LTACH when the level of care is medically necessary, pursuant to subsection (i)(2), (i)(3), or (i)(4), and instead approve only skilled nursing facility level of care or alternate lower level of care. The MCO may request and conduct a peer-to-peer review with the provider prior to approval of the service authorization request to collaboratively discuss alternative settings of care, including any community-based alternatives that may be part of a quality program.

6)         Nothing in this subsection (i)prohibits an enrollee from choosing or electing an alternate level of care.

7)         Service authorization programs must have mechanisms in place to ensure consistent application of review criteria, allowing for enrollee-specific exceptions pursuant to (i)(4), and shall consult with the provider involved in the service authorization request when appropriate. Any decision to deny a service authorization request or to authorize a health care service in an amount, duration, or scope that is less than requested must be made by an individual who has appropriate expertise in addressing the enrollee's medical needs.

8)         The MCO shall continue to establish practice guidelines as mandated by federal regulations, including but not limited to 42 CFR 438.236. Practice guidelines must incorporate requirements set forth in this subsection.

9)         Nothing in this subsection alters a service authorization program's obligation to make medical necessity determinations on requests for continuing stays at LTACHs based on all contractual requirements and applicable federal and state laws and regulations, including but not limited to 42 CFR 438.210.

j)          Timelines for Standard and Urgent Service Authorization Requests for Long Term Acute Care Hospitals and Post-Acute Care Services.

1)         Nothing in this subsection (j) supersedes or waives requirements regarding behavioral health and substance use disorder health care services necessary to comply with applicable federal or state law, federal regulation, federal grant requirements, any State or federal consent decrees or court orders, or applicable case law.

2)         A service authorization program shall issue a service authorization determination as expeditiously as the enrollee's health condition requires and no later than the timelines outlined in this subsection (j).

3)         Except for subsection (j)(4), the MCO must render a service authorization determination and notify the enrollee and the provider of the determination within five calendar days of receipt of the service authorization request, with an extension of up to five additional calendar days if the enrollee requests the extension or the service authorization program informs the provider that there is a need for additional written justification demonstrating that the health care service is medically necessary and the enrollee will not be harmed by the extension.

4)         If the provider indicates or the MCO determines that following the timeframes listed in subsection (j)(3) could seriously jeopardize the enrollee's life or health, or could potentially result in a hospital stay beyond medical necessity, the service authorization program must render a service authorization determination and notify the enrollee and the provider no later than 48 hours after receipt of the service authorization request, unless the service authorization program has not received clinical information sufficient upon which to make a service authorization determination. Where the service authorization program has not received sufficient clinical information upon which to make a determination, the service authorization program shall notify the provider no later than 24 hours after receipt of the service authorization request that additional clinical information is needed and shall allow the provider 24 hours to submit the requested additional clinical documentation.  The MCO must then render an approval or adverse benefit determination no later than 72 hours after receipt of the original service authorization request.

5)         In cases where the provider indicates that the service authorization request must be decided within the urgent timeframe, the service authorization program cannot override the provider's determination and treat the request as a standard request.

(Source:  Amended at 49 Ill. Reg. 15705, effective November 26, 2025)

Section 140.80  Hospital Provider Fund

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.

b)         Provider Assessments

1)         Subject to Sections 5A-3, 5A-10 and 5A-15 of the Code, for State fiscal years 2009 through 2018, or as long as continued under Section 5A-16, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $218.38 multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days; provided, however, the amount of $218.38 shall be increased by a uniform percentage to generate an amount equal to 75% of the State share of the payments authorized under Section 5A-12-5 of the Code, with that increase only taking effect upon the date that a State share for those payments is required under federal law.  For the period of April through June 2015, the amount of $218.38 used to calculate the assessment under this subsection (b)(1) shall be increased by a uniform percentage to generate $20,250,000 in the aggregate for that period from all hospitals subject to the annual assessment under this Section.  For State fiscal years 2009 and after, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2005 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on December 31, 2006, without regard to any subsequent adjustments or changes to such data. If a hospital's 2005 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Department may obtain the hospital provider's occupied bed days and Medicare bed days from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees.  Subject to Sections 5A-3, 5A-10, and 5A-16 of the Code, for State fiscal years 2019 and 2020, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $197.19 multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days. For State fiscal years 2019 and 2020, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Illinois Department may obtain the hospital provider's occupied bed days and Medicare bed days from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. Notwithstanding any other provision in this Section, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020.  Subject to Sections 5A-3 and 5A-10, and in accordance with federal approval and P.A. 101-0650, for the period of July 1, 2020 through December 31, 2020 and calendar years 2021 through 2024, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $221.50 multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days, provided, however, for the period of July 1, 2020 through December 31, 2020, the assessment shall be equal to 50% of the annual amount and the amount of $221.50 shall be retroactively adjusted by a uniform percentage to generate an amount equal to 50% of the Assessment Adjustment as defined in subsection (l). For the period of July 1, 2020 through December 31, 2020 and calendar years 2021 through 2024, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Illinois Department may obtain the hospital provider's occupied bed days and Medicare bed days from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. Should the change in the assessment methodology for fiscal years 2021 through December 31, 2022 not be approved on or before June 30, 2020, the assessment and payments under this Article in effect for fiscal year 2020 shall remain in place until the new assessment is approved. If the assessment methodology for July 1, 2020 through December 31, 2022, is approved on or after July 1, 2020, it shall be retroactive to July 1, 2020, subject to federal approval and provided that the payments authorized under Section 5A-12.7 have the same effective date as the new assessment methodology. In giving retroactive effect to the assessment approved after June 30, 2020, credit toward the new assessment shall be given for any payments of the previous assessment for periods after June 30, 2020. Notwithstanding any other provision of this Article, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State Fiscal Year 2020 on the basis of hypothetical data, the data that was the basis for the 2020 assessment shall be used to calculate the assessment under this paragraph until December 31, 2023. Beginning July 1, 2022 and through December 31, 2024, a safety-net hospital that had a change of ownership in calendar year 2021, and whose inpatient utilization had decreased by 90% from the prior year and prior to the change of ownership, may be eligible to pay a tax based on hypothetical data based on a determination of financial distress by the Department. Subject to federal approval, the Department may, by January 1, 2024, develop a hypothetical tax for a specialty cancer hospital which had a structural change of ownership during calendar year 2022 from a for-profit entity to a non-profit entity, and which has experienced a decline of 60% or greater in inpatient days of care as compared to the prior owners 2015 Medicare cost report. This change of ownership may make the hospital eligible for a hypothetical tax under the new hospital provision of the assessment defined in this Section. This new hypothetical tax may be applicable from January 1, 2024 through December 31, 2026.

A)        Subject to Sections 5A-3 and 5A-10, beginning January 1, 2025, an annual assessment on inpatient services is imposed on each hospital provider in an amount equal to $362, or any reduction thereof in accordance with this subsection, multiplied by the difference of the hospital's occupied bed days less the hospital's Medicare bed days; however, the rate shall be $221.50 until the Department receives federal approval and implements the reimbursement rates in subsection (r) of Section 5A-12.7. The Department may bill for the difference between the assessment rate of $362, or any reduction thereof in accordance with this subsection, and $221.50 no earlier than 17 calendar days after implementing the reimbursement rates in subsection (r) of Section 5A-12.7.

B)        Upon receiving federal approval for the reimbursement rates in subsection (r) of Section 5A-12.7, the Department shall bill the hospital for the incremental difference in total tax due resulting from the increase provided in this subsection for the number of months from January 1, 2025 through the date of federal approval. The amount shall be due and payable no later than December 31, 2025 and no earlier than 17 calendar days after implementing the reimbursement rates in subsection (r) of Section 5A-12.7. The Department shall bill hospitals in the same proportional rate as the Department has implemented the inpatient reimbursement rates in subsection (r) of Section 5A-12.7.

C)        Beginning January 1, 2025, a hospital's occupied bed days and Medicare bed days shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Department may obtain the hospital provider's occupied bed days and Medicare bed days from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees. If the reimbursement rates in subsection (r) of Section 5A-12.7 require reduction to comply with federal spending limits, then the tax rate of $362 shall be reduced, in accordance with subsection (s) of Section 5A-12.7, by the same percentage reduction to payments required to comply with federal spending limits.

2)         In addition to any other assessments imposed under this Section, effective July 1, 2016 and semiannually thereafter through June 2018, or as provided in Section 5A-16, in addition to any federally required State share as authorized under subsection (b)(1), the amount of $218.38 shall be increased by a uniform percentage to generate an amount equal to 75% of the ACA Assessment Adjustment, as defined in subsection (l)(1).

3)         Subject to Sections 5A-3, 5A-10, and 5A-15 of the Code for the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012, and for State fiscal years 2013 through 2018, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .008766 multiplied by the hospital's outpatient gross revenue; provided, however, the multiplier of .008766 shall be increased by a uniform percentage to generate an amount equal to 25% of the State share of the payments authorized under Section 5A-12-5, with that increase only taking effect upon the date that a State share for those payments is required under federal law.  For the period of April through June 2015, the amount of .008766 used to calculate the assessment under this subsection (b)(3) shall be increased by a uniform percentage to generate $6,750,000 in the aggregate for that period from all hospitals subject to the annual assessment under this Section.  For the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012 and for State fiscal years 2013 through 2018, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2009 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on June 30, 2011, without regard to any subsequent adjustments or changes to that data.  If a hospital's 2009 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Department may obtain the hospital provider's outpatient gross revenue from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees. For the period beginning June 10, 2012 through June 30, 2012, the annual assessment on outpatient services shall be prorated by multiplying the assessment amount by a fraction, the numerator of which is 21 days and the denominator of which is 365 days.  Subject to Sections 5A-3, 5A-10, and 5A-16, for State fiscal years 2019 and 2020, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .01358 multiplied by the hospital's outpatient gross revenue. For State fiscal years 2019 and 2020, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Department may obtain the hospital provider's outpatient gross revenue from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees. Notwithstanding any other provision in this Section, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020.  Subject to Sections 5A-3 and 5A-10, for the period of July 1, 2020 through December 31, 2020 and calendar years 2021 through 2024, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .01525 multiplied by the hospital's outpatient gross revenue, provided however, for the period of July 1, 2020 through December 31, 2020, the assessment shall be equal to 50% of the annual amount and the amount of .01525 shall be retroactively adjusted by a uniform percentage to generate an amount equal to 50% of the Assessment Adjustment, as defined in subsection (1). For the period of July 1, 2020 through December 31, 2020 and calendar years 2021 through 2024, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to that data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Illinois Department may obtain the hospital provider's outpatient revenue data from any source available, including, but not limited to, records maintained by the hospital provider. The data may be inspected at all times during business hours of the day by the Illinois Department or its duly authorized agents and employees. Should the change in the assessment methodology above for fiscal years 2021 through calendar year 2022 not be approved prior to July 1, 2020, the assessment and payments under this Article in effect for fiscal year 2020 shall remain in place until the new assessment is approved. If the change in the assessment methodology above for July 1, 2020 through December 31, 2022, is approved after June 30, 2020, it shall have a retroactive effective date of July 1, 2020, subject to federal approval and provided that the payments authorized under Section 12A-7 have the same effective date as the new assessment methodology. In giving retroactive effect to the assessment approved after June 30, 2020, credit toward the new assessment shall be given for any payments of the previous assessment for periods after June 30, 2020. Notwithstanding any other provision of this Article, for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State Fiscal Year 2020 on the basis of hypothetical data, the data that was the basis for the 2020 assessment shall be used to calculate the assessment under this paragraph until December 31, 2023. Beginning July 1, 2022 and through December 31, 2024, a safety-net hospital that had a change of ownership in calendar year 2021, and whose inpatient utilization had decreased by 90% from the prior year and prior to the change of ownership, may be eligible to pay a tax based on hypothetical data based on a determination of financial distress by the Department.

A)        Subject to Sections 5A-3 and 5A-10, beginning January 1, 2025, an annual assessment on outpatient services is imposed on each hospital provider in an amount equal to .03273, or any reduction thereof in accordance with this subsection, multiplied by the hospital's outpatient gross revenue; however the rate shall remain .01525, until the Department receives federal approval and implements the reimbursement rates of payment in subsection (r) of Section 5A-12.7. The Department may bill for the difference between the assessment multiplier of .03273 and .01525 no earlier than 17 calendar days after the first payment based on the reimbursement rates in subsection (r) of Section 5A-12.7.

B)        Upon receiving federal approval for the reimbursement rates in subsection (r) of Section 5A-12.7, the Department shall bill the hospital for the incremental difference in total tax due resulting from the increase provided in this subsection for the number of months from January 1, 2025 through the date of federal approval. The amount shall be due and payable no later than December 31, 2025 and no earlier than 17 calendar days after implementing the reimbursement rates in subsection (r) of Section 5A-12.7. The Department shall bill hospitals in the same proportional rate as the Department has implemented the outpatient reimbursement rates in subsection (r) of Section 5A-12.7.

C)        Beginning January 1, 2025, a hospital's outpatient gross revenue shall be determined using the most recent data available from each hospital's 2015 Medicare cost report as contained in the Healthcare Cost Report Information System file, for the quarter ending on March 31, 2017, without regard to any subsequent adjustments or changes to such data. If a hospital's 2015 Medicare cost report is not contained in the Healthcare Cost Report Information System, then the Department may obtain the hospital provider's outpatient revenue data from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees. If the reimbursement rates in subsection (r) of Section 5A-12.7 require reduction to comply with federal spending limits, then the tax rate of .03273 shall be reduced, in accordance with subsection (s) of Section 5A-12.7, by the same percentage reduction to payments required to comply with federal spending limits.

c)         Payment of Assessment Due

1)         The inpatient assessment imposed by Section 5A-2 of the Code for State fiscal year 2009 through State fiscal year 2018, or as provided in Section 5A-16, shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the 14^th State business day of each month.  No installment payments of an inpatient assessment shall be due and payable, however, until after the Comptroller has issued the payments required under Section 5A-12.2 of the Code.  Assessment payments postmarked on the due date will be considered as paid on time.

2)         Except as provided in Section 5A-4(a-5) of the Code, the outpatient assessment imposed by subsection (b)(3) for the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012 and for State fiscal year 2013 through State fiscal year 2018, or as provided in Section 5A-16, shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the 14^th State business day of each month.

A)        No installment payment of an outpatient assessment imposed by subsection (b)(3) shall be due and payable, however, until after:

i)          the Department notifies the hospital provider, in writing, that the payment methodologies to hospitals required under Section 5A-12.4 of the Code have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services (CMMS), and the waiver under 42 CFR 433.68 for the assessment imposed by subsection (b) of this Section, if necessary, has been granted by CMMS; and

ii)         the Comptroller has issued the payments required under Section 5A-12.4 of the Code.

B)        Assessment payments postmarked on the due date will be considered as paid on time. Upon notification to the Department of approval of the payment methodologies required under Section 5A-12.4 of the Code and the waiver granted under 42 CFR 433.68, if necessary, all installments otherwise due under subsection (b)(3) of this Section prior to the date of notification shall be due and payable to the Department upon written direction from the Department and issuance by the Comptroller of the payments required under Section 5A-12.4 of the Code.

3)         The assessment imposed under P.A. 101-0650 and Section 5A-2 of the Code for State fiscal year 2019 and each subsequent State fiscal year shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the 17^th State business day of each month.  The Department has discretion to establish a late date due to delays in payments being made to hospitals, as required by Section 5A-12.7 of the Code.

A)        No installment payment of an assessment imposed by P.A. 101-0650 and Section 5A-2 of the Code shall be due and payable, however, until after:

i)          The Department notifies the hospital provider, in writing, that the payment methodologies to hospitals required under Section 5A-12.6 or 5A-12.7 of the Code have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, and the waiver under 42 CFR 433.68 for the assessment imposed by P.A. 101-0650 and Section 5A-2 of the Code, if necessary, has been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services; and

ii)         The Comptroller and managed care organizations have issued the payments required under Section 5A-12.6 or 5A-12.7 of the Code.

B)        Upon notification to the Department of approval of the payment methodologies required under Section 5A-12.6 or 5A-12.7 of the Code and the waiver granted under 42 CFR 433.68, if necessary, all installments otherwise due under subsection (b)(3) prior to the date of notification shall be due and payable to the Department upon written direction from the Department and issuance by the Comptroller and managed care organizations of the payments required under Section 5A-12.6 or 5A-12.7 of the Code.

4)         Any assessment amount that is due and payable to the Department more frequently than once per calendar quarter shall be remitted to the Department by the hospital provider by means of electronic funds transfer.  The Department may provide for remittance by other means if the amount due is less than $10,000 or electronic funds transfer is unavailable for this purpose.

5)         All payments received by the Department shall be credited first to unpaid installment amounts (rather than to penalty or interest), beginning with the most delinquent installments.

d)         Notice Requirements, Penalty, and Maintenance of Records

1)         The Department shall send a notice of assessment to every hospital provider subject to an assessment under subsection (b), except that no notice shall be sent for the outpatient assessment imposed under subsection (b)(3) until the Department receives written notice that the payment methodologies to hospitals required under Section 5A-12.4 of the Code has been approved and the waiver under 42 CFR 433.68, if necessary, has been granted by CMMS.

2)         If a hospital provider conducts, operates, or maintains more than one hospital licensed by the Illinois Department of Public Health, a separate notice shall be sent for each hospital.

e)         Procedure for Partial Year Reporting/Operating Adjustments

1)         Cessation of business during the fiscal year in which the assessment is being paid.  If a hospital provider ceases to conduct, operate, or maintain a hospital for which the person is subject to assessment under subsection (b), the assessment for the State fiscal year in which the cessation occurs shall be adjusted by multiplying the assessment computed under subsection (d) by a fraction, the numerator of which is the number of days in the year during which the provider conducts, operates, or maintains the hospital and the denominator of which is 365.  Immediately upon ceasing to conduct, operate or maintain a hospital, the person shall pay the assessment for the year as adjusted (to the extent not previously paid).

2)         Commencing of business during the fiscal year in which the assessment is being paid.  A hospital provider who commences conducting, operating, or maintaining a hospital for which the person is subject to assessment under subsection (b), upon notice by the Department, shall pay the assessment under subsection (d) as computed by the Department in installments on the due dates stated on the notices and on the regular installment due dates for the State fiscal year occurring after the due date of the initial assessment notice. For State fiscal years 2009 through 2018, in the case of a hospital provider that did not conduct, operate or maintain a hospital in 2005, the inpatient assessment for that State fiscal year shall be computed on the basis of hypothetical occupied bed days for the full calendar year as determined by the Department.  For the portion of State fiscal year 2012 beginning June 10, 2012 through June 30, 2012, and for State fiscal years 2013 through 2018, in the case of a hospital provider that did not conduct, operate or maintain a hospital in 2009, the outpatient assessment imposed under subsection (b)(3) shall be computed on the basis of hypothetical gross outpatient revenue for the full calendar year as determined by the Department.  The assessment determination made by the Department is final.

3)         Partial Calendar Year Operation Adjustment.  For a hospital provider that did not conduct, operate, or maintain a hospital throughout the entire calendar year reporting period, the assessment for the State fiscal year shall be annualized for the portion of the reporting period the hospital was operational (dividing the assessment due by the number of days the hospital was in operation and then multiplying the amount by 365).  Information reported by a prior provider from the same hospital during the calendar year shall be used in the annualization equation, if available.

4)         Notwithstanding any other provision in this Section, for State fiscal years 2019 through calendar year 2022, in the case of a hospital provider that did not conduct, operate, or maintain a hospital in the year that is the basis of the calculation of the assessment under this Section, the assessment under subsection (b) for the State fiscal year shall be computed on the basis of hypothetical occupied bed days for the full calendar year as determined by the Illinois Department, except that for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020.

5)         Notwithstanding any other provision in this Section, for State fiscal years 2019 through calendar year 2022, in the case of a hospital provider that did not conduct, operate, or maintain a hospital in the year that is the basis of the calculation of the assessment under this Section, the assessment under subsection (b) for that State fiscal year shall be computed on the basis of hypothetical gross outpatient revenue for the full calendar year as determined by the Illinois Department, except that for a hospital provider that did not have a 2015 Medicare cost report, but paid an assessment in State fiscal year 2018 on the basis of hypothetical data, that assessment amount shall be used for State fiscal years 2019 and 2020.

6)         Change in Ownership and/or Operators.  The full quarterly installment must be paid on the designated due dates regardless of changes in ownership or operators.  Liability for the payment of the assessment amount (including past due assessments and any interest or penalties that may have accrued against the amount) rests on the hospital provider currently operating or maintaining the hospital regardless if these amounts were incurred by the current owner or were incurred by previous owners.  Collection of delinquent assessment fees from previous providers will be made against the current provider.  Failure of the current provider to pay any outstanding assessment liabilities incurred by previous providers shall result in the application of penalties described in subsection (f)(1).

f)         Penalties

1)         Any hospital that fails to pay the full amount of an installment when due shall be charged, unless waived by the Department for reasonable cause, a penalty equal to 5% of the amount of the installment not paid on or before the due date, plus 5% of the portion remaining unpaid on the last day of each monthly period thereafter, not to exceed 100% of the installment amount not paid on or before the due date. Waiver due to reasonable cause may include but is not limited to:

A)        provider has not been delinquent on payment of an assessment due, within the last three calendar years from the time the delinquency occurs.

B)        provider can demonstrate to the Department's satisfaction that a payment was made prior to the due date.

C)        provider is a new owner/operator and the late payment occurred in the quarter in which the new owner/operator assumed control of the facility.

2)         Within 30 days after the due date, the Department may begin recovery actions against delinquent hospitals participating in the Medicaid Program. Payments may be withheld from the hospital until the entire assessment, including any interest and penalties, is satisfied or until a reasonable repayment schedule has been approved by the Department.  If a reasonable agreement cannot be reached or if a hospital fails to comply with an agreement, the Department reserves the right to recover any outstanding provider assessment, interest and penalty by recouping the amount or a portion thereof from the hospital's future payments from the Department.  The provider may appeal this recoupment in accordance with the Department's rules at 89 Ill. Adm. Code 104.  The Department has the right to continue recoupment during the appeal process. Penalties pursuant to subsection (f)(1) will continue to accrue during the recoupment process.  Recoupment proceedings against the same hospital two times in a fiscal year may be cause for termination from the Medicaid Program.  Failure by the Department to initiate recoupment activities within 30 days shall not reduce the provider's liabilities nor shall it preclude the Department from taking action at a later date.

3)         If the hospital does not participate in the Medicaid Program, or is no longer doing business with the Department, or the Department cannot recover the full amount due through the claims processing system, within three months after the fee due date, the Department may begin legal action to recover the monies, including penalties and interest owed, plus court costs.

g)         Delayed Payment – Groups of Hospitals

The Department may establish delayed payment of assessments and/or waive the payment of interest and penalties for groups of hospitals such as disproportionate share hospitals or all other hospitals when:

1)         The State delays payments to hospitals due to problems related to State cash flow; or

2)         A cash flow bond pool's, or any other group financing plans', requests from providers for loans are in excess of its scheduled proceeds such that a significant number of hospitals will be unable to obtain a loan to pay the assessment.

h)         Delayed Payment – Individual Hospitals

In addition to the provisions of subsection (g), the Department may delay assessments for individual hospitals that are unable to make timely payments under this Section due to financial difficulties.  No delayed payment arrangements shall extend beyond the last business day of the calendar quarter following the quarter in which the assessment was to have been received by the Department as described in subsection (c). The request must be received by the Department prior to the due date of the assessment.

1)         Criteria.  Delayed payment provisions may be instituted only under extraordinary circumstances.  Delayed payment provisions may be made only to qualified hospitals who meet all of the following requirements:

A)        The provider has experienced an emergency that necessitates institution of delayed payment provisions.  Emergency in this instance is defined as a circumstance under which institution of the payment and penalty provisions described in subsections (c)(1), (c)(2), (f)(1) and (f)(2) would impose severe and irreparable harm to the clients served.  Circumstances that may create these emergencies include, but are not limited to, the following:

i)          Department system errors (either automated system or clerical) that have precluded payments, or that have caused erroneous payments such that the provider's ability to provide further services to clients is severely impaired;

ii)         Cash flow problems encountered by a provider that are unrelated to Department technical system problems and that result in extensive financial problems to a facility, adversely impacting on its ability to serve its clients.

B)        The provider serves a significant number of clients under the medical assistance program.  "Significant" in this instance means:

i)          A hospital that serves a significant number of clients under the medical assistance program; significant in this instance means that the hospital qualifies as a disproportionate share hospital (DSH) under 89 Ill. Adm. Code 148.120(a)(1) through 148.120(a)(2); or qualifies as a Medicare DSH hospital under the current federal guidelines.

ii)         A government-owned facility that meets the cash flow criterion under subsection (h)(1)(A)(ii).

iii)        A hospital that has filed for Chapter 11 bankruptcy and that meets the cash flow criterion under subsection (h)(1)(A)(ii).

C)        The provider must ensure that a delay of payment request, as defined under subsection (h)(3)(A), is received by the Department prior to the payment due date, and the request must include a Cash Position Statement that is based upon current assets, current liabilities and other data for a date that is less than 60 days prior to the date of filing.  Any liabilities payable to owners or related parties must not be reported as current liabilities on the Cash Position Statement.  A deferral of assessment payments will be denied if any of the following criteria are met:

i)          The ratio of current assets divided by current liabilities is greater than 2.0.

ii)         Cash, short term investments and long term investments equal or exceed the total of accrued wages payable and the assessment payment.  Long term investments that are unavailable for expenditure for current operations due to donor restrictions or contractual requirements will not be used in this calculation.

D)        The provider must show evidence of denial of an application to borrow assessment funds through a cash flow bond pool or financial institutions such as a commercial bank.  The denial must be 90 days old or less.

E)        The provider must sign an agreement with the Department that specifies the terms and conditions of the delayed payment provisions.  The agreement shall contain the following provisions:

i)          Specific reasons for institution of the delayed payment provisions;

ii)         Specific dates on which payments must be received and the amount of payment that must be received on each specific date described;

iii)        The interest or a statement of interest waiver as described in subsection (h)(5) that shall be due from the provider as a result of institution of the delayed payment provisions;

iv)        A certification stating that, should the entity be sold, the new owners will be made aware of the liability and any agreement selling the entity will include provisions that the new owners will assume responsibility for repaying the debt to the Department according to the original agreement;

v)         A certification stating that all information submitted to the Department in support of the delayed payment request is true and accurate to the best of the signator's knowledge; and

vi)        Other terms and conditions that may be required by the Department.

2)         A hospital that does not meet the above criteria may request a delayed payment schedule.  The Department may approve the request, notwithstanding the hospital not meeting the above criteria, upon a sufficient showing of financial difficulties and good cause by the hospital.  If the request for a delayed payment schedule is approved, all other conditions of this subsection (h) shall apply.

3)         Approval Process

A)        In order to receive consideration for delayed payment provisions, providers must ensure their request is received by the Department prior to the payment due date, in writing (telefax requests are acceptable) to the Bureau of Hospital and Provider Services.  The request must be received by the date designated by the Department.  Providers will be notified, in writing, as to the due dates for submitting delay of payment requests.  Requests must be complete and contain all required information before they are considered to have met the time requirements for filing a delayed payment request.  All telefax requests must be followed up with original written requests, postmarked no later than the date of the telefax.  The request must include:

i)          An explanation of the circumstances creating the need for the delayed payment provisions;

ii)         Supportive documentation to substantiate the emergency nature of the request including a cash position statement as defined in subsection (h)(1)(C), a denial of application to borrow the assessment as defined in subsection (h)(1)(D) and an explanation of the risk of irreparable harm to the clients; and

iii)        Specification of the specific arrangements requested by the provider.

B)        The hospital shall be notified by the Department, in writing prior to the assessment due date, of the Department's decision with regard to the request for institution of delayed payment provisions.  An agreement shall be issued to the provider for all approved requests.  The agreement must be signed by the administrator, owner, chief executive officer or other authorized representative and be received by the Department prior to the first scheduled payment date listed in that agreement.

4)         Waiver of Penalties.  The penalties described in subsections (f)(1) and (f)(2) may be waived upon approval of the provider's request for institution of delayed payment provisions.  In the event a provider's request for institution of delayed payment provisions is approved and the Department has received the signed agreement in accordance with subsection (h)(3)(B), the penalties shall be permanently waived for the subject quarter unless the provider fails to meet all of the terms and conditions of the agreement. In the event the provider fails to meet all of the terms and conditions of the agreement, the agreement shall be considered null and void and the penalties shall be fully reinstated.

5)         Interest.  The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate.  The applicable interest rate shall be identified in the agreement described in subsection (h)(1)(E). The interest may be waived by the Department if the facility's current ratio, as described in subsection (h)(1)(C), is 1.5 or less and the hospital meets the criteria in subsections (h)(1)(A) and (B).  Any waivers granted shall be expressly identified in the agreement described in subsection (h)(1)(E).

6)         Subsequent Delayed Payment Arrangements.  Once a provider has requested and received approval for delayed payment arrangements, the provider shall not receive approval for subsequent delayed payment arrangements until such time as the terms and conditions of any current delayed payment agreement have been satisfied or unless the provider is in full compliance with the terms of the current delayed payment agreement.  The waiver of penalties described in subsection (h)(4) shall not apply to a provider that has not satisfied the terms and conditions of any current delayed payment agreement.

i)          Administration and Enforcement Provisions

The Department shall establish and maintain a listing of all hospital providers appearing in the licensing records of the Department of Public Health, which shall show each provider's name and principal place of business and the name and address of each hospital operated, conducted, or maintained by the provider in this State. The listing shall also include the monthly assessment amounts owed for each hospital and any unpaid assessment liability greater than 90 days delinquent. The Department shall administer and enforce Sections 5A-1, 2, 3, 4, 5, 7, 8, 10, 12, 15, and 16 of the Code and collect the assessments and penalty assessments imposed under P.A. 101-0650 and Sections 5A-2 and 4 of the Code.  The Department, its Director, and every hospital provider subject to assessment measured by occupied bed days shall have the following powers, duties and rights:

1)         The Department may initiate either administrative or judicial proceedings, or both, to enforce the provisions of Sections 5A-1, 2, 3, 4, 5, 7, 8, 10, 12, 15 and 16 of the Code.  Administrative enforcement proceedings initiated shall be governed by the Department's rules at 89 Ill. Adm. Code 104.200 through 104.330.  Judicial enforcement proceedings initiated shall be governed by the rules of procedure applicable in the courts of this State.

2)         Any unpaid assessment under P.A. 101-0650 and Section 5A-2 of the Code shall become a lien upon the assets of the hospital upon which it was assessed.  If any hospital provider, outside the usual course of its business, sells or transfers the major part of any one or more of the real property and improvements, the machinery and equipment, or the furniture or fixtures of any hospital that is subject to the provisions of Sections 5A-1, 2, 3, 4, 5, 7, 8, 10, 12, 15 and 16 of the Code, the seller or transferor shall pay the Department the amount of any assessment, assessment penalty, and interest (if any) due from it under P.A. 101-0650 and Sections 5A-2 and 4 of the Code up to the date of the sale or transfer. The Illinois Department may, in its discretion, foreclose on such a lien, but shall do so in a manner that is consistent with Section 5e of the Retailers' Occupation Tax Act. Factors in consideration of whether to foreclose on a lien may include, but are not limited to, the amount of the unpaid lien, the likelihood of payment through alternative methods, the existence of liens with priority, the economic viability of the debtor, and the value of the property. If the seller or transferor fails to pay any assessment, assessment penalty, and interest (if any) due, the purchaser or transferee of the asset shall be liable for the amount of the assessment, penalties and interest (if any) up to the amount of the reasonable value of the property acquired by the purchaser or transferee.  The purchaser or transferee shall continue to be liable until the purchaser or transferee pays the full amount of the assessment, penalties, and interest (if any) up to the amount of the reasonable value of the property acquired by the purchaser or transferee or until the purchaser or transferee receives from the Department a certificate showing that the assessment, penalty and interest have been paid or a certificate from the Department showing that no assessment, penalty or interest is due from the seller or transferor under P.A. 101-0650 and Sections 5A-2, 4 and 5 of the Code.

3)         Payments under Section 5A-4 of the Code are not subject to the Illinois Prompt Payment Act [30 ILCS 540].  Credits or refunds shall not bear interest.

4)         In addition to any other remedy provided for and without sending a notice of assessment liability, the Department shall collect an unpaid assessment by withholding, as payment of the assessment, reimbursements or other amounts otherwise payable by the Department to the hospital provider, including, but not limited to, payment amounts otherwise payable from a managed care organization performing duties under contract with the Illinois Department.

A)        The requirements of this subsection may be waived in instances when a disaster proclamation has been declared by the Governor. In such circumstances, a hospital must demonstrate temporary financial distress and establish an agreement with the Illinois Department specifying when repayment in full of all taxes owed will occur.

B)        The requirements of this subsection may be waived by the Illinois Department in instances when a hospital has entered into and remains in compliance with are payment plan or a tax deferral plan. A repayment plan or tax deferral plan must be entered into no later than 30 days after notice of an unpaid assessment payment. No repayment plan may exceed a period of 36 months. No tax deferral plan may exceed a period of 6 months, and repayment after the end of a tax deferral plan shall not exceed 36 months. Failure to remain in compliance with are payment plan or tax deferral plan shall cause immediate termination of such plan unless there is prior written consent from the Illinois Department for a period of non-compliance.

C)        Beginning September 1, 2025, the Illinois Department shall immediately collect all overdue unpaid assessments and penalties through the collection methods authorized under this Section, unless a repayment plan or tax deferral plan has already been agreed to by September 1, 2025.

j)          Exemptions

The following classes of providers are exempt from the assessment imposed under Section 5A-4 of the Code unless the exemption is adjudged to be unconstitutional or otherwise invalid:

1)         A hospital provider that is a State agency, a State university, or a county with a population of 3,000,000 or more.

2)         A hospital provider that is a county with a population of less than 3,000,000 or a township, municipality, hospital district, or any other local governmental unit.

k)         Nothing in Section 5A-4 of the Code shall be construed to prevent the Department from collecting all amounts due under this Section pursuant to an assessment imposed before February 3, 2004.

l)          Definitions

As used in this Section, unless the context requires otherwise:

1)         "ACA Assessment Adjustment" means:

A)        For the period of July 1, 2016 through December 31, 2016, the product of .19125 multiplied by the sum of the fee-for-service payments to hospitals authorized under Section 5A-12.5 of the Code and the adjustments authorized under Section 5A-12.2(t) of the Code to managed care organizations for hospital services due and payable in the month of April 2016 multiplied by 6.

B)        For the period of January 1, 2017 through June 30, 2017, the product of .19125 multiplied by the sum of the fee-for-service payments to hospitals authorized under Section 5A-12.5 of the Code and the adjustments authorized under Section 5A-12.2(t) to managed care organizations for hospital services due and payable in the month of October 2016 multiplied by 6, except that the amount calculated under this subsection (l)(1)(B) shall be adjusted, either positively or negatively, to account for the difference between the actual payments issued under Code Section 5A-12.5 for the period beginning July 1, 2016 through December 31, 2016 and the estimated payments due and payable in the month of April 2016 multiplied by 6 as described in subsection (l)(1)(A).

C)        For the period of July 1, 2017 through December 31, 2017, the product of .19125 multiplied by the sum of the fee-for-service payments to hospitals authorized under Section 5A-12.5 of the Code and the adjustments authorized under Section 5A-12.2(t) of the Code to managed care organizations for hospital services due and payable in the month of April 2017 multiplied by 6, except that the amount calculated under this subsection (l)(1)(C) shall be adjusted, either positively or negatively, to account for the difference between the actual payments issued under Code Section 5A-12.5 for the period beginning January 1, 2017 through June 30, 2017 and the estimated payments due and payable in the month of October 2016 multiplied by 6 as described in subsection (l)(1)(B).

D)        For the period of January 1, 2018 through June 30, 2018, the product of .19125 multiplied by the sum of the fee-for-service payments to hospitals authorized under Section 5A-12.5 of the Code and the adjustments authorized under Section 5A-12.2(t) of the Code to managed care organizations for hospital services due and payable in the month of October 2017 multiplied by 6, except that:

i)          the amount calculated under this subsection (l)(1)(D) shall be adjusted, either positively or negatively, to account for the difference between the actual payments issued under Code Section 5A-12.5 for the period of July 1, 2017 through December 31, 2017 and the estimated payments due and payable in the month of April 2017 multiplied by 6 as described in subsection (l)(1)(C); and

ii)         the amount calculated under this subsection (l)(1)(D) shall be adjusted to include the product of .19125 multiplied by the sum of the fee-for-service payments, if any, estimated to be paid to hospitals under Section 5A-12.5(b) of the Code.

2)         "Assessment Adjustment" means, for the period of July 1, 2020 through December 31, 2020, the product of .3853 multiplied by the total of the actual payments made under Section 5A-12.7(c) through (k) of P.A. 101-0650 attributable to that period, less the total of the assessment imposed under subsections (b)(1) and (b)(3) of this Section for the period. For each calendar quarter beginning January 1, 2021 through December 31, 2022 the product of .3853 multiplied by the total of the actual payments made under Section 5A-12.7(c) through (k) of P.A. 101-0650 attributable to the period, less the total of the assessment imposed under subsections (b)(1) and (b)(3) of this Section for that period. Beginning on January 1, 2023, and each subsequent July 1 and January 1, the product of .3853 multiplied by the total of the actual payments made under subsections (c) through (j) and subsection (r) of Section 5A-12.7 attributable to the 6-month period immediately preceding the period to which the adjustment applies, less the total of the assessment imposed under subsections (a) and (b-5) of this Section for the 6-month period immediately preceding the period to which the adjustment applies.

3)         "CMMS" means the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.

4)         "Code" means the Illinois Public Aid Code [305 ILCS 5].

5)         "Department" means the Illinois Department of Healthcare and Family Services.

6)         "Fund" means the Hospital Provider Fund.

7)         "HCRIS" means the federal Centers for Medicare and Medicaid Services Healthcare Cost Report Information System.

8)         "Hospital" means an institution, place, building, or agency located in this State that is subject to licensure by the Illinois Department of Public Health under the Hospital Licensing Act, whether public or private and whether organized for profit or not-for-profit.

9)         "Hospital Provider" means a person licensed by the Department of Public Health to conduct, operate, or maintain a hospital, regardless of whether the person is a Medicaid provider.  For purposes of this definition, "person" means any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association or trust, or a receiver, executor, trustee, guardian, or other representative appointed by order of any court.

10)        "Inpatient Gross Revenue" means total inpatient gross revenue, as reported on the HCRIS Worksheet C, Part 1, Column 6, Line 101, less the sum of the following lines (including any subset lines of these lines):

A)        Line 34:  Skilled Nursing Facility.

B)        Line 35:  Other Nursing Facility.

C)        Line 35.01:  Intermediate Care Facility for the Mentally Retarded.

D)        Line 36:  Other Long Term Care.

E)        Line 45:  PBC Clinical Laboratory Services – Program Only.

F)         Line 60:  Clinic.

G)        Line 63:  Other Outpatient Services.

H)        Line 64:  Home Program Dialysis.

I)         Line 65:  Ambulance Services.

J)         Line 66:  Durable Medical Equipment – Rented.

K)        Line 67:  Durable Medical Equipment – Sold.

L)        Line 68:  Other Reimbursable.

11)        "Medicare Bed Days" means, for each hospital, the sum of the number of days that each bed was occupied by a patient who was covered by Title XVIII of the Social Security Act, excluding days attributable to the routine services provided to persons receiving skilled or intermediate long term care services. Medicare bed days shall be computed separately for each hospital operated or maintained by a hospital provider.

12)        "Medicare Gross Inpatient Revenue" means the sum of the following:

A)        The sum of the following lines from the HCRIS Worksheet D-4, Column 2 (excluding the Medicare gross revenue attributable to the routine services provided to patients in a psychiatric hospital, a rehabilitation hospital, a distinct part psychiatric unit, a distinct part rehabilitation unit or swing beds):

i)          Line 25:  Adults and Pediatrics.

ii)         Line 26:  Intensive Care Unit.

iii)        Line 27:  Coronary Care Unit.

iv)        Line 28:  Burn Intensive Care Unit.

v)         Line 29:  Surgical Intensive Care Unit.

vi)        Line 30:  Other Special Care Unit.

B)        From Worksheet D-4, Column 2, the amount from Line 103 less the sum of Lines 60, 63, 64, 66, 67 and 68 (and any subset lines of these lines).

C)        The amount from Worksheet D-6, Part 3, Column 3, Line 53.

13)        "Medicare Gross Outpatient Revenue" means the amount from the HCRIS Worksheet D, Part V, Line 101, Columns 5, 5.01, 5.02, 5.03 and 5.04 less the sum of Lines 45, 60, 63, 64, 65, 66 and 67 (and any subset lines of these lines).

14)        "Occupied Bed Days" means the sum of the number of days that each bed was occupied by a patient for all beds, excluding beds classified as long term care beds and assessed a licensed bed fee during calendar year 2001. Occupied bed days shall be computed separately for each hospital operated or maintained by a hospital provider.

15)        "Outpatient Gross Revenue" (prior to State fiscal year 2019 from Medicare 2552-96 cost reports) means, for each hospital, its total gross charges attributed to outpatient services as reported on the Medicare cost report at Worksheet C, Part I, Column 7, Line 101 less the sum of lines 45, 60, 63, 64, 65, 66, 67 and 68 (and any subset lines of these lines).

16)        "Outpatient Gross Revenue" (for State fiscal year 2019 and thereafter from Medicare 2552-10 cost reports) means, for each hospital, its total gross charges attributed to outpatient services as reported on the Medicare cost report at Worksheet C, Part I, Column 7, Line 200 less the sum of lines 61, 90, 94, 95, 96, 97, 99, 100, 101, 115, 116, and 117 (and any subset lines of these lines).

(Source:  Amended at 50 Ill. Reg. 5204, effective March 27, 2026)

Section 140.82  Developmentally Disabled Care Provider Fund

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.

b)         Provider Assessments

1)         Beginning on July 1, 1993, an assessment is imposed upon each developmentally disabled care provider in an amount equal to 6%, or the maximum allowed under federal regulation, whichever is less, of its adjusted gross developmentally disabled care revenue for the prior State fiscal year.  The revenue for each year will be reported on the Developmentally Disabled Care Provider Tax form to be filed by a date designated by the Department.  The Department reserves the right to audit the reported data. 

2)         Effective July 1, 2013, for the privilege of engaging in the occupation of long term care facility for persons under 22 years of age serving clinically complex residents provider, an assessment is imposed upon each long term care facility for persons under 22 years of age serving clinically complex residents in the same amount and upon the same conditions and requirements as imposed in Section 140.84 and a license fee is imposed in the same amount and upon the same conditions and requirements as imposed in Section 140.84.  Notwithstanding any provision of any other Act, the assessment and license fee imposed by this subsection (b)(2) shall be construed as a tax, but may not be added to the charges of an individual's nursing home care that is paid for in whole, or in part, by a federal, State, or combined federal-State medical care program, except for those individuals receiving Medicare Part B benefits solely.

c)         Payment of Assessment Due

1)         The assessment described in subsection (b) shall be due and payable in quarterly installments, each equaling one-fourth of the assessment for the year, on September 30, December 31, March 31, and May 31 of the year, modified to accommodate weekends and holidays.  Providers will be notified, in writing, of the due dates.  Assessment payments postmarked on the due date will be considered paid on time.

2)         All payments received by the Department shall be credited first to unpaid installment amounts (rather than to penalty or interest), beginning with the most delinquent installments.

d)         Reporting Requirements, Penalty, and Maintenance of Records

1)         After June 30 of each State fiscal year, and on or before September 30 of the succeeding State fiscal year, every developmentally disabled care provider subject to an assessment under subsection (b) shall file a report with the Department.  The report shall be on a form prepared by the Department.  The report shall include the adjusted gross developmentally disabled care revenue from the State fiscal year just ended and shall be utilized by the Department to calculate the assessment for the State fiscal year commencing on the preceding July 1.  If a developmentally disabled care provider operates or maintains more than one developmentally disabled care facility, a separate report shall be filed for each facility.  In the case of a developmentally disabled care provider existing as a corporation or legal entity other than an individual, the report filed by it shall be signed by its president, vice-president, secretary, or treasurer or by its properly authorized agent.

2)         If the developmentally disabled care provider fails to file its report for a State fiscal year on or before the due date of the report, there shall, unless waived by the Department for reasonable cause, be added to the assessment imposed in subsection (b) a penalty assessment equal to 25 percent of the assessment imposed for the year.

3)         Every developmentally disabled care provider subject to an assessment under subsection (b) shall keep records and books that will permit the determination of adjusted gross developmentally disabled care revenue on a State fiscal year basis.  All such books and records shall be maintained for a minimum of three years following the filing date of the assessment report and shall, at all times during business hours of the day, be subject to inspection by the Department or its duly authorized agents and employees.

4)         Amended Assessment Reports.  With the exception of amended assessment reports filed in accordance with subsections (d)(5) or (6), an amended assessment report must be filed within 30 calendar days after the original report due date.  The amended report must be accompanied by a letter identifying the changes and the justification for the amended report.  The provider will be advised of any adjustments to the original annual assessment amount through a written notification from the Department.  Penalties may be applied to the amount underpaid due to a filing error.

5)         Submission of Financial Audit Statements.  All developmentally disabled care providers are required to submit a copy of all financial statements audited by an external, independent auditor to the Department within 30 days after the close of the externally performed financial audits.  If the provider's year end does not coincide with the June 30 ending date for the assessment report, the provider must submit all financial audits covering the tax report period. An amended assessment report must accompany the external financial audit statements if the data submitted on the initial tax report changes based upon the findings of the external financial audits and as indicated in the audited external financial statements.  Penalties may be applied to the amount underpaid due to a filing error.

6)         Reconsideration of Adjusted Tax.  If the Department, through an audit conducted by the Department or its agent within three years after the end of the fiscal year in which the assessment was due, changes the assessment liability of a developmentally disabled care provider, the developmentally disabled care provider may request a review or reconsideration of the adjusted assessment within 30 days after the Department's notification of the change in assessment liability.  Requests for reconsideration of the assessment adjustment shall not be considered if those requests are not postmarked on or before the end of the 30 day review period.  Penalties may be applied to the amount underpaid due to a filing error.

e)         Procedure for Partial Year Reporting/Operating Adjustments

1)         Cessation of business during the fiscal year in which the assessment is being paid.  For a developmentally disabled care provider who ceases to conduct, operate, or maintain a facility for which the person is subject to assessment under subsection (b), the assessment for the State fiscal year in which the cessation occurs shall be adjusted by multiplying the assessment computed under subsection (d) by a fraction, the numerator of which is the number of months in the year during which the provider conducts, operates, or maintains the facility and the denominator of which is 12.  The person shall file a final, amended report with the Department not more than 30 calendar days after the cessation, reflecting the adjustment, and shall pay with the final report the assessment for the year as so adjusted, to the extent not previously paid.

2)         Commencing of business during the fiscal year in which the assessment is being paid.  A developmentally disabled care provider who commences conducting, operating, or maintaining a facility for which the person is subject to assessment under subsection (b) shall file an initial return for the State fiscal year in which the commencement occurs within 30 calendar days thereafter and shall pay the assessment under subsection (d) as computed by the Department in equal installments on the due date of the initial assessment determination and on the regular installment due dates for the State fiscal year occurring after the due date of the initial assessment determination.  In determining the annual assessment amount for the provider the Department shall develop hypothetical annualized revenue projections based upon geographic location, facility size and patient case mix.  The assessment determination made by the Department is final.

3)         Partial Fiscal Year Operation Adjustment.  For a developmentally disabled care provider that did not conduct, operate, or maintain a facility throughout the entire fiscal year reporting period, the assessment for the following State fiscal year shall be annualized based on the provider's actual developmentally disabled care revenue for the portion of the reporting period the facility was operational (dividing adjusted developmentally disabled care revenue by the number of months the facility was in operation and then multiplying that amount by 12).  Developmentally disabled care revenue realized by a prior provider from the same facility during the fiscal year shall be used in the annualization equation, if available.

4)         Change in Ownership and/or Operators.  The full quarterly assessment must be paid on the designated due dates regardless of changes in ownership or operators.  Liability for the payment of the assessment amount (including past due assessments and any interest or penalties that may have accrued against the amount) rests on the developmentally disabled care provider currently operating or maintaining the developmentally disabled care facility regardless if these amounts were incurred by the current owner or were incurred by previous owners.  Collection of delinquent assessment fees from previous providers will be made against the current provider.  Failure of the current provider to pay any outstanding assessment liabilities incurred by previous providers shall result in the application of penalties described in subsection (f)(1).

f)         Penalties

1)         Any facility that fails to pay the full amount of an installment when due shall be charged, unless waived by the Department for reasonable cause, a penalty equal to five percent of the amount of the installment not paid on or before the due date, plus five percent of the portion thereof remaining unpaid on the last day of each monthly period thereafter, not to exceed 100% of the installment amount not paid on or before the due date. Reasonable cause may include but is not limited to:

A)        a provider who has not been delinquent on payment of an assessment due within the last three calendar years from the time the delinquency occurs;

B)        a provider who can demonstrate to the Department's satisfaction that a payment was made prior to the due date; or

C)        that the provider is a new owner/operator and the late payment occurred in the quarter in which the new owner/operator assumed control of the facility.

2)         Within 30 days after the due date, the Department may begin recovery actions against delinquent facilities participating in the Medicaid Program. Payments may be withheld from the facility until the entire provider assessment, including any penalties, is satisfied, or until a reasonable repayment schedule has been approved by the Department.  If a reasonable agreement cannot be reached, or if the facility fails to comply with an agreement the Department reserves the right to recover any outstanding provider assessment, interest and penalty by recouping the amount or a portion thereof from the provider's future payments from the Department.  The provider may appeal this recoupment in accordance with the Department's rules at 89 Ill. Adm. Code 104.  The Department has the right to continue recoupment during the appeal process.  Penalties pursuant to subsection (f)(1) will continue to accrue during the recoupment process.  Recoupment proceedings against the same facility two times in a fiscal year may be cause for termination from the Program.  Failure by the Department to initiate recoupment activities within 30 days shall not reduce the provider's liabilities nor shall it preclude the Department from taking action at a later date.

3)         If the facility does not participate in the Medicaid Program, or is no longer doing business with the Department, or the Department cannot recover the full amount due through the claims processing system, within three months of the assessment due date, the Department may begin legal action to recover the monies, including penalties and interest owed, plus court costs.

g)         Delayed Payment – Groups of Facilities

The Department may establish delayed payment of assessments and/or waive the payment of interest and penalties for groups of facilities when:

1)         the State delays payments to facilities due to problems related to State cash flow; or

2)         a cash flow bond pool's or any other group financing plans' requests from providers for loans are in excess of its scheduled proceeds such that a significant number of facilities will be unable to obtain a loan to pay the assessment.

h)         Delayed Payment – Individual Facilities

In addition to the provisions of subsection (g), the Department may delay assessments for individual facilities that are unable to make timely payments under this Section due to financial difficulties.  No delayed payment arrangements shall extend beyond the last business day of the calendar quarter following the quarter in which the assessment was to have been received by the Department as described in subsection (c). The request must be received by the Department prior to the date of the assessment.

1)         Criteria.  Delayed payment provisions may be instituted only under extraordinary circumstances.  Delayed payment provisions shall be made only to qualified facilities who meet all of the following requirements:

A)        the facility has experienced an emergency which necessitates institution of delayed payment provisions.  Emergency in this instance is defined as a circumstance under which institution of the payment and penalty provisions described in subsections (c)(1), (c)(2), (f)(1), (f)(2) and (f)(3) would impose severe and irreparable harm to the clients served.  Circumstances that may create such emergencies include, but are not limited to, the following:

i)          Department system errors (either automated system or clerical) that have precluded payments, or that have caused erroneous payments such that the facility's ability to provide further services to clients is severely impaired;

ii)         cash flow problems encountered by a facility that are unrelated to Department technical system problems and that result in extensive financial problems to a facility adversely impacting on its ability to serve its clients.

B)        the facility serves a significant number of clients under the Medical Assistance Program.  Significant in this instance means:

i)          85 percent or more of their residents must be eligible for public assistance;

ii)         a government-owned facility, that meets the cash flow criteria under subsection (h)(1)(A)(ii).

iii)        a provider who has filed for Chapter 11 bankruptcy that meets the cash flow criterion under subsection (h)(1)(A)(ii).

C)        the facility must ensure that a delay of payment request, as defined in subsection (h)(3)(A), is received by the Department prior to the payment due date, and the request must include a Cash Position Statement that is based upon current assets, current liabilities and other data for a date that is less than 60 days prior to the date of filing.  Any liabilities payable to owners or related parties must not be reported as current liabilities on the Cash Position Statement.  A deferral of assessment payments will be denied if any of the following criteria are met:

i)          the ratio of current assets divided by current liabilities is greater than 2.0;

ii)         cash, short-term investments and long-term investments equal or exceed the total of accrued wages payable and the assessment payment.  Long-term investments that are unavailable for expenditure for current operations due to donor restrictions or contractual requirements will not be used in this calculation;

iii)        cash or other assets have been distributed during the previous 90 days to owners or related parties in an amount equal to or exceeding the assessment payment for dividends, salaries in excess of those allowable under Section 140.541 or payments for purchase of goods or services in excess of cost as defined in Section 140.537.

D)        the facility, with the exception of government owned facilities, must show evidence of denial of an application to borrow the assessment funds through a cash flow bond pool or financial institutions such as a commercial bank.  The denial must be 90 days old or less.

E)        the facility must sign an agreement with the Department that specifies the terms and conditions of the delayed payment provisions.  The agreement shall contain the following provisions:

i)          specific reasons for institution of the delayed payment provisions;

ii)         specific dates on which payments must be received and the amount of payment that must be received on each specific date described;

iii)        the interest or a statement of interest waiver as described in subsection (h)(5) that shall be due from the facility as a result of institution of the delayed payment provisions;

iv)        a certification stating that, should the entity be sold, the new owners will be made aware of the liability and any agreement selling the entity will include provisions that the new owners will assume responsibility for repaying the debt to the Department according to the original agreement;

v)         a certification stating that all information submitted to the Department in support of the delayed payment request is true and accurate to the best of the signator's knowledge; and

vi)        such other terms and conditions that may be required by the Department.

2)         A facility that does not meet the criteria listed in subsection (h)(1) may request a delayed payment schedule.  The Department may approve the request, notwithstanding the facility not meeting the above criteria, upon a sufficient showing of financial difficulties and good cause by the facility.  If the request for a delayed payment schedule is approved, all other conditions of this subsection (h) shall apply.

3)         Approval Process

A)        In order to receive consideration for delayed payment provisions, facilities must ensure that their request is received by the Department prior to the payment due date, in writing (telefax requests are acceptable) to the Bureau of Program and Reimbursement Analysis.  The request must be received by the due date designated by the Department.  Providers will be notified, in writing, of the due dates for submitting delay of payment requests. Requests must be complete and contain all required information before they are considered to have met the time requirements for filing a delayed payment request.  All telefax requests must be followed up with original written requests postmarked no later than the date of the telefax.  The request must include:

i)          an explanation of the circumstances creating the need for the delayed payment provisions;

ii)         supportive documentation to substantiate the emergency nature of the request and risk of irreparable harm to the clients; and

iii)        specification of the specific arrangements requested by the facility

B)        The facility shall be notified by the Department, in writing prior to the assessment due date, of the Department's decision with regard to the request for institution of delayed payment provisions.  An agreement shall be issued to the facility for all approved requests.  The agreement must be signed by the administrator, owner or other authorized representative and be received by the Department prior to the first scheduled payment date listed in such agreement.

4)         Waiver of Penalties.  The penalties described in subsections (f)(1) and (f)(2) may be waived upon approval of the facility's request for institution of delayed payment provisions.  In the event a facility's request for institution of delayed payment provisions is approved and the Department has received the signed agreement in accordance with subsection (h)(3)(B), the penalties shall be permanently waived for the subject quarter unless the facility fails to meet all of the terms and conditions of the agreement.  In the event the facility fails to meet all of the terms and conditions of the agreement, the agreement shall be considered null and void and the penalties shall be fully reinstated.

5)         Interest.  The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate.  The applicable interest rate shall be identified in the agreement described in subsection (h)(1)(E). The interest may be waived by the Department if the facility's current ratio, as described in subsection (h)(1)(C), is 1.5 or less and the facility meets the criteria in subsections (h)(1)(A) and (B).  Any such waivers granted shall be expressly identified in the agreement described in subsection (h)(1)(E).

6)         Subsequent Delayed Payment Arrangements.  Once a facility has requested and received approval for delayed payment arrangements, the facility shall not receive approval for subsequent delayed payment arrangements until the terms and conditions of any current delayed payment agreement have been satisfied or unless the provider is in full compliance with the terms of the current delay of payment agreement.  The waiver of penalties described in subsection (h)(4) shall not apply to a facility that has not satisfied the terms and conditions of any current delayed payment agreement.

i)          Administration and Enforcement Provisions

The Department shall administer and enforce Section 5C-6 of the Public Aid Code and collect the assessments, interest, and penalty assessments imposed under the law, using procedures employed in its administration of the Code generally and, as it deems appropriate, in a manner similar to that in which the Department of Revenue administers and collects the retailers' occupation tax under the Retailers' Occupation Tax Act ("ROTA").

j)          Nothing in Section 5C of the Code shall be construed to prevent the Department from collecting all amounts due under this Section pursuant to an assessment imposed before July 1, 1995.

k)         Definitions

1)         "Adjusted gross developmentally disabled care revenue" means the developmentally disabled care provider's total revenue for inpatient residential services, less contractual allowances and discounts on patients' accounts, but does not include non-patient revenue from sources such as contributions, donations or bequests, investments, day training services, television and telephone service, rental of facility space, or sheltered care revenue.  Adjusted gross developmentally disabled care revenue must be reported on an accrual basis for the tax reporting period.  All patient revenue accrued during the tax reporting period must be included even though reimbursement may occur after the tax reporting period.  Patient revenue must be reported on a basis that is consistent with methods used on the facility's last two cost reports.

2)         "Contractual Allowance" means the difference between charges at established rates and the amount estimated to be paid by third party payors or patients, as appropriate, pursuant to agreements/contracts with the developmentally disabled care provider; courtesy and policy discounts provided to employees, medical staff and clergy; and charity care, but "contractual allowance" does not mean any Provider Participation fees/taxes paid to the Department.

3)         "Department" means the Illinois Department of Healthcare and Family Services.

4)         "Developmentally disabled care facility" means an intermediate care facility for the mentally retarded within the meaning of Title XIX of the Social Security Act, whether public or private and whether organized for profit or not-for-profit, but shall not include any facility operated by the State.

5)         "Developmentally disabled care provider" means a person conducting, operating, or maintaining a developmentally disabled care facility.  For this purpose, "person" means any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association, or trust, or a receiver, executor, trustee, guardian or other representative appointed by order of any court.

6)         "Facility" means all intermediate care facilities as defined under "developmentally disabled care facility" (see subsection (k)(4)).

7)         "Fund" means the Developmentally Disabled Care Provider Fund.

8)         "Long term care facility for persons under 22 years of age serving clinically complex residents" means a facility licensed by the Department of Public Health as a long term care facility for persons under 22 meeting the qualifications of Section 5.4h of the Code.

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)

Section 140.84  Long Term Care Provider Fund

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].

b)         License Fee and Provider Assessment

1)         Beginning on July 1, 1993, and ending on June 30, 2022, a nursing home license fee is imposed upon each nursing home provider in an amount equal to $1.50 for each licensed nursing bed day for the calendar quarter in which the payment is due. All nursing beds subject to licensure under the Nursing Home Care Act or the Hospital Licensing Act, with the exception of swing-beds, as defined in subsection (k)(11) will be used to calculate the licensed nursing bed days for each quarter.  This license fee shall not be billed or passed on to any resident of a nursing home operated by the nursing home provider.  Changes in the number of licensed nursing beds will be reported to the Department quarterly, as described in subsection (d)(1). The Department reserves the right to audit the reported data.

2)         Beginning July 1, 2011 and ending on June 30, 2022, an assessment is imposed upon each long term care provider in an amount equal to $6.07 times the number of occupied bed days due and payable each month.  This assessment shall be construed as a tax, but shall not be billed or passed on to any resident of a nursing home operated by the nursing home provider.

3)         Beginning July 1, 2022, an assessment is imposed upon each long-term care provider in an amount varying with the number of paid Medicaid resident days per annum in the facility with the following schedule of occupied bed tax amounts. This assessment is due and payable each month and shall be construed as a tax but shall not be billed or passed on to any resident of a nursing home operated by the nursing home provider.

A)        The tax shall follow the schedule below and be rebased by the Department on an annual basis.

i)          0-5,000 paid Medicaid resident days per annum, $10.67.

ii)         5,001-15,000 paid Medicaid resident days per annum, $19.20.

iii)        15,001-35,000 paid Medicaid resident days per annum, $22.40.

iv)        35,001-55,000 paid Medicaid resident days per annum, $19.20.

v)         55,001-65,000 paid Medicaid resident days per annum, $13.86.

vi)        65,001+ paid Medicaid resident days per annum, $10.67.

vii)       Any non-profit nursing facilities without Medicaid-certified beds, $7 per occupied bed day.

B)        The Department shall publish each facility's rebased tax rate according to the schedule in this subsection 30 days prior to the beginning of the 6-month period beginning July 1, 2022 and thereafter 30 days prior to the beginning of each calendar year which shall incorporate the number of paid Medicaid days used to determine each facility's rebased tax rate.  The notice shall include the number of paid Medicaid days broken down by days paid by each Managed Care Organization, Fee for Service, and each contracted MMAI plan.  The notice shall also specify the dates of service used for the determination and the date on which the data was queried.  

C)        For each new calendar year and for the 6-month period beginning July 1, 2022, a facility's paid Medicaid resident days per annum shall be determined using the Department's Medicaid Management Information System to include Medicaid resident days for the year ending 9 months earlier. The Department will query the MMIS to make this determination as late as is reasonably possible subject to the publication deadline in subsection (b)(3)(B) and will adjust the number of paid Medicaid resident days per annum, if necessary, using the Department’s nursing home provider tax database to more accurately distinguish Medicare and Medicaid payment.  The number of paid Medicaid days shall also include hospice days and provisional days, if applicable.

4)         Appeals of Tax Rate Determinations

A)        Appeals of tax rate determinations shall be submitted in writing to the Department.  Appeals received within 30 days after tax rate notification shall, if upheld, be made effective as of the beginning of the tax year.  The effective date of all upheld appeals filed after the initial 30-day period shall be the first day of the month after the date the complete appeal was received.  Payments shall be made based on the Department's determination pending the results of the appeal.

B)        Appeals of tax rate determinations under this Section shall be submitted in writing to the Chief, Bureau of Long Term Care.  The Department shall rule on all appeals within 120 days after the date of appeal, except that if the Department requires additional information from the facility the period shall be extended until such time as the information is provided.  Appeals for any tax year must be filed before the close of the first quarter of the tax year.  Amounts owed as a result of an upheld appeal shall be applied as a credit towards future taxes owed and payable.

c)         Payment of License Fee and Assessment Due

1)         The license fee described in subsection (b) shall be due and payable in quarterly installments, on September 10, December 10, March 10, and June 10 of the year, modified to accommodate weekends and holidays.  Providers will be notified, in writing, of the quarterly due dates.  License fee payments postmarked on the due date will be considered as paid on time.

2)         The assessment described in subsection (b) shall be due and payable monthly, on the last State business day of the month for occupied bed days reported for the preceding third month prior to the month in which the tax is payable and due.  A facility that has its payments from the State delayed, due to problems related to State cash flow, may request an extension on the due date for payment pursuant to subsection (b) and shall pay each extended assessment payment within 30 days after each reimbursement for services by the Department.

A)        The Department shall provide for an electronic submission process for each long term care facility to report the number of occupied bed days of the long term care facility for the reporting period and other reasonable information the Department requires for the administration of its responsibilities. To the extent practicable, the Department shall coordinate the assessment reporting requirements with other reporting required of long term care facilities.

B)        Beginning July 1, 2013, a separate electronic submission shall be completed for each long term care facility in this State operated by a long term care provider.  The Department shall prepare an assessment, based on the reported occupied beds, and will bill the facility stating the amount due and payable each month and submit it to each long term care facility via an electronic process.  Each assessment payment shall be accompanied by a copy of the assessment bill sent to the long term care facility by the Department.

C)        The provider assessment imposed by this Section shall not be due and payable until after the Department notifies the long term care providers, in writing, that the payment methodologies to long term care providers required under Section 5-5.4 of the Public Aid Code have been approved and the waivers under 42 CFR 433.68, if necessary, have been granted by CMMS.

3)         All payments received by the Department shall be credited first to unpaid installment amounts (rather than to penalty or interest), beginning with the most delinquent installments.

4)         County nursing homes directed and maintained pursuant to Section 5-1005 of the Counties Code [55 ILCS 5] may meet their license fee or assessment obligation by the county government certifying to the Department that county expenditures have been obligated for the operation of the county nursing home in an amount at least equal to the amount of the license fee or assessment.  County governments wishing to provide such certification must:

A)        Sign a certification form certifying that the funds represent expenditures eligible for federal financial participation under Title XIX of the Social Security Act (42 U.S.C. 1396), and that these funds are not federal funds, or are federal funds authorized by federal law to be used to match other federal funds;

B)        Submit the certification document to the Department once a year along with a copy of that portion of the county budget showing the funds appropriated for the operation of the county nursing home.  These documents must be submitted within 30 days after the final approval of the county budget;

C)        Submit the monthly claim form in the amount of the rate established by the Department minus any third party liability amount.  This amount will be reduced by an amount determined by the amount certified and the number of months remaining in the fiscal year, prior to payment because a certification statement was provided in lieu of an actual license fee or assessment payment; and

D)        Make records available upon request to the Department and/or the United States Department of Health and Human Services pertaining to the certification of county funds.

d)         Reporting Requirements, Penalty, and Maintenance of Records

1)         On or before the due dates described in subsection (c)(1), each nursing home provider subject to a license fee under subsection (b) shall file a report with the Department reflecting any changes in the number of licensed nursing beds occurring during the reporting quarter. The report shall be on a form prepared by the Department.  The changes will be reported quarterly and shall be submitted with the revised quarterly license fee payment.  For the purpose of calculating the license fee described in subsection (b), all changes in licensed nursing beds will be effective upon approval of the change by the Illinois Department of Public Health.  Documentation showing the change in licensed nursing beds, and the date the change was approved by the Illinois Department of Public Health, must be submitted to the Department of Healthcare and Family Services with the licensed nursing bed change form. 

2)         After December 31 of each year, and on or before March 31 of the succeeding year, every long term care provider subject to assessment under subsection (c)(2) shall file a report with the Department.  The report shall be in a form and manner prescribed by the Department and shall state the revenue received by the long term care provider, reported in such categories as may be required by the Department, and other reasonable information the Department requires for the administration of its responsibilities.

3)         If a provider operates or maintains more than one nursing home, a separate report shall be filed for each facility.  In the case of a provider existing as a corporation or legal entity other than an individual, the report filed by it shall be signed by its president, vice president, secretary or treasurer or by its properly authorized agent.

4)         If the provider fails to file its report for a State fiscal year on or before the due date of the report, there shall, unless waived by the Department for reasonable cause, be added to the license fee or assessment imposed in subsection (b) a penalty fee equal to 25% of the assessment or license fee imposed for the year.  After July 1, 2013, no penalty will be assessed if the Department has not established a process for the electronic submission of information as it pertains to the assessment.

5)         Every provider subject to a license fee or assessment under subsection (b) shall keep records and books that will permit the determination of licensed nursing bed days on a quarterly basis and occupied beds on a monthly basis.  All such books and records shall be maintained for a minimum of three years following the filing date of each report and shall, at all times during business hours of the day, be subject to inspection by the Department or its duly authorized agents and employees.

6)         Amended License Fee and Assessment Reports.  With the exception of amended license fee or assessment reports filed in accordance with this subsection (d)(6), an amended license fee report or monthly assessment report must be filed within 30 calendar days after the original report due date.  The amended report must be accompanied by a letter identifying the changes and the justification for the amended report.  The provider will be advised of any adjustments to the original annual license fee or assessment amount through a written notification from the Department.  Penalties may be applied to the amount underpaid due to a filing error.

7)         Reconsideration of Adjusted License Fee or Assessment.  If the Department, through an audit conducted by the Department or its agent within three years after the end of the fiscal year in which the license fee or assessment was due, changes the license fee or assessment liability of a provider, the provider may request a review or reconsideration of the adjusted license fee or assessment within 30 days after the Department's notification of the change in license fee or assessment liability. Requests for reconsideration of the license fee or assessment adjustment shall not be considered if those requests are not postmarked on or before the end of the 30 day review period.  Penalties may be applied to the amount underpaid due to a filing error.

8)         Effective January 1, 2023, all providers operating or maintaining a long-term care facility shall notify the Department of all individual owners and any individuals or organizations that are part of a limited liability company with ownership of that facility, and the percentage ownership of each owner.  This ownership reporting requirement does not include individual shareholders in a publicly held corporation.  Submission of the information as part of the Department's cost reporting requirements shall satisfy this request.

e)         Procedure for Partial Year Reporting/Operating Adjustments

1)         Cessation of business during the period in which the license fee or assessment is being paid and the closure date has been set.  A provider who ceases to conduct, operate, or maintain a facility for which the person is subject to the license fee or assessment imposed under subsection (b) of this Section, and for which the closure date for the facility has been set, shall file a final report with the Department on or before the due date for the period in which the closure is to occur. The report will reflect the adjusted number of days the facility is open during the reporting period and shall be submitted with the final quarterly license fee or monthly assessment payment. Example: A facility is set to close on September 24.  On or before the due date for the reporting quarter of July 1 through September 30, the facility will submit a final report reflecting 86 days of operation (July 1 through September 24) and the corresponding quarterly license fee payment.

2)         Cessation of business after the monthly or quarterly due date.  A provider who ceases to conduct, operate, or maintain a facility for which the person is subject to the license fee or assessment imposed under subsection (b), and for which closure occurs after the due date for the reporting period, but prior to the last day of the reporting period, shall file an amended final report with the Department within 30 days after the closure date.  The amended report will reflect the number of days the facility was operational during the reporting period and the revised license fee or assessment amount.  Upon verifying the data submitted on the amended report, the Department will issue a refund for the amount overpaid.  Example: On December 10 a facility pays the license fee for 92 days covering the reporting quarter of October 1 through December 31.  The facility closes on December 27.  An amended report reflecting 88 days, the actual number of days the facility was operational during the quarter (October 1 through December 27) must be filed with the Department.

3)         Cessation of business prior to the monthly or quarterly due date.  A provider who ceases to conduct, operate, or maintain a facility for which the person is subject to the license fee or assessment imposed under subsection (b), and for which closure occurs prior to the due date for the reporting period, shall file a final report with the Department within 30 days after the closure date. The final report will reflect the number of days the facility was operational during the reporting period and the corresponding final license fee and assessment amount.  Closure dates will be verified with the Department of Public Health, and if necessary adjustments will be made to the final license fee and assessment due. Example:  Facility closes on January 17.  On or before February 17, the facility must file a final report for the reporting quarter of January 1 through March 31.  The report would reflect 17 days of operation (January 1 through January 17) during the quarter and must be accompanied by the final license fee payment for the facility.

4)         Commencing of business during the fiscal year in which the license fee or assessment is being paid.  A provider who commences conducting, operating, or maintaining a facility for which the person is subject to the license fee or assessment imposed under subsection (b) shall file an initial report for the reporting period in which the commencement occurs within 30 calendar days thereafter and shall pay the license fee and assessment under subsection (c).  In determining the annual assessment amount for the provider, the Department shall develop hypothetical annualized occupied bed projections based upon geographic location and facility.  The assessment determination made by the Department is final.

5)         Change in Ownership and/or Operators.  The full monthly/quarterly assessment/license fee must be paid on the designated due dates regardless of changes in ownership or operators.  Liability for the payment of the assessment/license fee amount (including past due assessment/license fees and any interest or penalties that may have accrued against the amount) rests on the provider currently operating or maintaining the nursing facility regardless if these amounts were incurred by the current owner or were incurred by previous owners.  Collection of delinquent assessment/license fees from previous providers will be made against the current provider.  Failure of the current provider to pay any outstanding assessment/license fee liabilities incurred by previous providers shall result in the application of penalties described in subsection (f)(1).

6)         Upon request, the Department will share with a potential buyer of a facility information on outstanding assessments and penalties owed by that facility.

f)         Penalties

1)         Any provider that fails to pay the full amount of a license fee or assessment when due, or fails to report a change in licensed nursing beds approved by the Department of Public Health prior to the due date of the license fee or assessment, shall be charged, unless waived by the Department for reasonable cause, a penalty equal to five percent of the amount of the license fee or assessment not paid on or before the due date, plus five percent of the portion thereof remaining unpaid on the last day of each monthly period thereafter, not to exceed 100% of the installment or assessment amount not paid on or before the due date. Reasonable cause may include but is not limited to:

A)        a provider who has not been delinquent on payment of a license fee or assessment due, within the last three calendar years from the time the delinquency occurs;

B)        a provider who can demonstrate to the Department's satisfaction that a payment was made prior to the due date; or

C)        that the provider is a new owner/operator and the late payment occurred in the reporting period in which the new owner/operator assumed control of the facility.

2)         Within 30 days after the due date, the Department may begin recovery actions against delinquent providers participating in the Medicaid Program.  Payments may be withheld from the provider until the entire license fee or assessment, including any penalties, is satisfied or until a reasonable repayment schedule has been approved by the Department.  If a reasonable agreement cannot be reached, or if a provider fails to comply with an agreement, the Department reserves the right to recover any outstanding license fee, assessment, interest and penalty by recouping the amount or a portion thereof from the provider's future payments from the Department.  The provider may appeal this recoupment in accordance with the Department's rules at 89 Ill. Adm. Code 104.  The Department has the right to continue recoupment during the appeal process. Penalties pursuant to subsection (f)(1) will continue to accrue during the recoupment process.  Recoupment proceedings against the same provider two times in a fiscal year may be cause for termination from the Program.  Failure by the Department to initiate recoupment activities within 30 days shall not reduce the provider's liabilities nor shall it preclude the Department from taking action at a later date.

3)         If the provider does not participate in the Medicaid Program, or is no longer doing business with the Department, or the Department cannot recover the full amount due through the claims processing system, within three months after the license fee or assessment due date, the Department may begin legal action to recover the monies, including penalties and interest owed, plus court costs.

g)         Delayed Payment – Groups of Facilities

The Department may establish delayed payment of fees/assessment and/or waive the payment of interest and penalties for groups of facilities when:

1)         the State delays payments to facilities due to problems related to State cash flow; or

2)         a cash flow bond pool's or any other group financing plans' requests from providers for loans are in excess of its scheduled proceeds such that a significant number of facilities will be unable to obtain a loan to pay the license fee.

h)         Delayed Payment – Individual Facilities

In addition to the provisions of subsection (g), the Department may delay license fees or assessments for individual facilities that are unable to make timely payments under this Section due to financial difficulties.  No delayed payment arrangements shall extend beyond the last business day of the calendar period or month following the quarter in which the license fee or the assessment payment was to have been received by the Department as described in subsection (c). The Department may not deny a request for delay of payment of the assessment imposed in subsection (b) if the provider has not been paid due to problems related to State cash flow for services provided during the month in which the assessment is levied.  The request must be received by the Department prior to the due date of the assessment.

1)         Criteria.  Delayed payment provisions may be instituted only under extraordinary circumstances.  Delayed payment provisions shall be made only to qualified facilities who meet all of the following requirements:

A)        the facility has experienced an emergency that necessitates institution of delayed payment provisions.  Emergency in this instance is defined as a circumstance under which institution of the payment and penalty provisions described in subsections (c)(1), (c)(2), (f)(1), (f)(2) and (f)(3) would impose severe and irreparable harm to the clients served.  Circumstances which may create such emergencies include, but are not limited to, the following:

i)          Department system errors (either automated system or clerical) that have precluded payments, or that have caused erroneous payments such that the facility's ability to provide further services to clients is severely impaired;

ii)         cash flow problems encountered by a facility that are unrelated to Department technical system problems and which result in extensive financial problems to a facility adversely impacting on its ability to serve its clients.

B)        the facility serves a significant number of clients under the Medical Assistance Program.  Significant in this instance means:

i)          85% or more of their residents must be eligible for public assistance;

ii)         a government-owned facility that meets the cash flow criterion under subsection (h)(1)(A)(ii);

iii)        a provider who has filed for Chapter 11 bankruptcy, which meets cash flow criterion under subsection (h)(1)(A)(ii).

C)        the facility must ensure that a delay of payment request, as defined under subsection (h)(3)(A), is received by the Department and the request must include a Cash Position Statement that is based upon current assets, current liabilities and other data for a date which is less than 60 days prior to the date of filing.  Any liabilities payable to owners or related parties must not be reported as current liabilities on the Cash Position Statement.  A deferral of license fee or assessment payments will be denied if any of the following criteria are met:

i)          the ratio of current assets divided by current liabilities is greater than 2.0;

ii)         cash, short term investments and long term investments equal or exceed the total of accrued wages payable and the license fee payment.  Long term investments that are unavailable for expenditure for current operations due to donor restrictions or contractual requirements will not be used in this calculation;

iii)        cash or other assets has been distributed during the previous 90 days to owners or related parties in an amount equal to or exceeding the license fee or assessment payment for dividends, salaries in excess of those allowable under Section 140.541 or payments for purchase of goods or services in excess of cost as defined in Section 140.537.

D)        the facility, with the exception of government owned facilities, must show evidence of denial of an application to borrow license fee or assessment funds through a cash flow bond pool or financial institutions such as a commercial bank.  The denial must be 90 days old or less.

E)        the facility must sign an agreement with the Department that specifies the terms and conditions of the delayed payment provisions.  The agreement shall contain the following provisions:

i)          specific reasons for institution of the delayed payment provisions;

ii)         specific dates on which payments must be received and the amount of payment that must be received on each specific date described;

iii)        the interest or a statement of interest waiver as described in subsection (h)(5) that shall be due from the facility as a result of institution of the delayed payment provisions;

iv)        a certification stating that, should the entity be sold, the new owners will be made aware of the liability and any agreement selling the entity will include provisions that the new owners will assume responsibility for repaying the debt to the Department according to the original agreement;

v)         a certification stating that all information submitted to the Department in support of the delayed payment request is true and accurate to the best of the signator's knowledge; and

vi)        other terms and conditions that may be required by the Department.

2)         A facility that does not meet the criteria in subsection (h)(1) may request a delayed payment schedule, prior to the due date.  The Department may approve the request, notwithstanding the facility not meeting the above criteria, upon a sufficient showing of financial difficulties and good cause by the facility.  If the request for a delayed payment schedule is approved, all other conditions of this subsection (h) shall apply.

3)         Approval Process

A)        In order to receive consideration for delayed payment provisions, facilities must ensure their request is received by the Department prior to the payment due date, in writing (telefax requests are acceptable) to the Bureau of Rate Development and Analysis.  The request must be received by the due date designated by the Department.  Providers will be notified, in writing, of the due dates for submitting delay of payment requests.  Requests must be complete and contain all required information before they are considered to have met the time requirements for filing a delayed payment request.  All telefax requests must be followed up with original written requests, postmarked no later than the date of the telefax.  The request must include:

i)          an explanation of the circumstances creating the need for the delayed payment provisions;

ii)         supportive documentation to substantiate the emergency nature of the request including a cash position statement as defined in subsection (h)(1)(C); a denial of application to borrow the license fee or assessment as defined in subsection (h)(1)(D) and an explanation of the risk of irreparable harm to the clients; and

iii)        specification of the specific arrangements requested by the facility.

B)        The facility shall be notified by the Department, in writing prior to the license fee or assessment due date, of the Department's decision with regard to the request for institution of delayed payment provisions.  An agreement shall be issued to the facility for all approved requests.  The agreement must be signed by the administrator, owner or other authorized representative and be received by the Department prior to the first scheduled payment date listed in such agreement.

4)         Waiver of Penalties.  The penalties described in subsections (f)(1) and (f)(2) may be waived upon approval of the facility's request for institution of delayed payment provisions.  In the event a facility's request for institution of delayed payment provisions is approved and the Department has received the signed agreement in accordance with subsection (h)(3)(B), the penalties shall be permanently waived for the subject quarter or month as it pertains to assessment, unless the facility fails to meet all of the terms and conditions of the agreement.  In the event the facility fails to meet all of the terms and conditions of the agreement, the agreement shall be considered null and void and such penalties shall be fully reinstated.

5)         Interest.  The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate.  The applicable interest rate shall be identified in the agreement described in subsection (h)(1)(E). The interest may be waived by the Department if the facility's current ratio, as described in subsection (h)(1)(C), is 1.5 or less and the facility meets the criteria in subsections (h)(1)(A) and (B).  Any such waivers granted shall be expressly identified in the agreement described in subsection (h)(1)(E).

6)         Subsequent Delayed Payment Arrangements.  Once a facility has requested and received approval for delayed payment arrangements, the facility shall not receive approval for subsequent delayed payment arrangements until such time as the terms and conditions of any current delayed payment agreement have been satisfied or unless the provider is in full compliance with the terms of the current delay of payment agreement.  The waiver of penalties described in subsection (h)(4) shall not apply to a facility that has not satisfied the terms and conditions of any current delayed payment agreement.

i)          Administration and Enforcement Provisions

The Department shall administer and enforce Section 5B-7 of the Code, and collect the license fees, assessments, interest, and penalty fees imposed under the law, using procedures employed in its administration of this Code generally and, as it deems appropriate, in a manner similar to that in which the Department of Revenue administers and collects the retailers' occupation tax under ROTA.

j)          Nothing in Section 5B of the Code shall be construed to prevent the Department from collecting all amounts due under this Section pursuant to an assessment imposed before July 1, 1995.

k)         Definitions

As used in this Section, unless the context requires otherwise:

1)         "Department" means the Illinois Department of Healthcare and Family Services.

2)         "Fund" means the Long Term Care Provider Fund.

3)         "Hospital provider" means a person licensed by the Department of Public Health to conduct, operate, or maintain a hospital, regardless of whether the person is a Medicaid provider.  For purposes of this definition, "person" means any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association, or trust, or a receiver, executor, trustee, guardian, or other representative appointed by order of any court.

4)         "Licensed nursing bed days" means, with respect to a nursing home provider, the sum for all nursing beds, with the exception of swing-beds, as described in subsection (k)(11), of the number of days during a calendar quarter on which each bed is covered by a license issued to that provider under the Nursing Home Care Act [210 ILCS 45] or the Hospital Licensing Act [210 ILCS 85].

5)         "Long term care facility" means a nursing facility, whether public or private and whether organized for profit or not-for-profit, that is subject to licensure by the Illinois Department of Public Health under the Nursing Home Care Act or the ID/DD Community Care Act [210 ILCS 47], including a county nursing home directed and maintained under Section 5-1005 of the Counties Code, and a part of a hospital in which skilled or intermediate long term care services within the meaning of Title XVIII or XIX of the Social Security Act are provided; except that the term "long term care facility" does not include a facility operated by a State agency or operated solely as an intermediate care facility for the developmentally disabled within the meaning of Title XIX of the Social Security Act.

6)         "Long term care provider" means a person licensed by the Department of Public Health to operate and maintain a skilled nursing or intermediate long term care facility or a hospital provider that provides skilled or intermediate long term care services within the meaning of Title XVII or XIX of the Social Security Act.  For purposes of this definition, "person" means any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association, or trust, or a receiver, executor, trustee, guardian, or other representative appointed by order of any court.

7)         "Nursing home" means a skilled nursing or intermediate long term care facility, whether public or private and whether organized for profit or not-for-profit, that is subject to licensure by the Illinois Department of Public Health under the Nursing Home Care Act, including a county nursing home directed and maintained under Section 5-1005 of the Counties Code; and a part of a hospital in which skilled or intermediate long-term care services within the meaning of Title XVIII or XIX of the Social Security Act are provided.  However, the term "nursing home" does not include a facility operated solely as an intermediate care facility for the mentally retarded within the meaning on Title XIX of the Social Security Act.

8)         "Nursing home provider" means a person licensed by the Department of Public Health to operate and maintain a skilled nursing or intermediate long term care facility which charges its residents, a third party payor, Medicaid, of Medicare for skilled nursing or intermediate long term care services; or a hospital provider that provides skilled or intermediate long term care services within the meaning of Title XVIII or XIX of the Social Security Act.

9)         "Occupied bed days" shall be computed separately for each long term care facility operated or maintained by a long term care provider, and means the sum, for all beds, of the number of days during the month on which each bed was occupied by a resident, other than a resident for whom Medicare Part A is primary payer. For a resident whose care is covered by the Medicare-Medicaid Alignment Initiative demonstration, Medicare Part A is considered the primary payer to the extent Medicare would have been the primary payer in the absence of the demonstration.

10)        "Person" means, in addition to natural persons, any political subdivision of the State, municipal corporation, individual, firm, partnership, corporation, company, limited liability company, association, joint stock association, or trust, or a receiver, executor, trustee, guardian, or other representative appointed by order of any court.

11)        "Swing-beds" means those beds for which a hospital provider has been granted an approval from the federal Centers for Medicare and Medicaid Services to provide post-hospital extended care services (42 CFR 409.30, October 1, 1991) and be reimbursed as a swing-bed hospital (42 CFR 413.114, October 1, 1991).

(Source:  Amended at 46 Ill. Reg. 19641, effective November 28, 2022)

Section 140.86  Supportive Living Facility Fund

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.

b)         Provider Assessment

Beginning on July 1, 2014, an annual assessment is imposed upon each supportive living facility in an amount equal to $2.30 for each supportive living facility's care days.  This assessment shall not be billed or passed on to any resident of a supportive living facility.

c)         Payment of Assessment and Assessment Due

1)         The assessment described in subsection (b) of this Section shall be due and payable monthly, on the last State business day of the month for care days reported for the preceding third month prior to the month in which the assessment is payable and due.  A facility that has its payments from the State delayed, due to problems related to State cash flow, may request an extension on the due date for payment pursuant to subsection (c) and shall pay the assessment within 30 days after reimbursement by the Department.

A)        The Department shall provide for an electronic submission process for each supportive living facility to report at a minimum the number of care days of the supportive living facility for the reporting period and other reasonable information the Department requires for the administration of its responsibilities. To the extent practicable, the Department shall coordinate the assessment reporting requirements with other reporting required of supportive living facilities.

B)        The Department shall prepare an assessment, based on the reported care days, and will bill the facility stating the amount due and payable each month and submit it to each supportive living facility via an electronic process.  Each assessment payment shall be accompanied by a copy of the assessment bill sent to the supportive living facility by the Department.

C)        The provider assessment imposed by this Section shall not be due and payable until after the Department notifies the supportive living facilities, in writing, that the payment methodologies to supportive living facilities required under Section 5-5.01a of the Public Aid Code have been approved and the waivers under 42 CFR 433.68, if necessary, have been granted by CMMS.

D)        The provider assessment imposed by this Section shall cease to be imposed if the amount of matching federal funds under Title XIX of the Social Security Act is eliminated or significantly reduced on account of the assessment.  Any remaining assessments shall be refunded to supportive living facilities in proportion to the amounts of the assessments paid by them.

3)         All payments received by the Department shall be credited first to unpaid assessment payment amounts (rather than to penalty or interest), beginning with the most delinquent assessment payments.

d)         Reporting Requirements, Penalty, and Maintenance of Records

1)         Every supportive living facility subject to the assessment described in subsection (b) shall report the number of care days of the supportive living facility for the reporting period on or before the last business day of the month following the reporting period.  Each supportive living facility shall ensure that an accurate e-mail address is on file with the Department in order for the Department to prepare and send an electronic bill to the supportive living facility.

2)         If a provider operates or maintains more than one supportive living facility, a separate report shall be filed for each facility.  In the case of a provider existing as a corporation or legal entity other than an individual, the report filed by it shall be signed by its president, vice president, secretary or treasurer or by its properly authorized agent.

3)         If the provider fails to file its monthly report on or before the due date of the report, there shall, unless waived by the Department for reasonable cause, be added to the assessment imposed in subsection (b) a penalty fee equal to 25% of the assessment due.

4)         Every provider subject to a license fee or assessment under subsection (b) shall keep records and books that will permit the determination of care days on a calendar year basis. All such books and records shall be kept in the English language and shall, at all times during business hours, be subject to inspection by the Department or its duly authorized agents and employees.

5)         Amended Assessment Reports.  With the exception of amended assessment reports filed in accordance with this subsection (d)(5), an amended monthly assessment report must be filed within 30 calendar days after the original report due date.  The amended report must be accompanied by a letter identifying the changes and the justification for the amended report.  The provider will be advised of any adjustments to the original assessment amount through a written notification from the Department.  Penalties may be applied to the amount underpaid due to a filing error.

6)         Reconsideration of Adjusted Assessment.  If the Department, through an audit conducted by the Department or its agent within three years after the end of the fiscal year in which the assessment was due, changes the assessment liability of a provider, the provider may request a review or reconsideration of the adjusted assessment within 30 days after the Department's notification of the change in assessment liability. Requests for reconsideration of the assessment adjustment shall not be considered if those requests are not postmarked on or before the end of the 30 day review period.  Penalties may be applied to the amount underpaid due to a filing error.

e)         Procedure for Partial Year Reporting/Operating Adjustments

1)         Cessation of Business Prior to the Monthly Due Date.  A provider who ceases to conduct, operate, or maintain a facility for which the provider is subject to the assessment imposed under subsection (b), and for which closure occurs prior to the due date for the assessment period, shall file a final report with the Department within 30 days after the closure date. The final report will reflect the number of days the facility was operational during the assessment period and the corresponding final assessment amount.  Closure dates will be verified with the Department of Public Health and, if necessary, adjustments will be made to the final assessment due. (Example:  Facility closes on January 17.  On or before February 17, the facility must file a final report for the reporting month of January 1 through January 31.  The report would reflect 17 days of operation (January 1 through January 17) during the month and must be accompanied by the final assessment payment for the facility.)

2)         Commencing of Business During the Month in Which the Assessment is Being Paid.  A provider who commences conducting, operating, or maintaining a facility for which the person is subject to the assessment imposed under subsection (b) shall file an initial report for the assessment period in which the commencement occurs within 30 calendar days after commencement and shall pay the assessment under subsection (c).

3)         Change in Ownership and/or Operators.  The full monthly assessment must be paid on the designated due dates regardless of changes in ownership or operators.  Liability for the payment of the assessment amount (including past due assessment and any interest or penalties that may have accrued against the amount) rests on the provider currently operating or maintaining the nursing facility regardless of whether these amounts were incurred by the current owner or were incurred by previous owners.  Collection of delinquent assessment/license fees from previous providers will be made against the current provider.  Failure of the current provider to pay any outstanding assessment/license fee liabilities incurred by previous providers shall result in the application of penalties described in subsection (f)(1).

4)         Upon request, the Department will share with a potential buyer of a facility information on outstanding assessments and penalties owed by that facility.

f)         Penalties

1)         Any provider that fails to pay the full amount of an assessment payment when due shall be charged, unless waived by the Department for reasonable cause, a penalty equal to one percent of the amount of the assessment payment not paid on or before the due date, plus one percent of the portion thereof remaining unpaid on the last day of each monthly period thereafter, not to exceed 100% of the assessment amount not paid on or before the due date. Reasonable cause may include but is not limited to:

A)        a provider who has not been delinquent on payment of an assessment payment due within the last three calendar years from the time the delinquency occurs;

B)        a provider who can demonstrate to the Department's satisfaction that a payment was made prior to the due date; or

C)        that the provider is a new owner/operator and the late payment occurred in the assessment period in which the new owner/operator assumed control of the facility.

2)         Within 30 days after the due date, the Department may begin recovery actions against delinquent providers participating in the Medicaid Program.  Payments may be withheld from the provider until the entire assessment, including any penalties, is satisfied or until a reasonable repayment schedule has been approved by the Department.  If a reasonable agreement cannot be reached, or if a provider fails to comply with an agreement, the Department reserves the right to recover any outstanding assessment, interest and penalty by recouping the amount or a portion thereof from the provider's future payments from the Department.  The provider may appeal this recoupment in accordance with the Department's rules at 89 Ill. Adm. Code 104.  The Department has the right to continue recoupment during the appeal process. Penalties pursuant to subsection (f)(1) will continue to accrue during the recoupment process.  Recoupment proceedings against the same provider two times in a fiscal year may be cause for termination from the program.  Failure by the Department to initiate recoupment activities within 30 days shall not reduce the provider's liabilities nor shall it preclude the Department from taking action at a later date.

3)         If the provider does not participate in the Medicaid Program, or is no longer doing business with the Department, or the Department cannot recover the full amount due through the claims processing system within three months after the license fee or assessment due date, the Department may initiate either administrative or judicial proceedings, or both, to enforce provisions of this Section. Administrative enforcement proceedings initiated under this subsection (f)(3) shall be governed by the Department's administrative rules. Judicial enforcement proceedings initiated under this subsection (f)(3) shall be governed by the rules of procedure applicable to the courts of this State.

4)         No proceedings for collection, refund, credit, or other adjustment of an assessment amount shall be issued more than three years after the due date of the assessment, except in the case of an extended period agreed to in writing by the Department and the supportive living facility before the expiration of this limitation period.

5)         Any unpaid assessment and/or penalties shall become a lien upon the assets of the supportive living facility upon which it was assessed. If any supportive living facility, outside the usual course of its business, sells or transfers the major part of any one or more of the real property and improvements, the machinery and equipment, or the furniture or fixtures of any supportive living facility that is subject to the provisions of this Section, the seller or transferor shall pay the Department the amount of any assessment, penalty and interest (if any) due from it under this Section up to the date of the sale or transfer. If the seller or transferor fails to pay any assessment, penalty and interest (if any) due, the purchaser or transferee of the asset shall be liable for the amount of the assessment, penalty and interest (if any) up to the amount of the reasonable value of the property acquired by the purchaser or transferee. The purchaser or transferee shall continue to be liable until the purchaser or transferee pays the full amount of the assessment, penalty, and interest (if any) up to the amount of the reasonable value of the property acquired by the purchaser or transferee or until the purchaser or transferee receives from the Department a certificate showing that the assessment, penalty, and interest have been paid or a certificate from the Department showing that no assessment, penalty, or interest is due from the seller or transferor under this Section. 

g)         Delayed Payment – Groups of Facilities

The Department may establish delayed payment of assessment and/or waive the payment of interest and penalties for groups of facilities when:

1)         the State delays payments to facilities due to problems related to State cash flow; or

2)         a cash flow bond pool's or any other group financing plans' requests from providers for loans are in excess of its scheduled proceeds such that a significant number of facilities will be unable to obtain a loan to pay the assessment.

h)         Delayed Payment – Individual Facilities

In addition to the provisions of subsection (g), the Department may delay assessments for individual facilities that are unable to make timely payments under this Section due to financial difficulties.  No delayed payment arrangements shall extend beyond the last business day of the month following the month the assessment payment was to have been received by the Department as described in subsection (c). The Department may not deny a request for delay of payment of the assessment imposed in subsection (b) if the provider has not been paid due to problems related to State cash flow for services provided during the month in which the assessment is levied.  The request must be received by the Department prior to the due date of the assessment.

1)         Criteria.  Delayed payment provisions may be instituted only under extraordinary circumstances.  Delayed payment provisions shall be made only to qualified facilities who meet all of the following requirements:

A)        The facility has experienced an emergency that necessitates institution of delayed payment provisions.  Emergency, in this instance, is defined as a circumstance under which institution of the payment and penalty provisions described in subsections (c)(1), (c)(2), (f)(1), (f)(2) and (f)(3) would impose severe and irreparable harm to the clients served.  Circumstances that may create these emergencies include, but are not limited to, the following:

i)          Department system errors (either automated system or clerical) that have precluded payments or that have caused erroneous payments such that the facility's ability to provide further services to clients is severely impaired;

ii)         cash flow problems encountered by a facility that are unrelated to Department technical system problems and that result in extensive financial problems for a facility, adversely impacting its ability to serve its clients.

B)        The facility serves a significant number of clients under the Medical Assistance Program.  Significant, in this instance, means:

i)          85% or more of the facility's residents are eligible for public assistance;

ii)         The facility is a government-owned facility that meets the cash flow criterion of subsection (h)(1)(A)(ii);

iii)        The facility is a provider who has filed for Chapter 11 bankruptcy, which meets the cash flow criterion of subsection (h)(1)(A)(ii).

C)        The facility must ensure that a delay of payment request, as defined under subsection (h)(3)(A), is received by the Department and the request must include a cash position statement that is based upon current assets, current liabilities and other data for a date that is less than 60 days prior to the date of filing.  Any liabilities payable to owners or related parties must not be reported as current liabilities on the Cash Position Statement.  A deferral of license fee or assessment payments will be denied if any of the following criteria are met:

i)          the ratio of current assets divided by current liabilities is greater than 2.0;

ii)         cash, short term investments and long term investments equal or exceed the total of accrued wages payable and the license fee payment.  Long term investments that are unavailable for expenditure for current operations due to donor restrictions or contractual requirements will not be used in this calculation;

iii)        cash or other assets have been distributed during the previous 90 days to owners or related parties in an amount equal to or exceeding the license fee or assessment payment for dividends, salaries in excess of those allowable under Section 140.541 or payments for purchase of goods or services in excess of cost as defined in Section 140.537.

D)        The facility, with the exception of government-owned facilities, must show evidence of denial of an application to borrow assessment funds through a cash flow bond pool or financial institution such as a commercial bank.  The denial must be 90 days old or less.

E)        The facility must sign an agreement with the Department that specifies the terms and conditions of the delayed payment provisions.  The agreement shall contain the following provisions:

i)          specific reasons for institution of the delayed payment provisions;

ii)         specific dates on which payments must be received and the amount of payment that must be received on each specific date described;

iii)        the interest or a statement of interest waiver as described in subsection (h)(5) that shall be due from the facility as a result of institution of the delayed payment provisions;

iv)        a certification stating that, should the entity be sold, the new owners will be made aware of the liability and any agreement selling the entity will include provisions that the new owners will assume responsibility for repaying the debt to the Department according to the original agreement;

v)         a certification stating that all information submitted to the Department in support of the delayed payment request is true and accurate to the best of the signator's knowledge; and

vi)        such other terms and conditions that may be required by the Department.

2)         A facility that does not meet the criteria of subsection (h)(1) may request, prior to the due date, a delayed payment schedule.  The Department may approve the request, notwithstanding the facility not meeting these criteria, upon a sufficient showing of financial difficulties and good cause by the facility.  If the request for a delayed payment schedule is approved, all other conditions of this subsection (h) shall apply.

3)         Approval Process

A)        In order to receive consideration for delayed payment, facilities must ensure their request is received by the Department prior to the payment due date, in writing (telefax requests are acceptable) to the Bureau of Hospital and Provider Services.  The request must be received by the due date designated by the Department.  Providers will be notified, in writing, of the due date for submitting delay of payment requests.  Requests must be complete and contain all required information before they are considered to have met the time requirements for filing a delayed payment request.  All telefax requests must be followed up with original written requests, postmarked no later than the date of the telefax.  The request must include:

i)          an explanation of the circumstances creating the need for the delayed payment provisions;

ii)         supportive documentation to substantiate the emergency nature of the request, including a cash position statement as defined in subsection (h)(1)(C), a denial of application to borrow the license fee or assessment as defined in subsection (h)(1)(D), and an explanation of the risk of irreparable harm to the clients; and

iii)        specification of the specific arrangements requested by the facility.

B)        The facility shall be notified by the Department, in writing prior to the assessment due date, of the Department's decision with regard to the request for institution of delayed payment provisions.  An agreement shall be issued to the facility for all approved requests.  The agreement must be signed by the administrator, owner or other authorized representative and be received by the Department prior to the first scheduled payment date listed in the agreement.

4)         Waiver of Penalties.  The penalties described in subsections (f)(1) and (f)(2) may be waived upon approval of the facility's request for institution of delayed payment provisions.  In the event a facility's request for institution of delayed payment provisions is approved and the Department has received the signed agreement in accordance with subsection (h)(3)(B), the penalties shall be permanently waived for the subject month as it pertains to assessment, unless the facility fails to meet all of the terms and conditions of the agreement.  In the event the facility fails to meet all of the terms and conditions of the agreement, the agreement shall be considered null and void and penalties shall be fully reinstated.

5)         Interest.  The delayed payments shall include interest at a rate not to exceed the State of Illinois borrowing rate.  The applicable interest rate shall be identified in the agreement described in subsection (h)(1)(E). The interest may be waived by the Department if the facility's current ratio, as described in subsection (h)(1)(C), is 1.5 or less and the facility meets the criteria in subsections (h)(1)(A) and (B).  Any waivers granted shall be expressly identified in the agreement.

6)         Subsequent Delayed Payment Arrangements.  Once a facility has requested and received approval for delayed payment arrangements, the facility shall not receive approval for subsequent delayed payment arrangements until the terms and conditions of any current delayed payment agreement have been satisfied or unless the provider is in full compliance with the terms of the current delay of payment agreement.  The waiver of penalties described in subsection (h)(4) shall not apply to a facility that has not satisfied the terms and conditions of any current delayed payment agreement.

i)          Administration and Enforcement Provisions

The Department shall administer and enforce Section 5G-5 of the Code and collect the assessments, interest, and penalty fees imposed under the law, using procedures employed in its administration of the Code generally and, as it deems appropriate, in a manner similar to that in which the Department of Revenue administers and collects the retailers' occupation tax under the Retailers' Occupation Tax Act (ROTA).

j)          Certification Fee

The Department shall collect an annual certification fee of $100 per each operational or approved supportive living facility for the purposes of funding the administrative process of reviewing new supportive living facility applications and administrative oversight of the health care services delivered by supportive living facilities. The certification fee imposed by this subsection shall cease to be imposed if the amount of matching federal funds under Title XIX of the Social Security Act is eliminated or significantly reduced on account of the certification fee.

k)         Definitions

As used in this Section, unless the context requires otherwise:

1)         "Department" means the Illinois Department of Healthcare and Family Services.

2)         "Fund" means the Supportive Living Facility Fund.

3)         "Supportive Living Facility" means an enrolled supportive living site as described Section 5-5.01a of the Code that meets the participation requirements under 89 Ill. Adm. Code 146.215.

4)         "Care Days" means, with respect to a supportive living facility, the sum for all apartment units, the number of days during the month in which each apartment unit was occupied by a resident.

(Source:  Added at 38 Ill. Reg. 23623, effective December 2, 2014)

Section 140.88  Managed Care Organization Provider Assessment

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.

b)         For State Fiscal Years 2020 through 2021, there is imposed upon MCO member months an assessment, calculated on base year data, as follows, for the appropriate tier:

1)         Tier 1 − $61.70 per member month;

2)         Tier 2 − $1.20 per member month; and

3)         Tier 3 − $2.40 per member month.

c)         For State Fiscal Year 2022, there is imposed upon MCO member months an assessment, calculated on base year data, as follows, for the appropriate tier:

1)         Tier 1 − $69.40 per member month;

2)         Tier 2 − $1.20 per member month; and

3)         Tier 3 − $2.40 per member month.

d)         For State Fiscal Year 2023, there is imposed upon MCO member months an assessment, calculated on base year data, as follows, for the appropriate tier:

1)         Tier 1 − $74.40 per member month;

2)         Tier 2 − $1.20 per member month; and

3)         Tier 3 − $2.40 per member month.

e)         For State Fiscal Year 2024, there is imposed upon MCO member months an assessment, calculated on base year data, as follows, for the appropriate tier:

1)         Tier 1 − $78.90 per member month;

2)         Tier 2 − $1.40 per member month; and

3)         Tier 3 − $2.40 per member month.

f)         The Department may adjust rates or tier parameters or both in order to maximize the revenue generated by the assessment consistent with federal regulations and to meet federal statistical tests necessary for federal financial participation. Any upward adjustment to the Tier 3 rate shall be the minimum necessary to meet federal statistical tests. [305 ILCS 5/5H-3(c)] The Department shall publish the tax tier rates for the prospective fiscal year via the Department's Provider Notice website at https://hfs.illinois.gov/medicalproviders/notices.html.

g)         The tiers are established as follows:

1)         Tier 1 includes the first 4,195,000 member months in a Medicaid MCO for the base year;

2)         Tier 2 includes member months over 4,195,000 in a Medicaid MCO during the base year; and

3)         Tier 3 includes member months during the base year in an MCO that is not a Medicaid MCO.

h)         The assessment payable for State FY 2020 shall be prorated and due and payable in monthly installments, each equaling one-eighth of the assessment for the year, on the first State business day of each month beginning November 1, 2019. The assessment payable for State FY 2021 and thereafter shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the first State business day of each month.

i)          The Department, in accordance with 305 ILCS 5/5H-4(c), shall notify each MCO of its annual assessment and the installment due dates at least 30 days prior to the start of each fiscal year.

j)          Proceeds from the assessment levied shall be deposited into the Fund, except for those proceeds upon a county provider as defined in 305 ILCS 5/15-1 , which shall be deposited directly into the County Provider Trust Fund [305 ILCS 5/5H-4].

k)         In the event of a merger, acquisition or any similar transaction involving entities subject to the assessment under this Section, the resultant entity shall be responsible for the full amount of the assessment for all entities involved in the transaction, with the member months allotted to tiers as they were prior to the transaction, and no member months shall change tiers as a result of any transaction.  An MCO that ceases doing business in the State during any fiscal year shall be liable only for the monthly installments due in months that it operated in the State.

l)          An MCO that is liable for the assessment under this Section shall keep accurate and complete records and pertinent documents as may be required by the Department, including but not limited to records of:  member months, premium revenue, and plans that provide coverage to individuals who are eligible for Medicare, Medicaid or a federal employee health benefits program.  Records required by the Department shall be retained for a period of 4 years after the assessment imposed under this Act to which the records apply is due, or as otherwise provided by law.  The Department or the Department of Insurance may audit all records necessary to ensure compliance with this Section and make adjustments to assessment amounts previously calculated based on the results of any such audit.

m)        If an MCO fails to make a payment due under this Section in a timely fashion, it shall pay an additional penalty of 5% of the amount of the installment not paid on or before the due date, or any grace period granted, plus 5% of the portion remaining unpaid on the last day of each 30-day period thereafter.  The Department is authorized to grant grace periods of up to 30 days upon request of an MCO for good cause due to financial or other difficulties, as determined by the Department.  If an MCO fails to make a payment within 60 days after the due date, the Department shall additionally impose a contractual sanction allowed against a Medicaid MCO and may terminate any such contract.

n)         For an MCO which is first doing business in the State after 2018, the base year data on which the MCO will be assessed shall be the first year in which the data was available to the Department to calculate the assessment.

(Source:  Amended at 49 Ill. Reg. 8201, effective May 27, 2025)

Section 140.94  Medicaid Developmentally Disabled Provider Participation Fee Trust Fund/Medicaid Long Term Care Provider Participation Fee Trust Fund (Repealed)

(Source:  Repealed at 42 Ill. Reg. 14383, effective July 23, 2018)

Section 140.95  Hospital Services Trust Fund (Repealed)

(Source:  Repealed at 42 Ill. Reg. 14383, effective July 23, 2018)

Section 140.96  General Requirements (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.30 at 13 Ill. Reg. 9497)

Section 140.97  Special Requirements (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.40 at 13 Ill. Reg. 9497)

Section 140.98  Covered Hospital Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.50 at 13 Ill. Reg. 9497)

Section 140.99  Hospital Services Not Covered (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.60 at 13 Ill. Reg. 9497)

Section 140.100  Limitation On Hospital Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.70 at 13 Ill. Reg. 9497)

Section 140.101  Transplants (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.80 at 13 Ill. Reg. 9497)

Section 140.102  Heart Transplants (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.90 at 13 Ill. Reg. 9497)

Section 140.103  Liver Transplants (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.100 at 13 Ill. Reg. 9497)

Section 140.104  Bone Marrow Transplants (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.110 at 13 Ill. Reg. 9497)

Section 140.110  Disproportionate Share Hospital Adjustments (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.120 at 13 Ill. Reg. 12118)

Section 140.116  Payment for Inpatient Services for GA (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.130 at 13 Ill. Reg. 9497)

Section 140.117  Hospital Outpatient and Clinic Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.140 at 13 Ill. Reg. 9497)

Section 140.200  Payment for Hospital Services During Fiscal Year 1982 (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.150 at 13 Ill. Reg. 9497)

Section 140.201  Payment for Hospital Services After June 30, 1982 (Repealed)

(Source:  Repealed at 9 Ill. Reg. 9564, effective June 5, 1985)

Section 140.202  Payment for Hospital Services During Fiscal Year 1983 (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.160 at 13 Ill. Reg. 9497)

Section 140.203  Limits on Length of Stay by Diagnosis (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.170 at 13 Ill. Reg. 9497)

Section 140.300  Payment for Pre-operative Days and Services Which Can Be Performed in an Outpatient Setting (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.180 at 13 Ill. Reg. 9497)

Section 140.350  Copayments (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.190 at 13 Ill. Reg. 9497)

Section 140.360  Payment Methodology (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.200 at 13 Ill. Reg. 9497)

Section 140.361  Non-Participating Hospitals (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.210 at 13 Ill. Reg. 9497)

Section 140.362  Pre July 1, 1989 Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.220 at 13 Ill. Reg. 9497)

Section 140.363  Post June 30, 1989 Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.230 at 13 Ill. Reg. 9497)

Section 140.364  Prepayment Review (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.240 at 13 Ill. Reg. 9497)

Section 140.365  Base Year Costs (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.250 at 13 Ill. Reg. 9497)

Section 140.366  Restructuring Adjustment (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.260 at 13 Ill. Reg. 9497)

Section 140.367  Inflation Adjustment (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.270 at 13 Ill. Reg. 9497)

Section 140.368  Volume Adjustment (Repealed)

(Source:  Peremptory repealer at 8 Ill. Reg. 18151, effective September 18, 1984)

Section 140.369  Groupings (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.280 at 13 Ill. Reg. 9497)

Section 140.370  Rate Calculation (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.290 at 13 Ill. Reg. 9497)

Section 140.371  Payment (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.300 at 13 Ill. Reg. 9497)

Section 140.372  Review Procedure (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.310 at 13 Ill. Reg. 9497)

Section 140.373  Utilization (Repealed)

(Source:  Repealed at 13 Ill. Reg. 3351, effective March 6, 1989)

Section 140.374  Alternatives (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.320 at 13 Ill. Reg. 9497)

Section 140.375  Exemptions (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.330 at 13 Ill. Reg. 9497)

Section 140.376  Utilization, Case-Mix and Discretionary Funds (Repealed)

(Source:  Repealed at 13 Ill. Reg. 3351, effective March 6, 1989)

Section 140.390  Subacute Alcoholism and Substance Abuse Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.340 at 13 Ill. Reg. 9497)

Section 140.391  Definitions (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.350 at 13 Ill. Reg. 9497)

Section 140.392  Types of Subacute Alcoholism and Substance Abuse Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.360 at 13 Ill. Reg. 9497)

Section 140.394  Payment for Subacute Alcoholism and Substance Abuse Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.370 at 13 Ill. Reg. 9497)

Section 140.396  Rate Appeals for Subacute Alcoholism and Substance Abuse Services (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.380 at 13 Ill. Reg. 9497)

Section 140.398  Hearings (Recodified)

(Source:  Recodified to 89 Ill. Adm. Code 148.390 at 13 Ill. Reg. 9497)

Section 140.400  Payment to Practitioners

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.

b)         Practitioners who meet the qualifications for and enter into a Primary Care Provider Agreement for participation in the Maternal and Child Health Program, as described in Subpart G, will receive enhanced reimbursement in accordance with Section 140.930(a)(1).

c)         For services rendered on or after June 1, 2013, a practitioner (radiologist) that meets the qualifications for and participates in the Department's Breast Cancer Quality Screening and Treatment Initiative shall be paid for mammography services at the effective Chicago Metropolitan Area Medicare Level established rate (Established Rate).  To qualify for this Established Rate, a practitioner shall:

1)         Enter into a Supplemental Provider Agreement with the Department; and

2)         Provide mammography services to participants in the Department's Medical Programs with the same timeliness as the practitioner provides to patients with other forms of insurance;

3)         Within 30 days after submitting the Supplemental Provider Agreement, and annually thereafter on or before August 31, submit a completed radiologist survey, using the Department's survey form; and

4)         Assist the Department with the development and implementation of improved quality standards and services.

d)         The Department will distribute (initially and upon revision of the amounts) to practitioners the maximum allowable amounts for the most commonly billed procedures codes.  Interested individuals may request a copy of the maximum allowable amounts from the Department by directing the request to the Bureau of Professional and Ancillary Services, Prescott E. Bloom Building, 201 South Grand Avenue East, Springfield, Illinois 62763-0001.  In addition, a participating individual practitioner may request the maximum allowable amounts for less commonly billed specific procedures that relate to the individual's practice.  This request must be in writing and identify specific procedure codes and associated descriptions.

e)         Supplemental payments to universities for certain practitioner services

1)         Supplemental payments are available for services that are provided by practitioners who are employed by an Illinois public university and are providing services eligible for payment under Titles XIX and XXI of the Social Security Act.

A)        For dates of service on or after September 1, 2020, supplemental payment will be made on a quarterly basis as described in this subsection (e).

B)        Supplemental payments under this subsection (e) are subject to federal approval.

C)        Supplemental payments shall be funded through cooperative agreements between the Department and the State university.

2)         Definitions

A)        "Average Commercial Rate" means the average contractually defined payment amount paid to the university for practitioner services, including patient share amounts, for each CPT code.  This average shall be based on the participating university's payments from the five largest private insurance carriers for CPT services.

B)        "Average Commercial Payment Ceiling" means the following computation:

i)          Multiplying the Average Commercial Rate by the number of paid claims provided in a quarter and paid to the university for clients eligible under Titles XIX and XXI of the Social Security Act.

ii)         Summing the products for all procedure codes as described in subsection (e)(2)(B)(i).

3)         The supplemental payments shall be determined as follows:

A)        The supplemental payment to the university shall equal the current period payment ceiling at the Medicare Equivalent of the Average Commercial Rate less all payments otherwise made by the Department for the same services for procedure codes rendered in the current period and paid to the university.  These supplemental payments shall be based on all available payments and adjustments on file with the Department at the time the payment amount is determined.

B)        The sum of payments made for each qualifying CPT service shall not exceed the Average Commercial Rate Ceiling.

4)         Periodic Updates to the Base Period Medicare Equivalent of the Average Commercial Rate:  The Department shall update the Average Commercial Rate annually, using the most recent data available.

f)         The Department will make payment to a provider for services provided by a substitute physician when the substitute physician is performing the duties of a qualified attending physician, and all of the following conditions are met:

1)         The attending physician is ill, on vacation, or otherwise unavailable because of an emergency situation;

2)         The substitute physician is a Doctor of Medicine (M.D.) or Osteopathy (D.O.) who holds a license to practice medicine in all its branches;

3)         The substitute practitioner is not terminated, suspended, barred or otherwise excluded from participation or has not voluntarily withdrawn from the Medical Assistance Program as part of a settlement agreement; and

4)         The substitution does not exceed 14 days for a single incident and up to a maximum of 90 days per year for the attending physician. If the substitute period extends beyond the 14 days per single incident, the substitute physician must enroll with the Department.

(Source:  Amended at 47 Ill. Reg. 16385, effective November 3, 2023)

Section 140.402  Copayments for Non-institutional Medical Services

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).

b)         In each instance in which a copayment is payable, the Department will reduce the amount payable to the affected provider by the respective amount of the required copayment.

c)         No provider of services listed in subsection (a) may deny service to an individual who is eligible for service on account of the individual's inability to pay the cost of a copayment.

d)         The following individuals receiving medical assistance are exempt from the copayment requirement set forth in subsection (a):

1)         Pregnant women, including a postpartum period of 60 days.

2)         Children under 19 years of age.

3)         All non-institutionalized individuals whose care is subsidized by the Department of Children and Family Services or the Department of Corrections.

4)         Hospice patients.

5)         Individuals residing in hospitals, nursing facilities, and intermediate care facilities for the developmentally disabled who, as a condition of receiving services, are required to pay all of their income, except an authorized protected amount for personal use, for the cost of their care.  For the purpose of this subsection (d)(5), the protected amount shall be no greater than the protected amount authorized for personal use under 89 Ill. Adm. Code 146.225(c).

6)         Residents of a State-certified, State-licensed, or State-contracted residential care program where residents, as a condition of receiving care in that program, are required to pay all of their income, except an authorized protected amount for personal use, for the cost of their residential care program. For the purpose of this subsection (d)(6), the protected amount shall be no greater than the protected amount authorized for personal use under 89 Ill. Adm. Code 146.225(c).

7)         Individuals enrolled in the "Health Benefits for Person with Breast or Cervical Cancer" program under 89 Ill. Adm. Code 120.500.

8)         American Indians or Alaskan Natives.

e)         The following medical services are exempt from any copayments:

1)         Renal dialysis treatment.

2)         Radiation therapy.

3)         Cancer chemotherapy.

4)         Insulin.

5)         Services for which Medicare is the primary payer.

6)         Emergency services as defined at 42 USC 1396u-2(b)(2) (section 1932(b)(2) of the Social Security Act) and 42 CFR 438.114(a).

7)         Any pharmacy compounded drugs.

8)         Any prescription (legend drug) dispensed or administered by a hospital, clinic or physician.

9)         Family planning services and supplies described in 42 USC 1396d(a)(4)(C) (section 1905(a)(4)(C) of the Social Security Act), including contraceptives and other pharmaceuticals for which the State claims or could claim federal financial participation at the enhanced rate under 42 USC 1396b(a)(5) (section 1903(a)(5) of the Social Security Act) for family planning services and supplies.

10)         Other therapeutic drug classes as specified by the Department.

11)         Preventive services as described in section 4106(b) of the Affordable Care Act.

(Source:  Amended at 44 Ill. Reg. 4616, effective March 3, 2020)

Section 140.403  Telehealth Services

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.

b)         Requirements for Telehealth Services

1)         Telemedicine

A)        A physician or other licensed health care professional must be present at all times with the patient at the originating site.

B)        The distant site provider must be a physician, physician assistant, podiatrist or advanced practice nurse who is licensed by the State of Illinois or by the state where the patient is located.

C)        The originating and distant site provider must not be terminated, suspended or barred from the Department's medical programs.

D)        Medical data may be exchanged through a telecommunication system.

E)        The interactive telecommunication system must, at a minimum, have the capability of allowing the consulting distant site provider to examine the patient sufficiently to allow proper diagnosis of the involved body system.  The system must also be capable of transmitting clearly audible heart tones and lung sounds, as well as clear video images of the patient and any diagnostic tools, such as radiographs.

2)         Telepsychiatry

A)        A physician, licensed health care professional or other licensed clinician, mental health professional (MHP), or qualified mental health professional (QMHP), as defined in 59 Ill. Adm. Code 132.25, must be present at all times with the patient at the originating site.

B)        The distant site provider must be a physician licensed by the State of Illinois or by the state where the patient is located and must have completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program.

C)        The originating and distant site provider must not be terminated, suspended or barred from the Department's medical programs.

D)        The distant site provider must personally render the telepsychiatry service.

E)        Telepsychiatry services must be rendered using an interactive telecommunication system.

F)         Group psychotherapy is not a covered telepsychiatry service.

c)         Reimbursement for Telehealth Services

1)         Originating Site Reimbursement

A)        A facility fee shall be paid to providers as defined in subsection (a)(4) of this Section.

B)        Local education agencies may submit telehealth services as a certified expenditure.

C)        Providers who receive reimbursement for a patient's room and board are not eligible for reimbursement as an originating site.

D)        Clinics reimbursed under the prospective payment system shall be eligible for a medical encounter as set forth in subsection (c)(3) of this Section.

2)         Reimbursement for Rendering Provider at the Distant Site

A)        Participating providers shall be reimbursed for the appropriate AMA Current Procedural Terminology (CPT) code for the telehealth service rendered.

B)        Nonparticipating providers may be reimbursed by the originating site provider, but will not be eligible for reimbursement from the Department.

3)         Clinic Reimbursement

A)        An encounter clinic serving as the originating site shall be reimbursed for its medical encounter as defined in Section 140.462.  The clinic is responsible for reimbursement to the distant site provider.

B)        An encounter clinic serving as the distant site shall be reimbursed as follows: 

i)          If the originating site is another encounter clinic, the distant site encounter clinic shall receive no reimbursement from the Department.  The originating site encounter clinic is responsible for reimbursement to the distant site encounter clinic; and

ii)         If the originating site is not an encounter clinic, the distant site encounter clinic shall be reimbursed for its medical encounter.  The originating site provider will receive a facility fee as defined in subsection (a)(4) of this Section.

d)         Record Requirements for Telehealth Services

1)         Medical records documenting the telehealth services provided must be maintained by the originating and distant sites and shall include, but not be limited to, the following:

A)        The records required in Section 140.28;

B)        The name and license number of the licensed health care professional or other licensed clinician present with the patient at the originating site;

C)        The name and license number of the provider at the distant site and, if the service involves telepsychiatry, documentation that the physician has completed an approved general psychiatry residency program or an approved child and adolescent psychiatry residency program;

D)        The locations of the originating and distant sites;

E)        The date and the beginning and ending times of the telehealth service; and

F)         The medical necessity for the telehealth service.

2)         When the originating site is an encounter clinic, records from the distant site must also be maintained.

3)         Appropriate steps must be taken by the originating and distant site staff to assure patient confidentiality, based on technical advances in compliance with all federal and state privacy and confidentiality laws.

4)         The type of interactive telecommunication system utilized at the originating and distant sites shall be documented.

5)         The billing records related to the use of the telecommunication system shall be maintained as provided in Section 140.28.

e)         Telehealth Requirements During a Public Health Emergency. Notwithstanding any other provision of this Part, and to protect the public health in connection with a public health emergency, the Department will reimburse medically necessary and clinically appropriate telehealth services that meet the requirements of this subsection (e) for dates of service on or after March 9, 2020 until the Department determines any or all of the services or flexibilities permitted under this subsection (e) are no longer necessary.  This determination will be based upon federal or State disaster declarations, Executive Orders of the Governor, termination of disaster-related flexibilities granted by federal agencies, or feedback from stakeholders.

1)         Telehealth services are medically necessary and clinically appropriate services covered under the Medical Assistance Program (see Section 140.3), and provided in accordance with federal law and regulations, that are delivered through a communication or technology system (see subsection (e)(5)) to a patient at an originating site by a provider located at a distant site. The Department will also reimburse for the following services that do not meet the definition of "telehealth services" during this public health emergency, including:

A)        Notwithstanding the restriction on services provided via phone in Section 140.6(m) and this Section, brief communication technology-based service, e.g. virtual check-in that uses audio-only real-time telephone interactions or synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission. Virtual check-ins must be rendered by a physician, advanced practice registered nurse, physician assistant, or other qualified health-care professional who can report evaluation and management (E/M) services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. The Department will reimburse for this service at the rate established on the Department's fee schedule. Federally Qualified Health Centers, Rural Health Clinics, and Encounter Rate Clinics may also receive reimbursement for this service at the rate established on the Department's fee schedule.

B)        Notwithstanding the restriction on services provided via phone in Section 140.6(m) and this Section, online patient portal or "E-visit" services are non-face-to-face patient-initiated communications using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. For these encounters, the patient must generate the initial inquiry and communications can occur over a 7-day period. The patient must verbally consent to receive virtual check-in services. The Department will reimburse for HCPCS codes G2061, G2062 and G2063 and CPT codes 99421, 99422 and 99423 at the rate established on the Department's fee schedule. Federally Qualified Health Centers, Rural Health Clinics, and Encounter Rate Clinics may also receive reimbursement for this service at the rate established on the Department's fee schedule.

C)        Notwithstanding the restriction on services provided via phone in Section 140.6(m) and this Section, the Department will reimburse for all behavioral health services (substance use disorder and mental health disorder) detailed in Section 140.453 (except for Mobile Crisis Response and Crisis Stabilization as defined in Section 140.453(d)(3)) and behavioral health services (substance use disorder and mental health disorder) contained on an applicable Department fee schedule provided using audio-only real-time telephone interactions, or video interaction in accordance with subsection (e)(5). The Department will reimburse for these services at the same rate paid for services provided on site.

2)         The distant site provider is any enrolled provider, operating within its scope of practice, and with the appropriate license or certification.

3)         Telehealth services are delivered to a patient that is located at an originating site. Any site that allows for the patient to use a communication or technology system as defined in subsection (e)(5) may be an originating site, including a patient's place of residence located within the State of Illinois or other temporary location within or outside the State of Illinois.

4)         An originating site will be eligible for a facility fee when it is a certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including but not limited to: substance use treatment programs licensed by the Department of Human Services' Division Substance Use Prevention and Recovery (SUPR), Supportive Living Program providers, Hospice providers, Community Integrated Living Arrangement (CILA) providers, and providers who receive reimbursement for a patient's room and board.

5)         To be eligible for reimbursement, the telehealth service must be delivered using:

A)        An "interactive telecommunication system" or "telecommunication system" as described in subsection (a); or

B)        A communication system where information exchanged between the physician or other qualified health care practitioner and the patient during the course of the synchronous telehealth service is of an amount and nature that would be sufficient to meet the key components and requirements of the same service when rendered via face-to-face interaction.

6)         Reimbursement for telehealth services will be made at the same rate paid for face-to-face services. Reimbursement for the services described in subsections (e)(1)(A) and (B) will be at the rate established on the Department's fee schedule. Reimbursement for the services described in subsection (e)(1)(C) will be made at the same rate paid for services provided on site.

7)         The distant site provider and originating site provider eligible for a facility fee must maintain adequate documentation of the telehealth services provided in accordance with the record requirements of subsection (d).

8)         A physician or other licensed health care professional is not required to be present at all times with the patient at the originating site.

(Source:  Amended at 45 Ill. Reg. 10996, effective August 27, 2021)

Section 140.405  Non-Institutional Rate Reductions

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.

(Source:  Amended at 45 Ill. Reg. 8958, effective June 29, 2021)

Section 140.410  Physicians' Services

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.

Section 140.411  Covered Services By Physicians

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.

Section 140.412  Services Not Covered By Physicians

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.

(Source:  Amended at 44 Ill. Reg. 226, effective December 23, 2019)

Section 140.413  Limitation on Physician Services

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.

2)         Sterilization

A)        Therapeutic sterilization – only when the procedure is either a necessary part of the treatment of an existing illness, or is medically indicated as an accompaniment of an operation on the female genitourinary tract.  Mental incapacity does not constitute an illness or injury that would authorize this procedure.

B)        Nontherapeutic sterilization – only for recipients age 21 or older and mentally competent. The physician must obtain the recipient's informed written consent in a language understandable to the recipient before performing the sterilization and must advise the recipient of the right to withdraw consent at any time prior to the operation.  The operation shall be performed no sooner than 30 days and no later than 180 days following the date of the recipient's written informed consent, except in cases of premature delivery or emergency abdominal surgery.  An individual may consent to be sterilized at the time of premature delivery or emergency abdominal surgery if at least 72 hours have passed since informed consent was given.

3)         Morbid Obesity.  Effective October 1, 2012, surgery for morbid obesity is covered only with prior approval by the Department.  The Department shall approve payment for this service only in those cases in which the physician determines that obesity is exogenous in nature, the recipient has had the benefit of other therapy with no success, endocrine disorders have been ruled out, and the body mass index (BMI) is 40 or higher, or 35 to 39.9 with serious medical complications.  The medical record must contain the following documentation of medical necessity:

A)        Documentation of review of systems (history and physical);

B)        Client height, weight and BMI;

C)        Listing of co-morbidities;

D)        Patient participation in a six month consecutive medically supervised weight loss program working in conjunction with a registered dietician and or physician within two years prior to the surgery, with at least four documented visits within the consecutive six months;

E)        Current and complete psychiatric evaluation indicating the patient is an appropriate candidate for weight loss surgery; and

F)         Documentation of nutritional counseling.

4)         Psychiatric Services

A)        Treatment – when the services are provided by a physician who has been enrolled as an approved provider with the Department. 

B)        Consultation – only when necessary to determine the need for psychiatric care.  Services provided subsequent to the initial consultation must comply with the requirements for treatment.

C)        Group Psychotherapy – payment may be made for up to two group sessions per week, with a maximum of one session per day.  The following conditions must be met for group psychotherapy:

i)          documentation maintained in the patient's medical record must indicate the person participating in the group session has been diagnosed with a mental illness as defined in the International Classification of Diseases (ICD-9-CM) or, upon implementation, International Classification of Diseases, 10^th Revision, Clinical Modification (ICD‑10‑CM), or the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).  The allowable diagnosis code ranges will be specified in the Handbook for Practitioners Rendering Medical Services;

ii)         beginning 1/1/10, the entire group psychotherapy service is directly performed by a physician licensed to practice medicine in all its branches who has completed an approved general psychiatry residency program or is providing the service as a resident or attending physician at an approved or accredited residency program;

iii)        the group size does not exceed 12 patients, regardless of payment source;

iv)        the minimum duration of a group session is 45 minutes;

v)         the group session is documented in the patient's medical record by the rendering physician, including the session's primary focus, level of patient participation, and begin and end times of each session;

vi)        the group treatment model, methods, and subject content have been selected on evidence-based criteria for the target population of the group and follows recognized practice guidelines for psychiatric services;

vii)       the group session is provided in accordance with a clear written description of goals, methods and referral criteria; and

viii)      Effective July 1, 2012, group psychotherapy is not covered for recipients who are residents in a facility licensed under the Nursing Home Care Act [210 ILCS 45] or the Specialized Mental Health Rehabilitation Act of 2013 [210 ILCS 49].

5)         Home Services.  Services provided to a recipient in his or her home – only when the recipient is physically unable to go to the physician's office.

6)         Services provided to recipients in group care facilities by a physician other than the attending physician – only for emergency services provided when the attending physician of record is not available or when the attending physician has made referral with the recipient's knowledge and permission.

7)         Services provided to recipients in a group care facility by a physician who derives a direct or indirect profit from total or partial ownership (or from other types of financial investment for profit in the facility) – only when occasioned by an emergency due to acute illness or unavailability of essential treatment facilities in the vicinity for short-term care pending transfer, or when there is no comparable facility in the area.

8)         Maternity Care.  Payment shall be made for pre-natal and post-natal care only when the following conditions are met:

A)        the physician, whether based in a hospital, clinic or individual practice, retains hospital delivery privileges, maintains a written referral arrangement with another physician who retains such privileges, or has been included in the Maternal and Child Health Program as a result of having entered into an appropriate Healthy Moms/Healthy Kids Program provider agreement;

B)        the written referral agreement is kept on file and is available for inspection at the physician's place of business, and details procedures for timely transfer of medical records; and

C)        maternal services are delivered in a manner consistent with the quality of care guidelines published by the American College of Obstetricians and Gynecologists in its Guidelines for Women's Health Care (2014) and Guidelines for Perinatal Care (2017), available at 409 12^th Street, S.W., Washington D.C. 20024-2188, or at https://www.acog.org.

9)         Physician Services to Children under Age 21

A)        Payment shall be made only when the physician meets one or more of the following conditions.  The physician:

i)          has admitting privileges at a hospital;

ii)         is certified or is eligible for certification in pediatrics or family practice by the medical specialty board recognized by the American Board of Medical Specialties;

iii)        is employed by or affiliated with a Federally Qualified Health Center;

iv)        is a member of the National Health Service Corps;

v)         has been certified by the Secretary of the Department of Health and Human Services as qualified to provide physician services to a child under 21 years of age;

vi)        has current, formal consultation and referral arrangements with a pediatrician or family practitioner for the purposes of specialized treatment and admission to a hospital.  The written referral agreement is kept on file and is available for inspection at the physician's place of business, and details procedures for timely transfer of medical records; or

vii)       has entered into a Maternal and Child Health provider agreement or has otherwise been transferred in from the Healthy Moms/Healthy Kids Program;

B)        The physician shall certify to the Department the way in which he or she meets the criteria of subsection (a)(9)(A); and

C)        Services to children shall be delivered in a manner consistent with the standards of the American Academy of Pediatrics and rules published by the Illinois Department of Public Health (77 Ill. Adm. Code 630, Maternal and Child Health Services; 77 Ill. Adm. Code 665, Child Health Examination Code; 77 Ill. Adm. Code 675, Hearing Screening; 77 Ill. Adm. Code 685, Vision Screening).

10)        Hysterectomy.  Only if the individual has been informed, orally and in writing, that the hysterectomy will render her permanently incapable of reproducing and the individual has signed a written acknowledgment of receipt of the information.  The Department will not pay for a hysterectomy that would not have been performed except for the purpose of rendering an individual permanently incapable of reproducing.

11)        Selected Surgical Procedures.  Includes:

A)        tonsillectomies or adenoidectomies;

B)        hemorrhoidectomies;

C)        cholecystectomies;

D)        disc surgery/spinal fusion;

E)        joint cartilage surgery/meniscectomies;

F)         excision of varicose veins;

G)        submucous resection/rhinoplasty/repair of nasal system;

H)        mastectomies for non-malignancies; and

I)         surgical procedures that generally may be performed in an outpatient setting (see Section 140.117), but only if the Department authorizes payment. The Department will in some instances require that a second physician agree that the surgical procedure is medically necessary prior to approving payment for one of these procedures.  The Department will require a second opinion when the attending physician has been notified by the Department that he or she will be required to obtain prior approval for payment for the surgeries listed.  (See Sections 140.40 through 140.42 for prior approval requirements.)  The Department will select physicians for this requirement based on the recommendation of a peer review committee that has reviewed the utilization pattern of the physician.

12)        Mammography Screening and Related Services.  Described in 305 ILCS 5/5-5.

13)        Pap Tests and Prostate-Specific Antigen Tests.  Coverage is provided for the following:

A)        An annual cervical smear or Pap smear test for women.

B)        An annual digital rectal examination and a prostate-specific antigen test, upon the recommendation of a physician licensed to practice medicine in all its branches, for:

i)          asymptomatic men age 50 and over;

ii)         African-American men age 40 and over; and

iii)        men age 40 and over with a family history of prostate cancer.

14)        Coronary Artery By-Pass Grafts.  Effective July 1, 2012, coronary artery by-pass grafts are covered only with prior approval by the Department. 

15)        Tobacco Cessation Counseling. Face-to-face tobacco cessation counseling only for pregnant and up to 60‑day postpartum women age 21 and over. The tobacco cessation counseling services:

A)        Must be provided by or under supervision of a physician, or by any other health care professional who is legally authorized to furnish those services under State law, and who is authorized to provide Medicaid covered services other than tobacco cessation services.

B)        Are limited to a maximum of three quit attempts, with four individual face-to-face counseling sessions per quit attempt, per calendar year.

C)        Must be properly documented in the patient's medical record and include the total time spent and what was discussed during the counseling session, including cessation techniques, resources available and follow-up.  Distinct documentation to support this service is required if reported in conjunction with another evaluation and management service.

D)        Rendered to participants under age 21 are not subject to the limitations in this subsection (a)(15).

16)       Gender-affirming Surgeries, Services and Procedures

A)        Gender-affirming surgeries, services and procedures are covered only with prior approval by the Department for individuals who are 21 years of age or older. In order for prior approval to be granted for genital surgeries, letters from two qualified medical providers must be submitted, including one from a Licensed Practitioner of the Healing Arts (LPHA), as defined in Section 140.453(b)(3)(A) through (D) and (F), and one from either the individual's primary care physician or the physician managing the individual's gender-related healthcare. In order for prior approval to be granted for non-genital surgeries, one letter from either the individual's primary care physician or the physician managing the individual's gender-related healthcare must be submitted.  The qualified medical provider or providers must have independently assessed the individual and must be referring the individual for the surgery. Together, the letter or letters must establish:

i)          That the individual:

●          has a diagnosis of gender dysphoria;

●          has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless that therapy is medically contraindicated or the individual is otherwise unable to take hormones;

●          has lived continuously for at least 12 months in the gender role that is congruent with their gender identity, in the case of an individual seeking genital surgery;

●          has completed an assessment by an LPHA, as defined in Section 140.453(b)(3)(A) through (D) and (F), which must include education and counseling of treatment options and implications; and psychotherapy, if indicated;

●          if a significant medical or mental health condition is present that would be a contraindication to the gender-affirming surgery, service or procedure, it must be reasonably well-controlled; and

●          has the capacity to make a fully informed decision and to consent to the treatment;

ii)         That the medical provider has communicated with the individual's other medical providers regarding the proposed surgery, service or procedure;

iii)        The medical necessity of the surgery, service or procedure; and 

iv)        Recommendations for post-operative care.

B)        The Department will cover all gender-affirming surgeries, services and procedures that are medically necessary to treat a particular individual's gender dysphoria and are listed on the Department's fee schedule and in the Practitioner Handbook. Gender-affirming surgeries, services and procedures shall include, but are not limited to, breast/chest surgeries, genital surgeries, and related therapies.

C)        If prior approval is for genital surgery, the surgery must be performed by a urologist, gynecologist, or plastic or general surgeon who is board-certified in the practitioner's area of expertise and has demonstrated specialized competence in gender-based genital reconstruction as indicated by documented supervised training or post-graduate training in the field of gender-based genital reconstruction.

D)        Surgeries resulting in sterilization must meet all requirements of subsection (a)(2); surgeries performed for the purpose of treating gender dysphoria are considered therapeutic sterilizations for purposes of this Section.

E)        Notwithstanding the age limitation in subsection (a)(16)(A), payment for gender-affirming surgeries, services and procedures for patients under 21 years of age will be made in specific cases if medical necessity is demonstrated and prior approval is received.

b)         In cases in which a physical examination by a second physician is needed, the Department will notify the recipient and designate a physician to perform the examination.  Physicians will be subject to this requirement for six months, after which a request can be submitted to the peer review committee to consider removal of the prior approval requirement.

(Source:  Amended at 44 Ill. Reg. 226, effective December 23, 2019)

Section 140.414  Requirements for Prescriptions and Dispensing of Pharmacy Items – Prescibers

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.

b)         Dispensed Items

1)         A participating prescriber may dispense pharmacy items subject to the Department's coverage policies.  The prescriber shall not charge for any samples dispensed or anesthesia agents administered for office surgical procedures.

2)         Effective July 1, 2012, the Department shall pay for covered outpatient drug items dispensed or administered by a non-pharmacy provider at a rate equal to the lowest of the provider's usual and customary charge to the public; or

A)        The Average Sales Price (ASP) plus 6 percent.  ASP means the ASP as defined in the Social Security Act, Title XVIII, section 1847A(c) (42 USC 1395 w-3a(c)) and calculated by the federal Centers for Medicare and Medicaid Services (CMMS); or

B)        The State upper limit.

3)         Effective July 1, 2012, in cases in which ASP is not available and no State upper limit has been developed, the Department's lowest maximum allowable price for all covered NDCs assigned to the HCPCS billing code (the methodology for determining the Department's maximum prescription prices is specified in Section 140.445(b)(1) and (b)(2)).

4)         Reimbursement rates for drugs dispensed or administered by non-pharmacy providers shall be updated no less frequently than twice per calendar year.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.416  Optometric Services and Materials

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.

c)         Optometric services and materials for which payment shall not be made include:

1)         Services which are not provided to address a recipient's particular visual problems or complaints.

2)         Lenses, frames and frame parts obtained from a source other than the DOC laboratory.

3)         Trifocals.

4)         Tinted lenses.

5)         Provider's transportation costs.

d)         Payment for services and materials shall be at the lesser of the provider's usual and customary charge or the maximums established by the Department pursuant to Section 140.400.

e)         Lenses, Frames and Frame Parts Requirements that Began During a Public Health Emergency. Notwithstanding subsections (b)(4) and (c)(2) of this Section and Section 140.418, and any other provision to the contrary in this Part, the Department will reimburse for lenses, frame parts and frames provided by the Department's laboratory vendors for dates of service on or after March 9, 2020 until the Department determines any or all of the services provided by the Department's laboratory vendors are no longer necessary or until the DOC laboratory resumes production of lenses, frames and frame parts.

(Source:  Amended at 45 Ill. Reg. 8958, effective June 29, 2021)

Section 140.417  Limitations on Optometric Services

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.

b)         Payment shall be made for bifocal lenses only when the following conditions are met:

1)         For first bifocals, the power of the bifocal addition is at least 1.00 diopter.

2)         For a change in bifocal lenses, the power of the bifocal addition is changed by at least 0.50 diopters or the distance power represents a change of at least 0.75 diopters.

c)         Payment shall be made for more than one examination per year only when the vendor documents the need for the additional examination.

d)         Effective July 1, 2012, payment shall be made for the following:

1)         One pair of eyeglasses or set of lenses for adults in a 24-month period.  Effective August 18, 2017, adults 21 years of age and older may receive an additional pair of eyeglasses or set of lenses within the 24-month period if the patient has had a surgical procedure that necessitates a new pair.

2)         Payment shall be made for more than one pair of eyeglasses or set of lenses per year for children through age 20 only when the physician or optometrist documents:

A)        that:

i)          the most recent pair of eyeglasses or set of lenses was lost or destroyed for reasons beyond the control of the recipient; or

ii)         there is a change in the prescription that meets the requirements in subsection (a)(2) or (b)(2); and

B)        that the additional pair is medically necessary.

e)         Payment for optometric materials dispensed by a supplier other than a physician or optometrist, except for replacement and repair items, shall be made only when they are prescribed by a licensed physician or optometrist.

f)         Effective July 1, 2012, prior approval pursuant to Section 140.40 is required for the services and materials described in this subsection (f).  Approval shall be given when, in the judgment of a Department consultant, the requested item or service is appropriate.

1)         Contact lenses and related contact lens services;

2)         Custom made artificial eyes;

3)         Low vision devices;

4)         Any item or service not specifically included in the schedule of procedures for optical services and supplies; and

5)         An additional pair of eyeglasses or set of lenses within a 24-month period for adults 21 years of age and older after eye surgery.

(Source:  Amended at 42 Ill. Reg. 20059, effective October 26, 2018)

Section 140.418  Department of Corrections Laboratory

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.

(Source:  Amended at 39 Ill. Reg. 4394, effective March 11, 2015)

Section 140.420  Dental Services

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.

e)         Payment shall not be made for experimental dental care and procedures performed only for cosmetic reasons.

f)         Effective for dates of service July 1, 2012 through June 30, 2014, notwithstanding other provisions of this Section or Section 140.421, dental services rendered to recipients age 21 years and older shall be limited to those dental services that are medically necessary to treat pain, infection, swelling, uncontrolled bleeding, or traumatic injury that can be treated by extraction and dental services that are medically necessary as a prerequisite for necessary medical care.

g)         Payment should be made to All Kids School-Based Dental Program providers that administer out-of-office delivery of allowed preventive dental services in a school setting to children under 19 years of age.  Dental providers must:

1)         Be enrolled with HFS as a dental provider;

2)         Be registered with the All Kids School-Based Dental Program;

3)         Follow guidelines for the IDPH Calendar;

4)         Have the ability to administer the allowed preventive dental services in the school setting;

5)         Complete and maintain a Dental Record of the school visit for each child;

6)         Complete an IDPH Proof of School Dental Examination Form;

7)         Provide a completed School Follow up Form for the school to provide to the parent/guardian;

8)         Provide a follow-up referral care plan for children that receive Caries Risk Assessment Codes of D0602 or D0603. The referral plan shall consist of one of the following referral options:

A)        InsureKidsNow web site;

B)        Follow-up care to the provider who provided service in school;

C)        Follow-up care will be provided at school; or

D)        School provider will have a case manager that assists children in getting follow-up care.

9)         Include the Caries Risk Assessment Codes (D0601, D0602 or D0603) in the school dental service claims; and

10)       Have an active collaborative agreement with a Public Health Dental Hygienist (PHDH), if applicable.

(Source:  Amended at 46 Ill. Reg. 5725, effective March 25, 2022)

Section 140.421  Limitations on Dental Services

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);

B)        Treatment necessary to correct the following conditions, effective January 1, 2025:

i)          Cleft palate or other craniofacial anomalies;

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);

v)         Overjet of 9mm or greater or;

vi)        Impacted teeth where eruption is impeded but extraction is not indicated.

C)        Effective January 1, 2025, if a prior authorization request for orthodontic treatment is denied, the provider who submitted the request shall be provided with the HLD scoring tool and the HLD score that prompted denial of the request.

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.

b)         The dentist may request post-approval when a dental procedure requiring prior approval is provided on an emergency basis.  Approval of the procedures shall be given if the dental procedure is medically necessary.

(Source:  Amended at 49 Ill. Reg. 3537, effective March 10, 2025)

Section 140.422  Requirements for Prescriptions and Dispensing Items of Pharmacy Items – Dentists (Repealed)

(Source:  Repealed at 33 Ill. Reg. 9048, effective June 15, 2009)

Section 140.423  Licensed Clinical Psychologist Services

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).

c)         LCPs may prescribe medications in accordance with the following:

1)         Hold a current prescribing psychologist license as defined in Section 4.2 of the Clinical Psychologist Licensing Act;

2)         Have and maintain a current written collaborative agreement with a collaborating physician as set forth in Section 4.3 of the Clinical Psychologist Licensing Act. Agreements must be updated, maintained on file at each practice location, and be available upon the Department's request.

3)         The collaborating physician is not required to be enrolled with the Department. However, the collaborating physician may not be terminated, suspended or barred by the Department from participating in the Medical Assistance Program.

4)         The LCP must notify the Department within 10 business days if an agreement is dissolved or if a change occurs in the collaborating physician under the agreement.

5)         All prescriptions must meet the requirements set forth in Section 140.414.

            d)         Payment shall not be made for the following services:

1)         Services identified in Section 140.6;

2)         Self-administered or self-scored tests of cognitive function; and

3)         Biofeedback therapy.

(Source:  Added at 41 Ill. Reg. 7526, effective June 15, 2017)

Section 140.424  Licensed Clinical Social Worker Services

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).

c)         Payment shall not be made for services identified in Section 140.6.

(Source:  Added at 41 Ill. Reg. 7526, effective June 15, 2017)

Section 140.425  Podiatry Services

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, 9^th 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.

2)         Effective October 1, 2014, payment shall be made for those podiatric services that are:

A)        Essential for the diagnosis and treatment of conditions of the feet and ankles.

B)        Listed in the CPT or 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.

C)        Performed by the podiatrist or under the direct supervision of the podiatrist.

D)        Routine foot care services (trimming of nails, treatment of calluses, corns, and similar services) when a participant is under active treatment for diabetes mellitus or has a systemic condition that has resulted in severe circulatory impairment or an area of desensitization in the legs or feet and routine type foot care is required.

d)         Payment shall not be made for the following services:

1)         Making a referral, obtaining a specimen, handling a specimen for analysis, or ordering a laboratory test;

2)         Visits and services provided to recipients eligible for Medicare benefits if the services are determined not medically necessary by Medicare;

3)         Services provided to recipients in group care facilities by a podiatrist who derives direct or indirect profit from total or partial ownership of the facility;

4)         Routine foot care, except as described in subsections (c)(1)(E) and (c)(2)(D);

5)         Screening for foot problems;

6)         Provider transportation costs;

7)         X-rays, and laboratory procedures performed at a location other than the podiatrist's own office;

8)         X-rays, laboratory work or similar services not specifically required by the condition for which the recipient is being treated;

9)         Routine post-operative visits.

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)

Section 140.426  Limitations on Podiatry Services

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.

Section 140.427  Acupuncture Services

a)         For purposes of enrollment in the Medical Assistance Program, an acupuncturist means a person who is licensed and is legally authorized to practice as a licensed acupuncturist, pursuant to the Acupuncture Practice Act [225 ILCS 2] and implementing rules (68 Ill. Adm. Code 1140). 

b)         Payment shall be made to acupuncturists for procedures related to chronic lower back pain and breech baby presentation.

(Source:  Section repealed at 33 Ill. Reg. 9048, effective June 15, 2009; new Section 140.427 added at 49 Ill. Reg. 4026, effective March 20, 2025)

Section 140.428  Chiropractic Services

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.

(Source:  Amended at 47 Ill. Reg. 3738, effective March 1, 2023)

Section 140.429  Limitations on Chiropractic Services (Repealed)

(Source:  Repealed at 14 Ill. Reg. 4543, effective March 12, 1990)

Section 140.430  Independent Clinical Laboratory Services

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.

(Source:  Amended at 23 Ill. Reg. 7122, effective June 1, 1999)

Section 140.431  Services Not Covered by Independent Clinical Laboratories

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.

(Source:  Amended at 23 Ill. Reg. 7122, effective June 1, 1999)

Section 140.432  Limitations on Independent Clinical Laboratory Services

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.

(Source:  Amended at 23 Ill. Reg. 7122, effective June 1, 1999)

Section 140.433  Payment for Clinical Laboratory Services

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.

(Source:  Amended at 23 Ill. Reg. 7122, effective June 1, 1999)

Section 140.434  Record Requirements for Independent Clinical Laboratories

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.

c)         In the absence of proper and complete records, no payment will be made and payments previously made for services that are not documented will be recouped.

(Source:  Amended at 23 Ill. Reg. 7122, effective June 1, 1999)

Section 140.435  Advanced Practice Registered Nurse Services

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).

b)         APRNs licensed with full practice authority under 68 Ill. Adm. Code 1300.465 are not required to have a collaborative agreement with a collaborating physician or practitioner. A written collaborative agreement with a collaborating physician or practitioner is required for all APRNs not licensed with full practice authority who are engaged in clinical practice, except for those APRNs who practice in a hospital, hospital affiliate or ambulatory surgical treatment center under Section 65-45 of the Nurse Practice Act.

c)         The collaborative agreement or agreements required under subsection (b) shall comply with all requirements described in the Nurse Practice Act and 68 Ill. Adm. Code 1300.  Agreements required under the Act and 68 Ill. Adm. Code 1300 must be updated, be maintained on file at each practice location, and be available upon the Department's request.

d)         The APRN must notify the Department if a collaborative agreement is dissolved prior to or immediately following the date of dissolution. The APRN must also notify the Department if a change occurs in the collaborating physician, dentist or podiatric physician under the agreement.  Upon notification or knowledge thereof, the Department will re-evaluate the APRN's enrollment status.  The Department will also withhold payment for services provided to eligible clients as of that date of dissolution or the change in the collaborative agreement, unless the APRN and/or the former or new collaborating physician, dentist or podiatric physician show reasonable cause for the payment arrangement to continue without interruption.

e)         The collaborating physician, dentist or podiatric physician is not required to be enrolled with the Department.  However, the collaborating physician or practitioner may not be terminated, suspended or barred by the Department from participating in the Medical Assistance Program. The Department will re-evaluate the APRN's enrollment status.  The Department will also withhold payment for services provided to eligible clients as of that date of the termination, suspension or barring of the collaborative physician or practitioner unless the APRN shows reasonable cause for the payment arrangement to continue without interruption.

f)         An APRN must submit the following information in their initial application for enrollment:

1)         An APRN who is not required to maintain a collaborative or written practice agreement under Section 140.431(b) must provide the names and addresses of the hospitals or ambulatory surgical treatment centers where the APRN practices; or

2)         An APRN who is required to maintain a collaborative or written practice agreement under Section 140.431 (b) must provide the following:

A)        Documentation of specialty of practice.

B)        Name and address of collaborating physician, dentist or podiatric physician.

C)        Federal Employer Identification Number (FEIN) of collaborating physician, dentist or podiatric physician.

D)        Medical license number of collaborating physician, dentist or podiatric physician.

E)        State of licensure, if other than Illinois, and address of collaborating physician, dentist or podiatric physician.

g)         To be eligible for reimbursement for individual psychiatric services, as defined in the American Medical Association Current Procedural Terminology (CPT) book, CPT code range 90791 through 90899, the rendering APRN must hold a current certification in Psychiatric and Mental Health Nursing.

h)         An APRN with a collaborative agreement, and enrolled with the Department, who later receives full practice authority licensure must notify the Department of this change.

(Source:  Amended at 46 Ill. Reg. 5725, effective March 25, 2022)

Section 140.436  Limitations on Advanced Practice Registered Nurse Services

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.

(Source:  Amended at 46 Ill. Reg. 5725, effective March 25, 2022)

Section 140.438  Diagnostic Imaging Services

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.

b)         Participation Requirements

1)         To participate in the Illinois Medical Assistance program, an Imaging Center must, in addition to any other Department requirements, be licensed or certified:

A)        for participation in the Medicare program; or

B)        by the Joint Commission; or

C)        by a state public health department; or

D)        by any government agency having jurisdiction over the services provided and/or the equipment being used.

2)         Portable X-ray Facilities shall be approved and certified for participation in the Medicare program. 

3)         Mammography Screening Centers shall be certified by the Illinois Emergency Management Agency or the certifying agency in the state where the center is located.

4)         Independent Diagnostic Testing Facilities shall be approved and certified for participation in the Medicare program.

c)         Reimbursement

1)         Diagnostic and imaging services shall be reimbursed on a fee-for-service basis only.

2)         Reimbursement may include the technical services, the professional services or both the technical and professional services.

3)         Reimbursement shall be made for only those diagnostic or imaging 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.

4)         Reimbursement shall be made only to providers who meet all applicable license, enrollment and reimbursement conditions of the Department.

5)         Reimbursement to IDTFs shall be made for only those diagnostic and imaging tests certified by Medicare.

6)         Except for mammograms, reimbursement shall not be made for routine screening x-rays.

7)         Reimbursement for a mammography facility provider that does not qualify under subsection (c)(8) of this Section shall be the lesser of charges or the Department's fee screen.

8)         For services rendered on or after June 1, 2013, a mammography facility provider that meets the qualifications for and participates in the Department's Breast Cancer Quality Screening and Treatment Initiative shall be paid for mammography services at the effective Chicago Metropolitan Area Medicare Level established rate (Established Rate).  To qualify for this Established Rate, a mammography facility provider shall:

A)        Enter into a Supplemental Provider Agreement with the Department; and

B)        Provide mammography services to participants in the Department's Medical Programs with the same timeliness as the facility provides to patients with other forms of insurance; and

C)        Within 30 days after submitting the Supplemental Provider Agreement, and annually thereafter on or before August 31, submit a completed mammography capacity survey, using the Department's survey form; and

D)        Submit facility-based mammography quality data using the Department's data collection forms; and

E)        Provide the Department with access to patient and service data upon request; and

F)         Assist the Department with the development and implementation of a plan to improve the quality of services.

d)         Record Requirements

1)         In addition to the record requirements specified in Section 140.28, providers of diagnostic and imaging services must comply with the administrative rules of the Illinois Department of Public Health governing the maintenance of medical records (77 Ill. Adm. Code 450, Illinois Clinical Laboratories Code).

2)         The basic records that must be retained include:

A)        Patient identification.

B)        Medical records containing the dates of service and the name of the referring physician.

C)        The referring practitioner's written orders.

D)        Copies of reports to referring practitioners.

E)        The report of the reading by the professional practitioner if both professional and technical components are billed.

F)         The report of the reading by the professional practitioner that must be retained in the professional practitioner's office if only the professional component is billed by the practitioner.

G)        Records that verify usual and customary charges to the general public.

3)         Medical records for Medical Assistance program clients must be made available to the Department or its designated representative in the performance of audits or investigations.

(Source:  Amended at 37 Ill. Reg. 7985, effective May 29, 2013)

Section 140.439  Critical Access Care Pharmacy Payment

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.

2)         Submit an attestation to the Department within 30 calendar days after the end of the fiscal quarter in a form and manner prescribed by the Department.

b)         CAP Payments for a fiscal year will be made quarterly and may not exceed the lesser of $10,000,000 or the total amount specifically appropriated to the Department for CAP Payments.

c)         All CAP Payment calculations shall be based on "CAP-Eligible Claims", which are defined as pharmacy claims:

1)         Billed by an eligible CAP to a Managed Care Organization (MCO) contracted with the Department for HealthChoice Illinois, or its successor program, for dates of service during the quarter being calculated;

2)         Paid for by the MCO; and

3)         For which a paid encounter claim record exists in the Department's Electronic Data Warehouse (EDW) prior to 90 calendar days after the end of the quarter being calculated.

d)         Individual CAP Payments will be made to individual pharmacy providers that meet the requirements of subsection (a).  Individual CAP Payment amounts are calculated using the total number of the individual pharmacy's CAP-Eligible Claims for the quarter being calculated multiplied by the lesser of:

1)         The individual payment amount; or

2)         The Department's dispensing fee for the medical assistance program in effect on April 1, 2018.

e)         The "individual payment amount" is equal to one quarter of the total amount appropriated for the CAP Program for a fiscal year divided by the total number of CAP-Eligible Claims for the quarter for all CAP pharmacies.

f)         To ensure the proper distribution of CAP Payments under this Section, the Department may conduct audits in accordance with 89 Ill. Adm. Code 140.30.

g)         Definitions.  For purposes of this Section, an "ownership or control interest" shall have the same meaning as a person with an ownership or control interest as defined in 42 CFR 455.101.

(Source:  Added at 43 Ill. Reg. 2227, effective February 4, 2019)

Section 140.440  Pharmacy Services

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.

c)         The Department shall pay for the dispensing of pharmacy items, subject to the provisions of subsection (d) and Section 140.443, which are prescribed by a physician, dentist or podiatrist within the scope of their professional practice.

d)         Beginning with drugs dispensed on or after April 1, 1991, Department coverage shall be limited to those drug manufacturers having rebate agreements in effect as provided under section 1927 of Title XIX of the Social Security Act (42 USC 1396s).  The Department shall provide all interested parties with an updated list of drug manufacturers having rebate agreements in effect.

e)         The Department may require approval for the reimbursement of any drug except as provided in Section 140.442. When reviewing requests for prior authorization, approval decisions shall be medically based.  The Department's electronic claims processing system shall be the mechanism for identification of whether a prescribed drug requires prior authorization to dispensing pharmacists.  A printed listing of prescribed drugs available without prior approval shall be provided to other interested parties upon request.

f)         An approved request does not guarantee payment.  The recipient for whom the services/items are approved must be eligible at the time they are provided. In addition, a valid, current prescription for the requested medication must be on file and maintained by the pharmacy in accordance with the Pharmacy Practice Act [225 ILCS 85].

g)         For purposes of Sections 140.440 through 140.448, pertaining to reimbursement for drugs, the following definitions apply:

1)         Nursing facility means any facility that provides medical group care services as defined in Section 140.500.

2)         Generic drug means those legend drugs that are multiple source drugs marketed or sold by two or more labelers, marketed or sold by the same labeler under two or more different proprietary names or marketed both under a proprietary name and without such a name.

3)         Brand name drug means single-source innovator drugs and innovator multiple-source drugs when prior authorization has been obtained for reimbursing the innovator product.

h)         The Department will cover hormone therapy, whether or not in preparation for gender-affirming surgery, in accordance with Section 140.442.

(Source:  Amended at 44 Ill. Reg. 226, effective December 23, 2019)

Section 140.441  Pharmacy Services Not Covered

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.

(Source:  Amended at 38 Ill. Reg. 12141, effective May 30, 2014)

Section 140.442  Drug Product Prior Approval and the Preferred Drug List

a)         The Department may require prior approval for the reimbursement of any drug product, except as provided in this Section.  Determinations of whether a drug product is listed as preferred on the Preferred Drug List (PDL) and when prior approval for any drug product is required shall be made in the following manner:

1)         The Department shall consult with the Drug and Therapeutics Advisory Board (the Board), comprised of individuals that possess appropriate expertise in the areas of pharmacology and medicine, when determining which drug products to list as preferred on the PDL, as well as which drug products outside of the PDL require prior approval.

2)         Board Members. The Board shall be compromised of voting members appointed by the Governor in accordance with Section 5-30.11 of the Public Aid Code.

3)         Board Advisors. The Department will select nonvoting clinicians to advise the Board in accordance with Section 5-30.11.

4)         Board members shall serve 3 year terms without compensation.  Board advisors are appointed by the Department to serve 3 years terms without compensation. 

5)         Board members and advisors shall disclose conflicts of interest and shall not participate in matters in which they have a potential conflict of interest.

6)         The Board shall meet not less than one time per calendar quarter.   The recommendations of the Board shall be non-binding upon the Department and can in no way bind or otherwise limit the Department's right to determine, in its sole discretion, those drugs that shall be available with or without prior approval, or as preferred or non-preferred products.

7)         Upon U.S. Food and Drug Administration approval of a new drug product, the new drug product shall require prior approval until the Department determines otherwise.  When a newly approved drug product enters the market, or when post-marketing information becomes available for existing drug products requiring prior approval, the drug manufacturer shall be responsible for submitting materials to the Department that the Department and the Board will consider in determining whether reimbursement for the drug product will require prior approval.

8)         New dosage strengths and new dosage forms of drug products already available without prior approval (see Section 140.440(e)) shall be available without prior approval upon the request of the manufacturer, unless otherwise designated by the Director. In such a case, the Director shall submit the new dosage strength, or new form, to the prior approval procedures described in this Section.

9)         To ensure all Board members and the Department have the same information regarding drug products, drug manufacturers shall provide, in writing, all relevant drug product information to the Department and the Board in its entirety. The Board shall only consider information given to both the entire Board and the Department when reviewing a drug product.

10)        The Board shall evaluate drug products in an impartial manner, and base recommendations on clinical and cost effectiveness factors.

11)        Board members shall make motions and take votes during the meeting, and the Department shall record the results in the meeting minutes.

12)        The Department shall make a final determination on the status of drug products reviewed by the Board.  Final determinations will be made using complete clinical and financial information received by the Department.  The Department shall notify the Board and the affected manufacturers of all final determinations within 30 business days after receipt of a recommendation from the Board.

13)         Drug manufacturers shall be afforded an opportunity to request reconsideration of products recommended for prior approval or non-preferred status.  The drug manufacturers may submit any information they deem appropriate to support their request for reconsideration of the drug product.  All reconsideration requests must be submitted in writing to the Department for inclusion on the agenda at a subsequent meeting.

14)         The Department shall require that contraceptive drugs and products are available without prior approval.

b)         Prior approval shall be given for drug products if:

1)         The drug is a legend item; and

2)         The drug product is used in accordance with predetermined standards consistent with the compendia consisting of the American Hospital Formulary Service Drug Information, the United States Pharmacopeia, as well as the peer-reviewed medical literature; and

3)         Either:

A)        The drug is necessary to prevent a higher level of care, such as institutionalization; or

B)        The prescriber has determined that the drug is medically necessary over other available treatments.

c)         Decisions on all requests for prior approval by telephone or other telecommunications device and, upon the Department's receipt of the request, shall be made by the same time of the Department's next working day.  In an emergency situation, the Department shall provide for the dispensing of at least a 72-hour supply of a covered prescription drug.

d)         In accordance with subsection (d)(2), the Department may require approval prior to reimbursement for a brand name prescription drug if the patient for whom the drug is prescribed has already received three brand name prescription drugs in the preceding 30-day period and is 21 years of age or older.

1)         For purposes of this subsection (d), brand name prescription drugs in the following therapeutic classes shall not count towards the limit of three brand name prescription drugs and shall not be subject to prior approval requirements because a patient has received three brand name prescription drugs in the preceding 30 days.

A)        Antiretrovirals;

B)        Antineoplastics; and

C)        Anti-Rejection Drugs.

2)         Brand name prescription drugs are exempt from the prior approval requirements of this subsection (d) if:

A)        there are no generic therapies for the condition treated within the same therapeutic drug class; or

B)        the Department determines that the brand name prescription drug is cost effective.

e)         Effective July 1, 2012, the Department may require prior approval prior to reimbursement for a prescription drug if the patient for whom the drug is prescribed has already received four prescription drugs in the preceding 30-day period.  For purposes of this subsection (e), prescription drugs in the following therapeutic classes shall not count towards the limit of four prescription drugs and shall not be subject to prior approval requirements because a patient has received four prescription drugs in the preceding 30 days:

1)         Antiretrovirals;

2)         Antineoplastics;

3)         Anti-Rejection Drugs; and

4)         Effective July 1, 2014, Antipsychotics.

(Source:  Amended at 44 Ill. Reg. 13678, effective August 7, 2020)

Section 140.443  Filling of Prescriptions

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.

b)         To the extent required by federal law, effective with new prescriptions executed on or after April 1, 2008, for clients covered under Title XIX of the Social Security Act, a non-electronic prescription must be written on a tamper-resistant prescription pad to be eligible for reimbursement.  This requirement applies to all prescriptions regardless of whether the Department is the primary payor.

1)         Non-electronic prescriptions are prescriptions that are not transmitted from the prescriber to the pharmacy via telephone, telefax, electronic prescribing (e-prescribing) mechanism, or other means of electronic transmission.

2)         Effective April 1, 2008, a prescription form is considered tamper-resistant when it contains any of the following characteristics and, effective October 1, 2008, to be considered tamper-resistant, a prescription form must contain all of the following characteristics: 

A)        one or more industry-recognized features designed to prevent unauthorized copying of a completed or blank form;

B)        one or more industry-recognized features to prevent the erasure or modification of information written on the prescription by the prescriber;

C)        one or more industry-recognized features designed to prevent the use of counterfeit prescription forms.

3)         If a patient presents at a pharmacy with a prescription written on a prescription pad that is not tamper-resistant, and the pharmacist contacts the prescriber via telephone, telefax, or other electronic communication device, and the prescriber or the prescriber's agent verifies the validity of the prescription, the prescription is then considered "electronic" and, therefore, exempt from the requirement that the prescription be written on a tamper-resistant pad.  In such cases, the pharmacist shall note on the original prescription that the prescriber was contacted and the prescriber or the prescriber's agent verified the validity of the prescription.

4)         If a patient presents at a pharmacy with a non-electronic prescription written on a pad that is not tamper-resistant, and the pharmacist is unable to contact the prescriber or the prescriber's agent to verify the validity of the prescription, and the pharmacist's professional judgment determines that not filling the prescription poses a health risk to the patient, the pharmacist may fill the prescription and the Department will reimburse for the prescription, provided that the patient is eligible for coverage of the drug and provided that the drug is covered by the Department.  The pharmacist must obtain from the prescriber or the prescriber's agent a verbal, faxed, electronic or compliant written prescription within 72 hours after the date on which the prescription was filled.

c)         Pharmacies shall not accept blank, presigned prescription forms.

d)         If a drug is available by generic name and the identical drug is prescribed by trade name, payment will be based on cost of the generic product unless prior authorization has been obtained for reimbursement based upon the innovator product, or unless the Department determines that the innovator product, reimbursed at the brand name pricing methodology, is more cost-effective than the generic equivalent.

e)         The Department shall not pay for dispensed items in excess of the maximum quantity established by the Department, unless prior approval has been granted to dispense an amount in excess of the maximum.

f)         The Department shall pay for refills only if the prescribing practitioner authorized refills on the original prescription in accordance with State law.

g)         Pharmacies may use a unit dose system in the dispensing of drugs when such a system is in compliance with all applicable State and federal laws. The total quantity dispensed on one prescription cannot exceed the quantity prescribed or the maximum allowable quantity.

h)         Effective January 1, 2013, brand-name, solid, oral drugs dispensed to clients residing in any facility that provides medical group care services as defined in Section 140.500, except Intermediate Care Facilities for the Developmentally Disabled (ICF/DD), must be dispensed in 14-day supplies.  Exceptions: Solid oral doses of antibiotics and drugs that are dispensed in their original container as indicated in the Food and Drug Administration Prescribing Information or are customarily dispensed in their original packaging to assist patients with compliance (for example, oral contraceptives), may be dispensed in supplies for greater than 14 days.

(Source:  Amended at 46 Ill. Reg. 2046, effective January 21, 2022)

Section 140.444  Compounded Prescriptions

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.

(Source:  Amended at 19 Ill. Reg. 16677, effective November 28, 1995)

Section 140.445  Prescribed Drugs

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.

b)         Effective February 1, 2013, for generic and brand name drugs purchased under the federal drug pricing program established under Section 340B of the federal Public Health Services Act, the Department shall pay the actual acquisition cost for the drug, as billed by the provider, or the Department's established 340B allowable reimbursement rate for the drug, plus a professional dispensing fee of $12.00 for brand and generic drugs.

(Source:  Amended at 46 Ill. Reg. 2046, effective January 21, 2022)

Section 140.446  Over-the-Counter Items (Repealed)

(Source:  Repealed at 46 Ill. Reg. 2046, effective January 21, 2022)

Section 140.447  Reimbursement

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.

(Source:  Amended at 25 Ill. Reg. 14957, effective November 1, 2001)

Section 140.448  Returned Pharmacy Items

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.

Section 140.449  Payment of Pharmacy Items

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

c)         No restrictions – The drug is available to all recipient categories, including nursing home residents and recipients of basic health coverage.

d)         Group Care Restricted – The drug is available to all recipients except recipients residing in nursing homes.  The nursing home must provide the following listed items to resident recipients at no charge to the recipient:

Acetest Reagent Tablets

Albustix Strips

Chemstrip BG Strips

Chemstrip GP Chemstrip K Papers

Chemstrip Test Kit

Chemstrip UG Strips

Chemstrip UGK Strips

Chemstrip 5

Clinistix Strip

Clinitest (2 Drop)

Clinitest Analysis Set

Clinitest Analysis Set (2 Drop)

Clinitest Tablet

Clinitest Tablet Foil

Combistix

Dextrostix Reagent Strips

Dextrostix Reagent Strips Foil

Diascan Dual Pad Strips

Diastix Strips

Exactech Test Strips

Glucofilm Test Strips

Glucoscan Test Strips

Glucostix Strips

Hema-Combistix

Hemastix Strips

Hematest Tablet

Keto-Diastix

Keto-Diastix 5

Ketostix Strips

Labstix

Lancet for Diabetic Use, Sterile

N-Uristix

One Touch Test Strips

TES-Tape

Tracer BG Strips

Trendstrips

Uristix

Visidex II Reagent Strips

Any product equivalent to those on the above list or any other nonlisted diabetic testing supply

e)        Group care limited – The drug is available only to recipients residing in nursing homes.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.450  Record Requirements for Pharmacies

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.

b)         A pharmacy shall permit access to these records by authorized Department personnel on request, and shall retain such financial records as are necessary to substantiate acquisition costs for a period of not less than three years from the date of service.

c)         A pharmacy shall maintain a log of signatures for the receipt or pick up of prescriptions by the person receiving the prescription.  Such log shall list each prescription by prescription number, the date the prescription was picked up and the signature of the person picking up the prescription, except that one signature is sufficient when picking up multiple prescriptions for a single individual.  The original prescription must be maintained and match the prescription number on the log.

d)         As an alternative to maintaining the signature log described in subsection (c) of this Section, a pharmacy may opt to utilize optical scanner bar technology to document that prescriptions were, in fact, received or picked up.  At the Department's request, any pharmacy choosing to utilize optical scanner bar technology must be able to produce paper copies of the information retained electronically through the use of this technology.

e)         For pharmacies providing drugs via mail order, a shipping log may be used as an alternative to the signature log described in subsection (c) of this Section.  This mail order shipping log, which may be maintained electronically, must contain the patient's name, address, prescription number, date the prescription was shipped, and the name and/or type of carrier.  At the Department's request, any pharmacy choosing to maintain its mail order shipping log electronically must be able to produce paper copies of the information retained in said shipping log.

f)         For pharmacies providing drugs to patients residing in a long term care facility licensed by the Illinois Department of Public Health, the pharmacy shall maintain a signature log as described in subsection (c) of this Section, except that one signature is sufficient for all the medications delivered for a patient and a facility staff member may sign for the receipt of the drugs. Both the facility and the pharmacy are accountable for ensuring the accuracy of the information in the log.

g)         For pharmacies providing drugs to patients who are receiving medications in their homes with the assistance of a home health agency or hospice licensed by the Illinois Department of Public Health, or a registered nurse licensed by the Illinois Department of Professional Regulation, the pharmacy shall maintain a signature log as described in subsections (c) and (f) of this Section, except that one signature is sufficient for all the medications delivered for a patient and a home health agency representative or hospice representative may sign for the receipt of the drugs.  Both the pharmacy and the home health agency or hospice are accountable for ensuring the accuracy of the information in the log.

h)         The information required in subsections (c), (f) and (g) of this Section may be kept in an electronic form, including electronic signatures, provided that paper copies of the information, including signatures, can be printed from the electronic file.

(Source:  Amended at 28 Ill. Reg. 4958, effective March 3, 2004)

Section 140.451  Prospective Drug Review and Patient Counseling

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.

c)         Commonly accepted drug review criteria are those criteria that are consistent with peer-reviewed medical literature (that is, scientific, medical and pharmaceutical publications in which original manuscripts are rejected or published only after having been critically reviewed by unbiased independent experts) and the following compendia:

1)         American Hospital Formulary Service Drug Information;

2)         United States Pharmacopeia-Drug Information;

3)         American Medical Association Drug Evaluations;

4)         DRUG DEX Information System; and

5)         Facts and Comparisons.

(Source:  Added at 22 Ill. Reg. 16302, effective August 28, 1998)

Section 140.452  Community-based Mental Health Providers Qualified for Payment

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.

b)         To receive payment for community-based mental health services, providers must be enrolled for participation in the Medical Assistance Program, pursuant to Sections 140.11 and 140.12.

c)         Community Mental Health Centers may receive reimbursement for all services described in Section 140.454.

d)         Behavioral Health Clinics may receive reimbursement for all services described in Section 140.454, except Behavioral Health Clinics may not receive reimbursement for the services described in the following subsections of Section 140.453:  Assertive Community Treatment (Section 140.453(d)(4)(A)) and Psychosocial Rehabilitation (Section 140.453(d)(2)(F)).

e)         Independent Practitioners may receive reimbursement only for the following services: Integrated Assessment and Treatment Planning (Section 140.453(d)(1)); Therapy/Counseling (Section 140.453(d)(2)(G)); and MRO Crisis Services (Section 140.453(d)(3)).

(Source:  Amended at 43 Ill. Reg. 6736, effective May 28, 2019)

Section 140.453  Community-based Mental Health Service Definitions and Professional Qualifications

a)         Inter-Departmental Collaboration and Administration.  The Department of Human Services-Division of Mental Health (DHS-DMH) and the Department of Children and Family Services (DCFS), pursuant to an executed interagency agreement, shall ensure the administration and coordination of mental health services.

b)         Community-based Mental Health Professional Qualifications.  All individuals qualified under this Section to provide services shall only provide the services listed in this Section within their scope of practice, as defined or by federal or state law, regulation or policy.

1)         All professional definitions provided in this subsection (b) are only applicable to services detailed in this Section.

2)         Independent Practitioner (IP). An IP, as defined by Section 140.452(a)(3), may receive direct reimbursement for services pursuant to Section 140.452(e). All other credentialed staff detailed in this Section except Peer Support Workers as defined by subsection (b)(7), must be employees of a Community Mental Health Center or Behavioral Health Clinic that may qualify for reimbursement for the services provided.

3)         Licensed Practitioner of the Healing Arts (LPHA).  An LPHA is defined as:

A)        A physician who holds a valid license in the state of practice and is legally authorized under state law or rule to practice medicine in all its branches, so long as that practice is not in conflict with the Medical Practice Act of l987;

B)        An advanced practice nurse with psychiatric specialty that holds a valid license in the state of practice and is legally authorized under state law or rule to practice as an advanced practice nurse, so long as that practice is not in conflict with the Illinois Nurse Practice Act or the Medical Practice Act of 1987;

C)        A clinical psychologist who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a clinical psychologist, so long as that practice is not in conflict with the Clinical Psychologist Licensing Act;

D)        A licensed clinical professional counselor possessing a master's degree who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a licensed clinical professional counselor, so long as that practice is not in conflict with the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107];

E)        A marriage and family therapist who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a marriage and family therapist, so long as that practice is not in conflict with the Marriage and Family Therapist Licensing Act [225 ILCS 55];

F)         A clinical social worker possessing a master's or doctoral degree who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a social worker, so long as that practice is not in conflict with the Clinical Social Work and Social Work Practice Act.

4)         Qualified Mental Health Professional (QMHP).  A QMHP is defined as one of the following:

A)        Any individual identified as an LPHA in subsection (b)(3);

B)        A registered nurse who holds a valid license in the state of practice, is legally authorized under state law or rule to practice as a registered nurse, so long as that practice is not in conflict with the Illinois Nurse Practice Act, and has training in mental health services or one year of clinical experience, under supervision, in treating problems related to mental illness, or specialized training in the treatment of children and adolescents.

C)        An occupational therapist who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as an occupational therapist, so long as that practice is not in conflict with the Illinois Occupational Therapy Practice Act [225 ILCS 75] with at least one year of clinical experience in a mental health setting.  In the event the state of practice does not provide a legal authority for licensure, the individual must meet the requirements of 42 CFR 484.4 for an occupational therapist.

D)        An individual possessing a master's or doctoral degree in counseling and guidance, rehabilitation counseling, social work, psychology, pastoral counseling, family therapy, or a related field and has:

i)          Successfully completed 1,000 hours of practicum and/or internship under clinical and educational supervision; or

ii)         One year of documented clinical experience under the supervision of a QMHP.

5)         Mental Health Professional (MHP)

A)       An MHP is defined as one of the following:

i)          Any individual identified as a QMHP in subsection (b)(4); or

ii)         An individual meeting the following qualifications, delivering services under the supervision of a QMHP:

•           An individual possessing a bachelor's degree in counseling and guidance, rehabilitation counseling, social work, education, vocational counseling, psychology, pastoral counseling, family therapy, or related human service field;

•           An individual possessing a bachelor's degree in any field, other than those identified in subsection (b)(4)(D), with two years of documented clinical experience in a mental health setting under the supervision of a QMHP;

•           A practical nurse who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a practical nurse, so long as that practice is not in conflict with the Illinois Nurse Practice Act;

•           An individual possessing a certificate of psychiatric rehabilitation from a DHS-approved program, plus a high school diploma or GED, plus two years' documented experience in providing mental health services;

•           A recovery support specialist with a current certification from the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc.;

•           A family partnership professional with current certification from the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc.;

•           An occupational therapy assistant with at least one year of experience in a mental health setting that holds a valid license in the state of practice and is legally authorized under state law or rule to practice as an occupational therapist assistant, so long as that practice is not in conflict with the Illinois Occupational Therapy Practice Act.  In the event the state of practice does not provide a legal authority for licensure, the individual must meet the requirements of 42 CFR 484.4 for an occupational therapist; or

•           An individual with a high school diploma or GED and a minimum of five years documented clinical experience in mental health or human services.

•           An individual who has completed a behavioral health technician or other psychiatric training certification through the Medical Education and Training Campus in Fort Sam Houston, Texas, with one year documented clinical experience in a mental health setting under supervision of a QMHP.          

B)        Any individual designated as an MHP prior to July 1, 2011 shall retain that designation throughout the continual course of his/her employment.  In the event that the individual leaves the current employer, the designation is no longer valid.

6)         Rehabilitative Services Associate (RSA).  An RSA is defined as one of the following:

A)        Any individual identified as a QMHP in subsection (b)(4); or

B)        An individual meeting the following qualifications, delivering services under the supervision of a QMHP:

i)          Any individual identified as an MHP in subsection (b)(5);

ii)         Any individual who is 21 years of age and demonstrates all of the following:

•           Skill in the delivery of rehabilitative services to adults or children;

•           The ability to work within a provider agency's structure and accept supervision; and

•           The ability to work constructively with individuals receiving services, other providers of service, and the community; or,

iii)        An individual qualified as a PSW pursuant to subsection (b)(7).

7)         Peer Support Worker (PSW). A PSW delivers services from the peer perspective, under the supervision of a QMHP, and must be an individual who:

A)        Is 21 years of age;

B)        Has individual lived experience, or experience as a caregiver of a child, with behavioral health needs;

C)        Demonstrates the ability to work within agency structure, accept supervision, and participate as a member of a multi-disciplinary team, when applicable; and

D)        Has completed a Department-approved peer support training or certification process.

c)         Service Reimbursements.  The services detailed in subsections (d) and (e) may be eligible for reimbursement pursuant to the Department's published fee schedule when the services are:

1)         Recommended by an LPHA or IP, operating within his/her scope of practice.  Unless otherwise noted in this Section, the term services "recommended by an LPHA or IP" shall mean:

A)        The services of Integrated Assessment and Treatment Planning performed by an LPHA or IP to determine an individual's potential clinical need for services; or

B)        Those services identified by the LPHA or IP following the completion of an Integrated Assessment and Treatment Plan;

2)         Provided to an individual for the maximum reduction of mental disability and restoration to the best possible functional level in accordance with 42 CFR 440.130.  A mental disability, for the purposes of receiving services under this Section is established as follows:

A)        The identification of a diagnosis, a functional impairment, and treatment recommendations by the LPHA or IP following the completion of the Integrated Assessment and Treatment Plan; or

B)        For children under age 21 who do not meet the criteria listed in subsection (c)(2)(A), the identification of more than one documented criterion for a mental disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a documented impact on the child's functioning in more than one life domain, and treatment recommendations by the LPHA or IP following the completion of the Integrated Assessment and Treatment Plan;

3)         Provided consistent with any service limitations, utilization controls, and prior authorizations established by the Department.  All prior authorizations for the services detailed in this Section shall be completed by the Department or its approved agent; and

4)         Provided for the direct benefit of the child, which may include support provided to immediate caregivers of the eligible child.

d)         Medicaid Rehabilitation Option (MRO).  The following services are established as qualified mental health services under section 1905(a)(13)(C) of the Social Security Act (42 USC 1396d(19)).

1)         Integrated Assessment and Treatment Planning (IATP).  IATP is the formal process of information gathering and review that utilizes a standardized assessment and service planning tool in order to: identify a client's integrated healthcare needs and strengths across all domains; recommend services needed to ameliorate a client's condition and improve well-being; and develop, review, and update an individualized treatment plan.

A)        The IATP shall:

i)          Be completed once every 180 days;

ii)         Only be reimbursed upon utilization of a Department approved assessment and service planning instrument as published on the Department's website;

iii)        Be reviewed, approved and signed by an LPHA;

iv)        Be provided to the client, or the client's parent or guardian, upon completion or revision.

B)        The IATP service is also inclusive of the following functions:

i)          Clinical assessment activities, performed by, or under the supervision of, an LPHA using a nationally standardized assessment instrument resulting in a written report or documented outcome that includes the identification of a clinical issue or tentative diagnosis to assist in the completion of IATP;

ii)         Diagnostic assessment activities, only when provided consistent with the Clinical Psychologist Licensing Act [225 ILCS 15] and using a nationally standardized psychological assessment instrument, resulting in a written report that includes the identification of issues, tentative diagnosis, and recommendations for treatment or services; and

iii)        The completion of the Level of Care Utilization System (LOCUS) screen, or its successor instrument.

C)        IATP may be provided:

i)          By Community Mental Health Centers, Behavioral Health Clinics, or Independent Practitioners;

ii)         At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

iii)        On an individual basis;

iv)        By an MHP, QMHP, LPHA; and

v)         By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

2)         General MRO Services

A)        Community Support Services. Community Support Services shall consist of therapeutic interventions that facilitate illness self-management, identification and use of natural supports, and skill building. 

i)          Community Support Services includes: engaging the individual to have input into his/her service delivery and recovery process; development of relapse prevention strategies and plans; assistance in development of functional, interpersonal and community coping skills (including adaptation to home, school, family and work environments); and skill-building related to symptom self-monitoring.  Community Support Services may include an evidence-informed approach to skills training.

ii)         Community Support Services may only be provided:

•           By a Community Mental Health Center or Behavioral Health Clinic;

•           At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

•           In an individual or group modality;

•           By an RSA, MHP, QMHP, LPHA; and

•           By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

B)        Intensive Outpatient (IO) Services. Intensive Outpatient Services are scheduled group therapeutic sessions made available for at least four hours per day, five days per week, for individuals at risk of, or with a history of, psychiatric hospitalization. 

i)          IO Services may only be provided:

•           By a Community Mental Health Center or Behavioral Health Clinic;

•           Through programs approved pursuant to Table N;

•           At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

•           By a QMHP;

•           In a group modality; and

•           On a face-to-face basis.

ii)         IO services may be subject to prior authorization, pursuant to Section 140.40.

C)        Medication Administration.  Medication Administration consists of preparing the individual and the medication for administration and observing the individual for possible adverse reactions.  Medication Administration services may only be provided:

i)          By a Community Mental Health Center or Behavioral Health Clinic;

ii)         At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

iii)        On an individual basis;

iv)        By face-to-face contact; and

v)         By staff that hold a valid license in the state of practice and are legally authorized under state law or rule to administer medication, so long as that practice is not in conflict with the Illinois Nurse Practice Act or the Medical Practice Act of 1987 (e.g., a physician, a psychiatrist, advanced practice nurse, registered nurse or a practical nurse).

D)        Medication Monitoring.  Medication Monitoring includes observation, evaluation and discussion of target symptoms responses, adverse effects, laboratory results, tardive dyskinesia screens, and new target symptoms or medications. Medication Monitoring services may only be provided:

i)          By a Community Mental Health Center or Behavioral Health Clinic;

ii)         At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

iii)        On an individual basis;

iv)        By an RSA, MHP, QMHP or LPHA, as designated in writing to provide the service by staff that hold a valid license in the state of practice and are legally authorized under state law to prescribe medication pursuant to the Illinois Nurse Practice Act or the Medical Practice Act of 1987; and

v)         By video or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403. Phone consultation is allowed only when a client is experiencing adverse symptoms and phone consultation with another professional is necessary.

E)        Medication Training.  Medication Training includes training individuals on self-administration and safeguarding of medication and communication with other professionals, family or caregivers on medication issues.  Medication Training services may only be provided:

i)          By a Community Mental Health Center or Behavioral Health Clinic;

ii)         At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

iii)        In an individual or group modality;

iv)        By video or face-to-face contact; and

v)         By an RSA, MHP, QMHP or LPHA, as designated in writing to provide the service by staff that hold a valid license in the state of practice and are legally authorized under state law to prescribe medication pursuant to the Illinois Nurse Practice Act or the Medical Practice Act of 1987.

F)         Psychosocial Rehabilitation (PSR). PSR shall be rehabilitative therapy for individuals designed to increase abilities and resources necessary for community living, socialization, work and recovery.  Core activities include cognitive-behavioral interventions, problem solving, interventions to reduce or ameliorate symptoms of a co-occurring disorder and other rehabilitative interventions.  PSR is provided in an organized program through individual and group interventions.  The focus of treatment interventions includes capacity building to facilitate independent living and adaptation, problem solving and coping skills development.

i)          PSR services may only be provided:

•           On-site at a Community Mental Health Center;

•           Through a program that is approved pursuant to Table N;

•           In an individual or group modality.  The staffing ratio for groups shall not exceed one full-time equivalent staff to 15 individuals;

•           By an RSA, MHP, QMHP and LPHA; and

•           By face-to-face contact.

ii)         PSR may be subject to prior authorization, pursuant to Section 140.40.

G)        Therapy/Counseling.  Therapy/Counseling is a treatment modality that uses interventions based on psychotherapy theory and techniques to promote emotional, cognitive, behavioral or psychological changes.  Therapy/Counseling Services may be provided:

i)          By a Community Mental Health Center, Behavioral Health Clinic, or Independent Practitioner;

ii)         At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

iii)        In an individual, group or family modality;

iv)        By an MHP, QMHP and LPHA; and

v)         By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

3)         MRO Mental Health Crisis Services

A)        Crisis Services. Crisis Services are short-term, time-limited interventions that may be provided prior to, or without, an established IATP.

i)          Crisis Intervention.  Crisis Intervention is short-term intervention for clients who, in the course of treatment or intervention, appear to need immediate intensive intervention to achieve crisis symptom reduction and stabilization.  Crisis Intervention shall be provided:

•           By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Section 140.6(n) and 140.403; and

•           By a QMHP, LPHA or MHP with immediate access to a QMHP. 

ii)         Mobile Crisis Response (MCR).  MCR is a mobile, responding to the location of the client, intervention seeking to achieve crisis symptom reduction, stabilization, and restoration of the client to a previous level of functioning, establishing support for the client's caregivers when applicable, mitigating the crisis event.  MCR activities are tailored to the needs of the client, require face-to-face crisis screening, and may include: short-term intervention; crisis safety planning; brief counseling; consultation with other qualified providers to assist with the client's specific crisis; referral and linkage to community services; and, in the event that the client cannot be stabilized in the community, facilitation of a safe transition to a higher level of care.  MCR shall be provided:

•           By a provider certified by the Department to provide MRO Crisis Services pursuant to Table N;

•           On a face-to-face basis;

•           By a crisis team trained in crisis de-escalation techniques, led by a QMHP, LPHA or MHP with immediate access to a QMHP and at least one other individual meeting any of the qualifications detailed in subsection (b); and

•           Utilizing a Department approved crisis screening instrument available on the Department's website.

iii)        Crisis Stabilization.  Crisis Stabilization services are available immediately following an MCR event and are designed to prevent additional behavioral health crises from occurring by providing strengths-based, individualized, direct supports on a one-on-one basis to clients in the home or community setting.  Crisis Stabilization services shall be provided:

•           By a provider certified by the Department to provide MRO Crisis Services pursuant to Table N;

•           Upon demonstrated need for stabilizing supports as documented in the client's Crisis Safety Plan following the review, approval, and signature by an LPHA.  The Crisis Safety Plan contains an identification of diagnosis, need or functional impairment; a treatment recommendation of Crisis Stabilization service accompanied by a recommendation for service amount, frequency and duration; and documentation of the entity responsible for service delivery;

•           On a face-to-face basis; and

•           By an MHP, with immediate access to a QMHP, trained in crisis intervention techniques.

4)         Team-based MRO Services

A)        Assertive Community Treatment (ACT) Services. ACT Services consist of integrated crisis, treatment and rehabilitative supports provided by an interdisciplinary team to individuals with serious and persistent mental illness or co-occurring mental health and substance use disorders.  ACT Services are intended to promote symptom stability, management of co-morbid health conditions, and appropriate use of psychotropic medications, as well as to restore personal care, community living, work and social skills.  ACT Services encompass counseling and therapy, medication management and monitoring, skill building, and crisis stabilization services.  ACT Services focus on the restoration of functional skills (e.g., psychosocial, adaptive, self-care) to promote and maintain community living. 

i)          ACT Services shall be:

•           Provided only by Community Mental Health Centers;

•           At least one member of the team who is either a Certified Recovery Support Specialist (CRSS) or Certified Family Partnership Professional (CFPP), based upon the age of the clients served by the team.  A person with lived experience may be included on a team that does not have a CRSS or CFPP if he/she obtains certification within 18 months after his/her date of hire; and

•           Available 24 hours per day, seven days a week, each week of the year.

ii)         ACT Services may only be provided:

•           To eligible individuals age 18 or older;

•           At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

•           In an individual or group modality; and

•           By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

iii)        ACT Services may be subject to prior authorization, pursuant to Section 140.40.

iv)        ACT Services shall be delivered by a team led by a full-time:

•           LPHA;

•           Licensed social worker (LSW) possessing at least a master's degree in social work, who holds a valid license in the state of practice and is legally authorized under that state's law or rule to practice as an LSW so long as that practice is not in conflict with the Clinical Social Work and Social Work Practice Act [225 ILCS 20] and who has specialized training in mental health services, or with at least two years experience in mental health services;

•           Licensed professional counselor possessing at least a master's degree, who holds a valid license in the state of practice and is legally authorized under that state's law or rule to practice as a licensed professional counselor so long as that practice is not in conflict with the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107] and who has specialized training in mental health services, or with at least two years experience in mental health services;

•           Registered nurse (RN) who holds a valid license in the state of practice and is legally authorized under that state's law or rule to practice as a RN, so long as that practice is not in conflict with the Nursing and Advanced Practice Nursing Act [225 ILCS 65], and who has at least one year of clinical experience in a mental health setting or a master's degree in psychiatric nursing; or

•           Occupational therapist (OT) who holds a valid license in the state of practice, is legally authorized under that state's law or rule to practice as an OT, so long as that practice is not in conflict with the Illinois Occupational Therapy Practice Act [225 ILCS 75] and who has at least one year of clinical experience in a mental health setting.

B)        Community Support Team (CST). CST consists of mental health rehabilitation services and supports to decrease hospitalization and crisis episodes and to increase community functioning in order for the individual to achieve rehabilitative, resiliency and recovery goals.  CST facilitates illness self-management, skill building, identification and use of adaptive and compensatory skills, identification and use of natural supports, and use of community resources. 

i)          CST Services shall be:

•           Provided only by programs approved pursuant to Table N;

•           Delivered by a team led by a full-time QMHP; and

•           Available 24 hours per day, seven days a week, each week of the year.

ii)         CST Services may only be provided:

•           By a Community Mental Health Center or Behavioral Health Clinic;

•           At all service locations and setting deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

•           On an individual basis;

•           By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

iii)        CST Services may be subject to prior authorization, pursuant to Section 140.40.

C)        Violence Prevention Community Support Team (VP-CST).  VP-CST consists of trauma-informed therapeutic interventions and supports focused on reducing traumatic stress symptoms and increasing community functioning for individuals who have experienced chronic exposure to firearm violence.  VP-CST facilitates symptom self-monitoring and management, identification and use of natural supports, and skill building.  The service includes engaging individuals in the service delivery and trauma recovery process; development of strategies and plans to increase safety and community stabilization; and assistance in the development of functional, interpersonal, and community coping skills.

i)          VP-CST services must be delivered:

•           Consistent with the fidelity requirements outlined in the Department's provider handbook for community-based behavioral health and available on the Department's website;

•           By a Community Mental Health Center or Behavioral Health Clinic that has been approved to deliver VP-CST pursuant to Table N;

•           By a team overseen by a full-time QMHP;

•           By staff who meet the qualifications of a PSW, RSA, MHP, QMHP, or LPHA;

•           In an individual, group, or family modality;

•           By video, phone, or face-to-face contact, notwithstanding the restriction on services provided via phone in 89 Ill. Adm. Code 140.6(m) and 140.403;

•           At a service location and setting deemed appropriate for reimbursement, as detailed in the Department's published fee schedule; and

•           Available 24 hours per day, seven days a week, each week of the year.

ii)         VP-CST services may be subject to prior authorization, pursuant to Section 140.40.

e)         Targeted Case Management (TCM).  The following services are established pursuant to section 1905(a)(19) of the Social Security Act (42 USC 1396d(a)(19)).

1)         Types of TCM Services

A)        Client-centered Consultation Case Management. Client-centered Consultation Case Management consists of client-specific professional communications among provider staff or between provider staff and staff of other providers who are involved with service provision to the individual.  Professional communications include offering or obtaining a professional opinion regarding the individual's current functioning level or improving the individual's functioning level, discussing the individual's progress in treatment, adjusting the individual's current treatment, or addressing the individual's need for additional or alternative mental health services.  Client-centered Consultation Case Management services may only be provided:

i)          To eligible individuals receiving one or more services detailed in Section 140.453(d)(2) (General MRO Services);

ii)         By a Community Mental Health Center or Behavioral Health Clinic;

iii)        At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

iv)        On an individual basis;

v)         By an RSA, MHP, QMHP and LPHA; and

vi)        By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

B)        Mental Health Case Management Services. Mental Health Case Management Services consist of: assessment, planning, coordination and advocacy services for individuals who need multiple services and require assistance in gaining access to and in using behavioral health, physical health, social, vocational, educational, housing, public income entitlements and other community services to assist the individual in the community.  Mental Health Case Management Services may also include identifying and investigating available resources, explaining options to the individual, and linking the individual with necessary resources.  Mental Health Case Management Services may be provided:

i)          For 30 days prior to completion of the Integrated Assessment and Treatment Plan;

ii)         By a Community Mental Health Center or Behavioral Health Clinic;

iii)        At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

iv)        On an individual basis;

v)         By an RSA, MHP, QMHP and LPHA; and

vi)        By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

C)        Transition Linkage and Aftercare Case Management Services shall be provided to assist in an effective transition in living arrangements, consistent with the individual's welfare and development.  This includes discharge from institutional settings, transition to adult services, and assisting the individual or the individual's family or caretaker with the transition.

i)          Transition, Linkage and Aftercare Limitation.  The Department will not fund more than 40 hours of this service per State fiscal year for an eligible individual.

ii)         Transition, Linkage and Aftercare may only be provided:

•           By a Community Mental Health Center or Behavioral Health Clinic;

•           At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

•           On an individual basis;

•           By an MHP, QMHP and LPHA; and

•           By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

iii)        Transition Linkage and Aftercare Case Management Services may be subject to prior authorization, pursuant to Section 140.40.

2)         Limitation on Targeted Case Management Services.  The Department shall not fund more than 240 total hours of targeted case management services per State fiscal year per individual (not per provider).

(Source:  Amended at 46 Ill. Reg. 16740, effective September 20, 2022)

Section 140.454  Types of Mental Health Services

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.

(Source:  Amended at 42 Ill. Reg. 12986, effective June 25, 2018)

Section 140.455  Payment for Mental Health Services

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.

(Source:  Amended at 43 Ill. Reg. 6736, effective May 28, 2019)

Section 140.456  Hearings

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.

(Source:  Amended at 42 Ill. Reg. 12986, effective June 25, 2018)

Section 140.457  Therapy Services

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.

d)         Effective with dates of services February 1, 2022 and after, payment shall be made for Adaptive Behavior Support (ABS) services for treatment of autism spectrum disorders when provided pursuant to 89 Ill. Adm. Code 140.465.

(Source:  Amended at 48 Ill. Reg. 864, effective December 27, 2023)

Section 140.458  Prior Approval for Therapy Services

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.

b)         Effective October 1, 2014, prior approval shall be required for all individuals, except for individuals eligible for services under Medicare and except when the individual is under age 21 and the date of service is prior to July 1, 2015.

c)         Approval will be granted when, in the judgment of a consulting physician and/or professional staff of the Department, the services are medically necessary and appropriate to meet the individual's medical needs.

d)         The decision to approve or deny a request for prior approval will be made within 21 days after the date the request and all necessary information is received.

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)

Section 140.459  Payment for Therapy Services

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.

b)         Maximum Reimbursement Rates.  The maximum reimbursement rate:

1)         Effective July 1, 2020, therapy outpatient services provided by a hospital are reimbursed as defined in 148.140.

2)         For all other therapy services (paid per quarter hour), rates shall be as published on the Department's website in the Therapy Fee Schedule located at http://www2.illinois/gov/hfs/MedicalProviders/MedicaidReimbursement/Pages/TherapyFeeSchedule.aspx.

(Source:  Amended at 46 Ill. Reg. 5725, effective March 25, 2022)

Section 140.460  Clinic Services

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.

b)         Behavioral Health Clinics are eligible to receive payment for community-based mental health services as defined in Section 140.454, except Behavioral Health Clinics may not receive reimbursement for the services described in Section 140.453(d)(4)(A) (Assertive Community Treatment) and (d)(2)(F) (Psychosocial Rehabilitation).

c)         Clinics enrolled for participation in the Medical Assistance Program pursuant to Sections 140.11 and 140.12 to receive reimbursement on an encounter rate basis are prohibited from receiving reimbursement from the Department for the provision of services in Section 140.453 in any form other than their established behavioral health encounter rate.

(Source:  Amended at 43 Ill. Reg. 6736, effective May 28, 2019)

Section 140.461  Clinic Participation, Data and Certification Requirements

a)         Hospital-based organized clinics must:

1)         Have an administrative structure, staff program, physical setting, and equipment to provide comprehensive medical care.

2)         Agree to assume complete responsibility for diagnosis and treatment of the patients accepted by the clinic, or provide, at no additional cost to the Department, for the acquisition of these services through contractual arrangements with external medical providers.

3)         Meet one of the following requirements:

A)        Be adjacent to or on the premises of a hospital:

i)          licensed under the Hospital Licensing Act or the University of Illinois Hospital Act; or

ii)         that meets all comparable conditions and requirements of the Hospital Licensing Act in effect for the state in which it is located.

B)        Have provider-based status under Medicare pursuant to 42 CFR 413.65.

C)        Be clinically integrated as evidenced by all of the following:

i)          Professional staff of the clinic have clinical privileges at the main hospital; the main hospital maintains the same monitoring and oversight of the clinic as it does for any other department of the hospital; medical staff committees or other professional committees at the main hospital are responsible for medical activities in the clinic, including quality assurance, utilization review, and the coordination and integration of services, to the extent practicable, between the clinic and the main hospital; medical records for patients treated in the clinic are integrated into a unified retrieval system of the main hospital, or cross reference that retrieval system; and inpatient and outpatient services of the clinic and the main hospital are integrated, and patients treated at the clinic who require further care have full access to all services of the main hospital and are referred when appropriate to the corresponding inpatient or outpatient department or service of the main hospital.

ii)         Fully integrated within the financial system of the main hospital, as evidenced by shared income and expenses between the main hospital and the clinic.

iii)        Held out to the public and other payers as part of the main hospital.

iv)        Operated under the ownership and control of the main hospital, as evidenced by the following: the business enterprise that constitutes the clinic is 100 percent owned by the main hospital; the main hospital and the clinic have the same governing body; the clinic is operated under the same organizational documents (e.g., bylaws and operating decisions) as the main hospital; and the main hospital has final responsibility for personnel policies (such as fringe benefits or code of conduct), and final approval for medical staff appointments in the clinic.

v)         Located within a 35 mile radius of the main hospital campus as defined in 42 CFR 413.65.

4)         Meet the applicable requirements of 89 Ill. Adm. Code 148.40(d).

b)         Encounter Rate Clinics

1)         Encounter rate clinics must:

A)        have participated in the Medical Assistance Program as an encounter rate clinic as of July 1, 1998; or

B)        be a clinic operated by an Illinois county with a population of over three million. 

2)         Individual practitioners associated with these clinics may apply for participation in the Medical Assistance Program in their individual capacities. In order to participate in the Maternal and Child Health Program, as described in Subpart G, encounter rate clinics shall be required to meet the additional participation requirements described in Section 140.924(a)(2).

c)         Rural health clinics must be certified by the Centers for Medicare and Medicaid Services as meeting the requirements for Medicare participation.

d)         Federally Qualified Health Centers (FQHC):

1)         Must meet one of the following criteria:

A)        Receive a grant under Section 329, 330 or 340 of the Public Health Service Act (42 USC 329, 330 or 340).

B)        Based on the recommendation of the Health Resources and Services Administration within the U.S. Department of Health and Human Services, be determined to meet the requirements for receiving a grant.

2)         Section 1902(a)(55) of the Social Security Act (42 USC 1396a(a)(55)), requires states to receive and initially process Medicaid applications from low-income pregnant women and children under 19 years of age at locations other than the local Department of Human Services (DHS) office.  These sites are referred to as outstations.

A)        Outstations will be located at those FQHCs that the Department determines serve heavy Medicaid populated areas.  For areas in which the Department determines that maintaining outstation workers is not economical, the DHS Family Community Resource Center (FCRC) will continue to be the application location.

B)        The FQHCs, which will provide outstation eligibility staff to accept and assist in the initial processing of the Medicaid application for pregnant women and children, will forward the completed application to the appropriate DHS FCRC.  Initial processing means accepting and completing the application, providing information and referrals, obtaining required documentation to complete processing of the application, assuring that the information contained on the application form is complete and conducting any necessary interviews.  Neither the FQHCs nor the outstation workers will evaluate the information contained on the application, nor make any determination of eligibility or ineligibility.  The DHS FCRC is responsible for these functions.

C)        Costs allowable under the federal outstation mandate for completing the Medicaid application will be itemized in Section B of Schedule I of the FQHC Medicaid cost report and will be provided annually in the FQHC cost reporting process.  These allowable costs will be collected, computed and calculated, and will result in the establishment of an outstation administrative rate and a Medicaid rate.  The allowable costs are:

i)          Salary of outstation worker.

ii)         Fringe benefits.

iii)        Training.

iv)        Travel.

v)         Supplies.

D)        FQHC outstation workers must receive certification through Maternal and Child Health (MCH) process training by the Department before they begin to perform eligibility processing functions.  Failure to become certified results in any MCH application completed by an ineligible worker being non-allowed on the cost report.

E)        FQHCs must have adequate staff trained with proper backup to accommodate unforeseen problems.  FQHCs must be able to meet the demand of this initiative, either using staff at one location or rotating staff as dictated by workload or staffing availability.  The FQHC must have staff available at each outstation location during regular office operating hours.

F)         Outstation intake staff may perform other FQHC intake processing functions, but the time spent on outstation activities must be documented and must be identifiable for cost reporting and auditing purposes.

G)        The FQHC must display a notice in a prominent place at the outstation location advising potential applicants of the times that outstation intake workers will be available.  The notice must include a telephone number that applicants may call for assistance.

H)        The FQHC must comply with federal and State laws and regulations governing the provision of adequate notice to persons who are blind or deaf or who are unable to read or understand the English language.

e)         Individual practitioners associated with such centers may apply for participation in the Medical Assistance Program in their individual capacities.

f)         School Based/Linked Health Clinics (centers) must be certified by the Department of Human Services (DHS) that they are meeting the minimum standards established by DHS (77 Ill. Adm. Code 2200). Examples of certification requirements include:

1)         School based health centers must be located in schools or on school grounds, serving at least the students attending that school.

2)         School linked health centers are located off school grounds, but a formal relationship must exist to serve students attending a particular school or multiple schools within the district.

3)         All medical services performed by mid-level practitioners (i.e., medical services providers who are not physicians), such as nurse practitioners, must be under the direction of a physician.

4)         The center must have a medical director.  The medical director of the center must be a qualified physician, licensed in Illinois to practice medicine in all its branches.  Each center's medical director must develop standing orders and protocols for services provided at the center.  The medical director shall ensure compliance with the policies and procedures pertaining to medical procedures and health care services.  The medical director shall supervise the medical protocols involving direct care of students.  The center must have consultant or back-up physicians with hospital admitting privileges.  The consultant provider of the clinic for obstetrical care, as appropriate, must have delivery privileges.  All medical services must be delivered in accordance with the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Academy of Family Practice Guidelines and the standards established by outside regulatory agencies.

5)         All laboratory services must be in compliance with the Clinical Laboratory Improvement Amendments (CLIA) of 1988 (42 USC 263a).  DHS will provide ongoing monitoring to assure that appropriate standards are followed.

6)         The center shall be staffed by Illinois licensed, registered, and/or certified health professionals who are trained and experienced in community and school health, and who have knowledge of health promotion and illness prevention strategies for children and adolescents.  The center must ensure that staff are assigned responsibilities consistent with their education and experience, supervised, evaluated annually and trained in the policies and procedures of the center.

7)         The center must establish procedures for the availability of primary care providers and for 24-hour per day, 12-month per year access to routine, urgent and emergency care, telephone appointments and advice.  The center must have in place telephone answering methods that notify students and parents/guardians where and how to access 24-hour back-up services when the center is not open.

8)         Services may be provided to eligible students who have obtained written parental consent, or who are 18 years of age, and/or who are otherwise able to give their own consent.

9)         The center must coordinate care and the exchange of information necessary for the provision of health care of the student, between the center and a student's primary care practitioner, medical specialist or managed care entity.  Written policies must address obtaining student and/or parental consent to share information regarding a student's health care.

10)         The center must operate in accordance with a systematic process for referring students to community-based health care providers when the center is not able to provide the services required by the student.  The center may provide medical care to a Managed Care Entity (MCE) enrolled student.  The center shall refer that MCE enrolled student to the MCE primary care provider for continuing and definitive care.

A)        The center shall refer a student who requires specialty medical and/or surgical services to his or her primary care provider or MCE to obtain a referral for a specialist.

B)        The center shall document in the student's record that the referral was made, and document follow-up on the outcome of the referral when relevant to the health care provided by the center.

11)         The center must develop a collaborative relationship with other health care providers, insurers, managed care organizations, the school health program, students and parents or guardians with the goal of assuring continuity of care, pertinent medical record sharing and reducing duplication and fragmentation of services.

12)         Data Requirements

The center shall maintain a health record system that provides for consistency, confidentiality, storage and security of records for documenting significant student health information and the delivery of health care services.

g)         Hospital Outpatient Departments

Hospital outpatient departments may include facilities that meet the requirements of subsection (a)(3) of this Section.

h)         County-operated Outpatient Facilities

A county-operated outpatient facility is a non-hospital-based clinic operated by and located in an Illinois county with a population exceeding three million.

1)         Critical Clinic Providers.  A critical clinic provider is a county-operated outpatient facility that is within or adjacent to a large public hospital as defined in 89 Ill. Adm. Code 148.25(a)(1).

2)         County Ambulatory Health Centers.  A county ambulatory health center is a county-operated outpatient facility that is not a critical clinic provider.

3)         County-operated outpatient facilities shall submit outpatient cost reports to the Department within 90 days after the close of the facility's fiscal year.

(Source:  Amended at 38 Ill. Reg. 15081, effective July 2, 2014)

Section 140.462  Covered Services in Clinics

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).

c)         Rural Health Clinics

Those core services for which the clinic or center may bill an encounter as described in 42 CFR 440.90 (2000) are as follows:

1)         Physician's Services, including covered services of nurse practitioners, nurse midwives and physician-supervised physician assistants.  Group psychotherapy services must meet the guidelines set forth in Section 140.413(a)(4)(C).

2)         Group Psychotherapy Services – Payment may be made for up to two group sessions per week, with a maximum of one session per day.  The following conditions must be met for group psychotherapy:

A)        documentation maintained in the patient's medical record must indicate the person participating in the group session has been diagnosed with a mental illness as defined in the International Classification of Diseases 9^th Revision, Clinical Modification (ICD-9-CM) or, upon implementation, International Classification of Diseases, 10^th Revision, Clinical Modification (ICD-10-CM), or the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).  The allowable diagnosis code ranges will be specified in the Handbook for Practitioners Rendering Medical Services;

B)        beginning February 1, 2013, the entire group of psychotherapy services must be directly performed by one of the following practitioners:

i)          a physician licensed to practice medicine in all its branches who has completed an approved general psychiatry residency program or is providing the service as a resident or attending physician at an approved or accredited residency program;

ii)         an Advanced Practice Registered Nurse holding a current certification in Psychiatric and Mental Health Nursing as set forth in 68 Ill. Adm. Code 1305.Appendix A;

iii)        Psychologist;

iv)        Licensed Clinical Social Worker;

v)         Licensed Clinical Professional Counselor; or

vi)        Licensed Marriage and Family Therapist;

C)        the group size does not exceed 12 patients, regardless of payment source;

D)        the minimum duration of the group session is 45 minutes;

E)        the group session is documented in the patient's medical record by the rendering practitioner, including the session's primary focus, level of patient participation, and begin and end times of each session;

F)         the group treatment model, methods and subject content have been selected on evidence-based criteria for the target population of the group and follows recognized practice guidelines for psychiatric services;

G)        the group session is provided in accordance with a clear written description of goals, methods and referral criteria; and

H)        group psychotherapy is not covered for recipients who are residents in a facility licensed under the Nursing Home Care Act [210 ILCS 45] or the Specialized Mental Health Rehabilitation Act [210 ILCS 48].

3)         Other services for which a separate encounter may be billed include dentist and behavioral health services as defined in Section 140.463(a).

4)         Medically-necessary services and supplies furnished by or under the direction of a physician or dentist within the scope of licensed practice that have been included in the cost report but neither fee-for-service nor encounter billings may be billed.  Some examples of these services include:

A)        medical case management;

B)        laboratory services;

C)        occupational therapy;

D)        patient transportation;

E)        pharmacy services;

F)         physical therapy;

G)        podiatric services;

H)        speech and hearing services;

I)         x-ray services;

J)         health education;

K)        nutrition services;

L)        optometric services.

5)         A rural health clinic (RHC) that adds behavioral health services or dental services on or after October 1, 2001, must notify the Department in writing.  These services are to be billed as an encounter with a procedure code that appropriately identifies the service provided.

6)         Any service that is no longer provided on or after October 1, 2001, or any new service added on or after October 1, 2001, must be communicated to the Department in writing prior to billing for the services.

7)         Effective January 1, 2001, the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) precludes fee-for-service billings for any RHC services with the exception of services identified in subsections (c)(8) and (c)(9).

8)         Effective July 1, 2012 through June 30, 2013, a physician or APRN may submit fee-for-service billings for implantable contraceptive devices administered in an RHC.  Reimbursement for the implantable contraceptive devices shall be made in accordance with the following:

A)        To the extent that the implantable device was purchased under the 340B Drug Pricing Program, the device must be billed at the RHC's actual acquisition cost;

B)        The RHC must be listed as the payee on the claim;

C)        Reimbursement shall be made at the RHC 's actual acquisition cost or the rate on the Department's practitioner fee schedule, whichever is applicable;

D)        This reimbursement shall be separate from any encounter payment the RHC may receive for implanting the device.

9)         Effective July 1, 2013, an RHC may submit fee-for-service billings for Long Acting Reversible Contraceptives (LARCs).  For dates of service October 1, 2014 and after, an RHC may submit fee-for-service billing for non-surgical transcervical permanent contraceptive devices.  Reimbursement for the implantable contraceptive device shall be made in accordance with the following:

A)        To the extent that the LARCs or transcervical permanent contraceptive devices were purchased under the 340B Drug Pricing Program, the device must be billed at the RHC's actual acquisition cost;

B)        Reimbursement shall be made at the RHC 's actual acquisition cost or the rate on the Department's practitioner fee schedule, whichever is applicable;

C)        This reimbursement shall be separate from any encounter payment the RHC may receive for implanting the device.

10)         Tobacco cessation counseling services may be billed as an encounter if furnished by a provider as defined in Section 140.413(a)(15) within the designated coverage limitations.

d)         Federally Qualified Health Centers

Those core services for which the clinic or center may bill an encounter as described in 42 CFR 440.90 (2000) are as follows:

1)         Physician's services, including covered services of nurse midwives, nurse practitioners and physician-supervised physician assistants.  Group psychotherapy services must meet the guidelines set forth in Section 140.413(a)(4)(C).

2)         Group Psychotherapy Services – Payment may be made for up to two group sessions per week, with a maximum of one session per day.  The following conditions must be met for group psychotherapy:

A)        documentation maintained in the patient's medical record must indicate the person participating in the group session has been diagnosed with a mental illness as defined in the International Classification of Diseases 9^th Revision, Clinical Modification (ICD-9-CM) or, upon implementation, International Classification of Diseases, 10^th Revision, Clinical Modification (ICD-10-CM), or the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).  The allowable diagnosis code ranges will be specified in the Handbook for Practitioners Rendering Medical Services;

B)        beginning February 1, 2013, the entire group of psychotherapy services must be directly performed by one of the following practitioners:

i)          a physician licensed to practice medicine in all its branches who has completed an approved general psychiatry residency program or is providing the service as a resident or attending physician at an approved or accredited residency program;

ii)         an Advanced Practice Nurse holding a current certification in Psychiatric and Mental Health Nursing as set forth in 68 Ill. Adm. Code 1305.Appendix A;

iii)        Psychologist;

iv)        Licensed Clinical Social Worker;

v)         Licensed Clinical Professional Counselor; or

vi)        Licensed Marriage and Family Therapist;

C)        the group size does not exceed 12 patients, regardless of payment source;

D)        the minimum duration of the group session is 45 minutes;

E)        the group session is documented in the patient's medical record by the rendering practitioner, including the session's primary focus, level of patient participation, and begin and end times of each session;

F)         the group treatment model, methods and subject content have been selected on evidence-based criteria for the target population of the group and follows recognized practice guidelines for psychiatric services;

G)        the group session is provided in accordance with a clear written description of goals, methods and referral criteria; and

H)        group psychotherapy is not covered for recipients who are residents in a facility licensed under the Nursing Home Care Act [210 ILCS 45] or the Specialized Mental Health Rehabilitation Act [210 ILCS 48].

3)         Other services for which separate encounters may be billed include:

A)        dental services provided by a dentist or a dental hygienist, as defined and in accordance with the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center; and

B)        behavioral health services as defined in Section 140.463(a).

4)         Medically-necessary services and supplies furnished by or under the direction of a physician or dentist within the scope of licensed practice have been included in the cost report but neither fee-for-service nor encounter billings may be billed.  Some examples of these services include:

A)        medical case management;

B)        laboratory services;

C)        occupational therapy;

D)        patient transportation;

E)        pharmacy services;

F)         physical therapy;

G)        podiatric services;

H)        optometric services;

I)         speech and hearing services;

J)         x-ray services;

K)        health education;

L)        nutrition services.

5)         A federally qualified health center (FQHC) that adds behavioral health services or dental services on or after October 1, 2001, must notify the Department in writing.  These services are to be billed as an encounter with a procedure code that appropriately identifies the service.

6)         Any service that is no longer provided on or after October 1, 2001, or any new service added on or after October 1, 2001, must be communicated to the Department in writing.

7)         Effective January 1, 2001, the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) precludes fee-for-service billings for any FQHC services provided with the exception of services identified in subsections (d)(8) and (d)(9).

8)         Effective July 1, 2012 through June 30, 2013, a physician or APRN may submit fee-for-service billings for implantable contraceptive devices administered in an FQHC.  Reimbursement for the implantable contraceptive devices shall be made in accordance with the following:

A)        To the extent that the implantable device was purchased under the 340B Drug Pricing Program, the device must be billed at the FQHC's actual acquisition cost;

B)        The FQHC must be listed as the payee on the claim;

C)        Reimbursement shall be made at the FQHC's actual acquisition cost or the rate on the Department's practitioner fee schedule, whichever is applicable;

D)        This reimbursement shall be separate from any encounter payment the FQHC may receive for implanting the device.

9)         Effective July 1, 2013, an FQHC may submit fee-for-service billings for LARCs.  For dates of service October 1, 2014 and after, an FQHC may submit fee-for-service billing for non-surgical transcervical permanent contraceptive devices.  Reimbursement for the implantable contraceptive device shall be made in accordance with the following:

A)        To the extent that the LARCs or transcervical permanent devices were purchased under the 340B Drug Pricing Program, the device must be billed at the FQHC's actual acquisition cost;

B)        Reimbursement shall be made at the FQHC's actual acquisition cost or the rate on the Department's practitioner fee schedule, whichever is applicable;

C)        This reimbursement shall be separate from any encounter payment the FQHC may receive for implanting the device.

10)         Tobacco cessation counseling services may be billed as an encounter if furnished by a provider as defined in Section 140.413(a)(15) within the designated coverage limitations.

e)         School Based/Linked Health Clinics (Centers)

Covered services are the following services, when delivered in a school based/linked health center setting as described in Section 140.461(f):

1)         Basic medical services:  well child or adolescent exams, consisting of a comprehensive health history, complete physical assessment, screening procedures and age appropriate anticipatory guidance; immunizations; EPSDT services; diagnosis and treatment of acute illness and injury; basic laboratory tests; prescriptions and dispensing of commonly used medications for identified health conditions, in accordance with Medical Practice and Pharmacy Practice Acts; and acute management and on-going monitoring of chronic conditions, such as asthma, diabetes and seizure disorders.

2)         Reproductive health services:  gynecological exams; diagnosis and treatment of sexually transmitted diseases; family planning; prescribing and dispensing of birth control or referral for birth control services; pregnancy testing; treatment or referral for prenatal and postpartum care; and cancer screening.

(Source:  Amended at 43 Ill. Reg. 4094, effective March 25, 2019)

Section 140.463  Clinic Service Payment

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 1395x(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 1395x(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 1396a(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.

B)        The baseline payment rates shall be based upon allowable costs, reported by the Center, that are determined by the Department to be reasonable and efficient.  The method for determining allowable cost factors is similar to that used for Medicare (42 USC 1395g), with the following significant differences.  The Department's methodology shall:

i)          Consider costs associated with services not covered under Medicare (e.g., pharmacy, patient transportation, medical case management, health education, nutritional counseling).

ii)         Apply reasonable constraints on allowable cost, as described in subsection (b)(10) of this Section.

iii)        Apply reasonable constraints on the total cost per encounter.

C)        The baseline payment rates for a Center shall be the average (arithmetic mean) of the annual reasonable costs per encounter, calculated separately for each of the fiscal years for which cost report data must be submitted using the methodology specified in subsections (b)(2), (3) and (4) of this Section for the medical encounter rate, dental encounter rate, and Behavioral Health Services encounter rate, respectively.

2)         Annual Reasonable Cost Per Medical Encounter

A)        The annual reasonable cost per medical encounter shall be the lesser of:

i)          The annual cost per encounter, as calculated in subsection (b)(2)(D) of this Section; or

ii)         The reasonable cost of providing a medical encounter, which shall be 105 percent of the Statewide median of the calculated annual costs per encounter for FQHCs or RHCs, as the case may be.

B)        The core services component.

The core services component is the sum of the following two components:

i)          The allowable direct cost per encounter, which is the quotient of the allowable direct cost, as defined in subsection (b)(1)(B) of this Section, for core services divided by the greater of the number of encounters reported by direct staff (e.g., staff specified in subsection (b)(10)(A) and, for the determination of encounter payment rates effective prior to January 1, 2002, subsection (b)(10)(C)); or the number of encounters resulting from the application of the minimum efficiency standards found in subsections (b)(10)(A) and (b)(10)(C); and

ii)         The allowable overhead cost per encounter, which is the product of the allowable direct cost per encounter multiplied by the Center's allowable overhead rate factor.

C)        Supplemental services component.

The supplemental services component is the sum of the following two components:

i)          The allowable supplemental cost per encounter, which is the quotient of the cost of services (e.g., pharmacy, patient transportation, medical case management, health education, nutritional counseling), excepting core services, dental services and, effective January 1, 2002, Behavioral Health Services, provided by the Center, divided by the greater of the number of encounters reported by direct staff; or the number of encounters resulting from application of the minimum productivity standards found in subsections (b)(10)(A) and (b)(10)(C) of this Section; and

ii)         The allowable overhead cost per encounter, which is the product of the allowable supplemental cost per encounter multiplied by the Center's allowable overhead rate factor.

D)        Annual cost per encounter.

The annual cost per medical encounter is the sum of the core services component, as determined in subsection (b)(2)(B) of this Section, and the supplemental services component, as determined in subsection (b)(2)(C).

3)          Annual Reasonable Cost Per Dental Encounter

A)        The annual reasonable cost per dental encounter shall be the lesser of:

i)          The annual cost per encounter, as calculated in subsection (b)(3)(B) of this Section; or

ii)         The reasonable cost of providing a dental encounter, which shall be 105 percent of the Statewide median of the calculated annual costs per encounter for FQHCs or RHCs, as the case may be.

B)        Annual cost per encounter.

The annual cost per encounter is the sum of the following two components:

i)          The allowable direct cost per encounter, which is the quotient of the allowable direct dental cost, as defined in subsection (b)(1)(B), divided by the greater of the number of encounters reported by direct dental staff; or the number of encounters resulting from the application of the minimum efficiency standard found in subsection (b)(10)(B); and

ii)         The allowable overhead cost per encounter, which is the product of the allowable direct cost per encounter multiplied by the Center's allowable overhead rate factor.

4)         Annual Reasonable Cost Per Behavioral Health Service Encounter

Effective for services provided on or after January 1, 2002, a separate annual reasonable cost per Behavioral Health Service encounter shall be determined.

A)        The annual reasonable cost per Behavioral Health Service encounter shall be the lesser of the following:

i)          The annual cost per encounter, as calculated in subsection (b)(4)(B) of this Section.

ii)         The reasonable cost of providing a Behavioral Health Service encounter, which shall be 105 percent of the Statewide median of the calculated annual cost per encounter for FQHCs or RHCs, as the case may be.

B)        Annual cost per encounter.

The annual cost per encounter is the sum of the following two components:

i)          The allowable direct cost per encounter, which is the quotient of the allowable direct cost for Behavioral Health Services, as defined in subsection (b)(1)(B) of this Section, divided by the greater of the number of encounters reported by direct behavioral health staff; or the number of encounters resulting from the application of the minimum efficiency standard found in subsection (b)(10)(C); and

ii)         The allowable overhead cost per encounter, which is the product of the allowable direct cost per encounter multiplied by the Center's allowable overhead rate factor.

5)         For any individual eligible under the medical assistance programs, a Center may bill only one medical encounter, one dental encounter, and one behavioral health encounter per day.  A Center will be reimbursed for a service only if it has enrolled with the Department to provide that service.

6)         Claims submitted to the Department must identify all services provided during the encounter.

7)         Cost Basis

Each Center must annually complete a cost report, in a format specified by the Department, for the Center's fiscal year.  Each FQHC must also annually submit a copy of financial statements audited by an independent Certified Public Accountant.  The cost report and audited financial statements must be filed with the Department within 180 days after the close of the Center's fiscal year, except for cost reports and audited financial statements for Center fiscal years 1999 and 2000 which, in the case of FQHCs, must be filed with the Department no later than November 30, 2001, and in the case of RHCs, must be filed no later than March 30, 2002.  Except for the first year during which the Center begins operations, the cost report must cover a full fiscal year ending on June 30 or other fiscal year that has been approved by the Department.  Payments will be withheld from any Center that has not submitted the cost report by the applicable filing date, and no payments will be made until such time as the reports or audited statements are received and approved by the Department.

8)         Establishment of Initial Year Payment Amount for a New Center

For any Center that begins operation on or after January 1, 2001, the payment rate per encounter shall be the median of the payment rates per encounter of neighboring FQHCs or RHCs with similar caseloads, as determined by the Department.  If the Department determines that there are no such comparable Centers, then the rate per encounter shall be the median of the payment rates per encounter Statewide for all FQHCs or RHCs, as the case may be.

9)         Rate Adjustments

A)        Initial rate determinations.

i)          On or about January 1, 2002, the Department shall determine the medical and dental encounter rates for each participating FQHC.  These rates shall be paid for services provided on or after January 1, 2001. Claims submitted and adjudicated prior to the entry of these rates into the Department's claims processing system shall be reconciled for each affected FQHC.

ii)         On or about January 1, 2003, the Department shall determine the medical and dental encounter rates for each participating RHC.  These rates shall be paid for services provided on or after January 1, 2001.  Claims submitted and adjudicated prior to the entry of these rates into the Department's claims processing system shall be reconciled for each affected RHC.

B)        Annual adjustment.

i)          Beginning January 1, 2002, and annually thereafter, except as specified in subsection (b)(9)(B)(ii) of this Section, the Department will adjust baseline rates by the most recently available MEI.  The adjusted rates shall be paid for services provided on or after the date of adjustment.

ii)         In the instance of a Center that provided Behavioral Health Services prior to January 1, 2002, for the purpose of applying the January 1, 2002, adjustment by the most recently available MEI, the baseline medical services encounter rate applicable for services provided from January 1, 2001, through December 31, 2001, shall be redetermined after removal of costs and encounters attributable to Behavioral Health Services.

C)        Scope of service adjustment.

If a Center significantly changes its scope of services, the Center may request that new baseline encounter rates be determined.  Adjustments to encounter rates will be made only if the change in the scope of services results in the inclusion of Behavioral Health Services or dental services or a difference of at least five percent from the Center's current rate.  The Department may initiate a rate adjustment, based on audited financial statements or cost reports, if the scope of services has been modified to include Behavioral Health Services or dental services or would otherwise result in a change of at least five percent from the Center's current rate.

10)        Reasonable Cost Considerations

The following minimum efficiency standards will be applied to determine reasonable cost:

A)        Medical direct care productivity.

The Center must average 4,200 encounters annually per full-time equivalent (FTE) for physicians and 2,100 encounters per FTE for mid-level health care staff (i.e., physician assistants, nurse practitioners, specialized nurse practitioners and nurse midwives).

B)        Dental direct care productivity.

The Center must average 1.5 encounters per hour per FTE for dentists.

C)        Behavioral health direct care productivity.

The Center must average 2,100 annual encounters per FTE for licensed clinical psychologists, licensed clinical social workers and licensed clinical professional counselors.

D)        Guideline for non-physician health care staff.

The maximum ratio of staff is four FTE non-physician health care staff for each FTE staff subject to the direct care productivity standards in subsections (b)(10)(A) and (B) of this Section.

E)        Allowable overhead.

The maximum Medicaid allowable overhead cost is 35 percent of allowable total cost.

11)         Adjustments for Medical Services Paid for by a Managed Care Organization (MCO)

The Department shall make payment adjustments to a Center if it provides care through a contractual arrangement with a Medicaid MCO and is reimbursed an amount, reported to the Department, that is less than the minimum payment required in 42 USC 1396a(aa).  The amount of any such payment adjustment shall be at a fixed annual rate as determined by the Department.  For each Center so eligible, a payment adjustment shall take into consideration the total payments made by the MCO to the Center (including all payments made on a service-by-service, encounter or capitation basis).  In the event that Center cost data related to MCO services are unavailable to the Department, an estimate of such costs may be used that takes into consideration other relevant data.  Adjustments will be made, at least quarterly, only for Medicaid eligible services.  All such services must be defined in a contract between the Center and the MCO.  Such contracts must be made available to the Department.

12)        Audits

All cost reports will be audited by the Department.  The Center will be advised of any adjustment resulting from these audits.

13)        Alternate Payment Methodology for Government-Operated Centers

A)        A Center operated by a State or local government agency may elect to be reimbursed under the alternate payment methodology described in this subsection (b)(13).

B)        The State or local government agency shall enter into an interagency or intergovernmental agreement, as appropriate, with the Department that specifies the responsibilities of the two parties with respect to services provided by the Center and the funding of those services.

C)        The Center operated by a State or local government agency shall be reimbursed by the Department on a per encounter basis according to the provisions of subsections (b)(1) through (11) of this Section.

D)        The State or local government agency shall certify the expenditure of public funds in excess of reimbursement received from the Department, under subsection (b)(13)(C) of this Section, and any reimbursement from other payers (e.g., an insurance company, a managed care organization) for services provided to individuals eligible for medical assistance programs administered by the Department, provided the funds were not derived from a federal funding source or were not otherwise used as a State or local match for federal funds.  The certification shall be in the form and format specified by the Department.  The certification shall be filed within 30 days after the submission of the annual cost report.  The certification shall compare expenditures within that cost reporting period to payments received or receivable for that same period.

E)        The certified expenditures shall be used by the Department to claim federal financial participation.  Federal funds resulting from the claiming of the certified expenditures shall be distributed, according to the provisions of the agreement referenced in subsection (b)(13)(B) of this Section, to the State or the government agency that operates the Center that provided the services.

14)         Alternate Payment Methodology for Certain Qualifying Centers

A)        No later than 30 days after the initial rate determination specified in subsection (b)(9)(A) of this Section, the Department shall determine the eligibility of each Center for this alternative payment methodology.  A Center will qualify for this alternative payment methodology if the Department's estimate of the total amount to be paid to the Center for services provided during the 12-month period ending December 31, 2001, under the reimbursement policy and rates in effect prior to the initial rate determination, is greater than the total amount that will be paid for those same services under the initial rates.  The Department shall notify each qualifying Center, in writing, of the result of this determination.

B)        A qualifying Center may, for services provided from January 1, 2002 through December 31, 2002, elect to be reimbursed under the alternate payment methodology described in this subsection (b)(14).  A qualifying Center must notify the Department, in writing, no later than 30 days after the date of the written notification from the Department, of its election to be reimbursed under this alternative payment methodology.

C)        A Center electing this alternative payment system shall be reimbursed by the Department on a per encounter basis according to the provisions of subsections (b)(1) through (11) of this Section, except the medical encounter payment rate shall be increased by an amount equal to twice the quotient resulting from the Department's estimate of the difference between the total amount to be paid to the Center for services provided during the 12-month period ending December 31, 2001, under the initial rates as determined in subsection (b)(9)(A); and the total amount that would have been paid under the payment rates in effect prior to the initial rate determination, divided by the Department's estimate of total medical encounters during the 12-month period ending December 31, 2001.

15)        Alternate Behavioral Health Payment Methodology for Certain Qualifying Centers

Centers that are certified by the Department of Human Services-Division of Mental Health, or the Department of Children and Family Services to provide Behavioral Health Services may elect an alternate payment methodology for their Behavioral Health Services.  An election of this alternate payment methodology will allow the Centers to be reimbursed under the provisions of 59 Ill. Adm. Code 132 for Behavioral Health Services provided.  A qualifying Center must notify the Department in writing, no later than 30 days after the date of the written notification from the Department, of its election to be reimbursed under this alternate payment methodology.

16)        All service sites operated by a Center shall be reimbursed using the Center's established encounter rates, except in the instance where the site submitted separate cost reports and separate baseline rates were determined for the site.

c)         Rate Appeals Process

1)         All appeals of audit adjustments or rate determinations must be submitted in writing to the Department.  Appeals must be submitted within 60 calendar days after the notification of such adjustments or rate determinations. If upheld, the revised audit adjustment or rate determination shall be made effective as of the beginning of the rate period.

2)         To be accepted for review, the written appeal shall include the following:

A)        The current approved reimbursement rate, allowable costs, and the additional reimbursable costs sought through the appeal.

B)        A clear, concise statement of the basis for the appeal.

C)        A detailed statement of financial, statistical, and related information in support of the appeal, indicating the relationship between the additional reimbursable costs as submitted and the circumstances creating the need for increased reimbursement.

D)        A statement by the Center's chief executive officer or financial officer that the application of the rate appeal and information contained in the Center's reports, schedules, budgets, books, and records submitted are true and accurate.

3)         Rate appeals may be considered for the following reasons:

A)        Mechanical or clerical errors committed by the provider in reporting historical expenses used in the calculation of allowable costs.

B)        Mechanical or clerical errors committed by the Department in auditing historical expenses as reported and/or in calculating reimbursement rates.

4)         The Department shall rule on all appeals within 120 calendar days after receipt of the complete appeal, except that, if additional information is required from the facility, the period shall be extended until such time as the information is provided.

5)         Appeals shall be submitted to the Department's Office of Health Finance, 201 South Grand Avenue East, Springfield, Illinois 62763-0002.

(Source:  Amended at 31 Ill. Reg. 14749, effective October 22, 2007)

Section 140.464  Hospital-Based and Encounter Rate Clinic Payments

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.

2)         Rate Adjustments

A)        On or about October 1, 2014, the Department shall determine the medical and dental encounter rates for each clinic.  These rates shall be paid for services provided on or after October 1, 2014.  Claims submitted and adjudicated prior to the entry of these rates into the Department's claims processing system shall be reconciled for each affected clinic.

B)        Beginning January 1, 2015, and annually thereafter, the Department will adjust baseline rates by the most recently available MEI.  The adjusted rates shall be paid for services provided on or after the date of adjustment.

3)         Rate Appeals Process

A)        All appeals of audit adjustments or rate determinations must be submitted in writing to the Department.  Appeals must be submitted within 60 calendar days after the notification of the adjustments or rate determinations.  If upheld, the revised audit adjustment or rate determination shall be made effective as of the beginning of the rate period.

B)        To be accepted for review, the written appeal shall include the following:

i)          The current approved reimbursement rate, allowable costs and the additional reimbursable costs sought through the appeal.

ii)         A clear, concise statement of the basis for the appeal.

iii)        A detailed statement of financial, statistical and related information in support of the appeal, indicating the relationship between the additional reimbursable costs as submitted and the circumstances creating the need for increased reimbursement.

iv)        A statement by the clinic's chief executive officer or financial officer that the application of the rate appeal and information contained in the clinic's reports, schedules, budgets, books and records submitted are true and accurate.

C)        Rate appeals may be considered for the following reasons:

i)          Mechanical or clerical errors committed by the provider in reporting historical expenses used in the calculation of allowable costs.

ii)         Mechanical or clerical errors committed by the Department in auditing historical expenses as reported and/or in calculating reimbursement rates.

D)        The Department shall rule on all appeals within 120 calendar days after receipt of the complete appeal, except that, if additional information is required from the facility, the period shall be extended until such time as the information is provided.

E)        Appeals shall be submitted to the Department's Office of Health Finance, 201 South Grand Avenue East, Springfield, Illinois 62763-0002.

c)         County-Operated Outpatient Facilities

1)         For critical clinic providers, as described in Section 140.461(h)(1), reimbursement for all services, including pharmacy-only-encounters, provided shall be on an all-inclusive per day encounter rate that shall equal reported direct costs of critical clinic providers for each facility's cost reporting period ending in 1995, and available to the Department as of September 1, 1997, divided by the number of Medicaid services provided during that cost reporting period as adjudicated by the Department through July 31, 1997.

2)         For county ambulatory health centers, the final rate is determined as follows:

A)        Base Rate.  The base rate shall be the rate calculated as follows:

i)          Allowable direct costs shall be divided by the number of direct encounters to determine an allowable cost per encounter delivered by direct staff.

ii)         The resulting quotient, as calculated in subsection (c)(2)(A)(i), shall be multiplied by the Medicare allowable overhead rate factor to calculate the overhead cost per encounter.

iii)        The resulting product, as calculated in subsection (c)(2)(A)(ii), shall be added to the resulting quotient, as calculated in subsection (c)(2)(A)(i), to determine the per encounter base rate.

iv)        The resulting sum, as calculated in subsection (c)(2)(A)(iii), shall be the base rate.

B)        Supplemental Rate

i)          The supplemental service cost shall be divided by the total number of direct staff encounters to determine the direct supplemental service cost per encounter.

ii)         The supplemental service cost shall be multiplied by the allowable overhead rate factor to calculate the supplemental overhead cost per encounter.

iii)        The quotient derived in subsection (c)(2)(B)(i) shall be added to the product derived in subsection (c)(2)(B)(ii) to determine the per encounter supplemental rate.

iv)        The resulting sum, as described in subsection (c)(2)(B)(iii), shall be the supplemental rate.

C)        Final Rate.  The final rate shall be the sum of the base rate and the supplemental rate.

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)

Section 140.465  Adaptive Behavior Support Services

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).

2)         Independently enrolled ABS Clinicians may bill only for services the ABS Clinician personally provides or that are provided, under the ABS Clinician's supervision, by an ABS Technician with whom the ABS Clinician has an established employment, contractual, or similar relationship.

3)         The services detailed in subsection (c) will be eligible for reimbursement pursuant to the Department's published fee schedule when the services are:

A)        Recommended by a licensed physician or a licensed clinical psychologist operating within their scope of practice;

B)        Provided to an individual under the age of 21 with a diagnosis of autism spectrum disorder (ASD), as indicated by a comprehensive diagnostic evaluation, to prevent disease, disability, and other health conditions or their progression, to prolong life, and to promote physical and mental health and efficiency in accordance with 42 CFR 440.130(c);

C)        Delivered in an office, home, or community setting inclusive of school-based settings.  The Department reserves the right to conduct annual on-site reviews of the locations in which ABS services are delivered;

D)        Provided consistent with all requirements of this Section and any service limitations, utilization controls, and prior authorization requirements (Section 140.40) established by the Department; and

E)        Provided for the direct benefit of the individual, which may include collaboration with, or training of, the primary caregivers of the eligible individual.

b)         ABS Professional Qualifications. ABS services may only be delivered by those qualified professionals defined under this Section and enrolled for participation in the Illinois Medical Assistance Program.  Qualified professionals may only provide ABS services within their scope of practice, as defined by federal or state law, regulation, or policy.

1)         ABS Clinician.  An ABS Clinician is defined as an individual providing professional services and enrolled independently or providing services as an employee of a BHC and who meets any of the following qualifications:

A)        A Licensed Clinical Psychologist (LCP); or

B)        A Board Certified Behavior Analyst (BCBA) or Board Certified Behavior Analyst Doctoral (BCBA-D), certified and in good standing with the Behavior Analyst Certification Board (BACB); or

C)        A Board Certified Assistant Behavior Analyst (BCaBA), certified and in good standing with the BACB, delivering services under the supervision of an LCP, a BCBA, or a BCBA-D; or

D)        Any of the following practitioners licensed within the state of practice and who have advanced training in developmental interventions from a Department-approved training entity, as detailed in the applicable Department-issued provider handbook:

i)          A Licensed Clinical Social Worker (LCSW);

ii)         A Licensed Clinical Professional Counselor (LCPC);

iii)        A Licensed Marriage and Family Therapist (LMFT);

iv)        A licensed Occupational Therapist; or

v)         A licensed Speech-Language Pathologist.

2)         ABS Technician.  An ABS Technician is defined as an individual meeting the following qualifications, delivering services under the supervision of an independently enrolled ABS Clinician or an ABS Clinician providing services as an employee of a BHC:

A)        A Registered Behavior Technician (RBT), certified and in good standing with the Behavior Analyst Certification Board; or

B)        An individual who is 18 years of age or older, has a high school diploma or GED, and has received technical training in developmental interventions from a Department-approved training entity as detailed in the applicable Department-issued provider handbook.

3)         ABS Technicians must receive clinical supervision from an ABS Clinician in an amount minimally equivalent to 5% of the ABS Technician's time spent delivering ABS services per month. 

A)        Clinical supervision by the ABS Clinician must include, at a minimum, two face-to-face, real-time contacts per month.

B)        ABS Technicians credentialed as an RBT must receive their clinical supervision from an ABS Clinician credentialed as an LCP, BCBA, a BCBA-D, or a BCaBA.

C)        ABS Technicians not credentialed as an RBT who meet the qualifications of subsection (b)(2)(B) must receive their clinical supervision from an LCP or from an ABS Clinician credentialed as described in subsection (b)(1)(D).

c)         Covered ABS Services.  The following services are established as qualified ABS services when rendered by an ABS Clinician or ABS Technician:

1)         Behavior Assessment and Treatment Planning (BATP). BATP is the formal process of assessing an individual's current maladaptive or disruptive behaviors, functional skills, skill deficits, skill acquisition and maintenance of skills, and developing or updating individualized treatment goals, objectives and service recommendations based upon the assessment findings.  Additional BATP functions include: administering, scoring, and interpreting the assessments; interviews with the individual's parents or guardians; non-face-to-face analysis of treatment history; and discussing findings and recommendations with the individual and their parent or guardian, as appropriate.

A)        The BATP must:

i)          Be completed prior to the initiation of Behavior Analysis Intervention (BAI) services and reviewed and updated, as necessary, once every 180 days thereafter;

ii)         Be reviewed, approved, and signed by an ABS Clinician; and

iii)        Be signed by, and a copy provided to, the individual and the individual's parent or guardian, as appropriate, upon completion or revision.

B)        BATP services may be subject to prior authorization, pursuant to Section 140.40.

2)         Behavior Analysis Intervention (BAI). BAI services consist of evidence-based interventions identified on the individual's BATP that use behavioral stimuli and consequences to produce socially significant improvement in behavior.  BAI services include: direct observation, measurement, and functional analysis of the relationships between environment and behavior; and, parent/caregiver coaching and training for the immediate and direct clinical benefit of the individual.

A)        BAI services must be delivered consistent with evidence-based practice guidelines using one of the following HFS-recognized treatment modalities:

i)          Comprehensive Applied Behavior Analysis (ABA).  Comprehensive ABA addresses developmental gains in individuals exhibiting adaptive living skill deficits, impairments in social skill or communication skill acquisition, or severe behaviors (harm to self, others, or property).  This service is generally targeted towards individuals aged six years and younger; however, a request for this service cannot be denied based on this age recommendation alone;

ii)         Focused ABA. Focused ABA functions as an adjunct service supporting the delivery of a broad array of therapeutic support services, generally providing targeted intervention to a limited number of key functional skills or challenging behaviors; or,

iii)        Developmental intervention.

B)        BAI services delivered using the Comprehensive or Focused ABA modality must be rendered by ABS Clinicians credentialed as an LCP, BCBA, or a BCaBA, or by ABS Technicians credentialed as an RBT.

C)        BAI services may be subject to prior authorization, pursuant to Section 140.40.

3)         The following functions or activities are not covered services under this Section:

A)        Comprehensive diagnostic evaluation (CDE) services;

B)        Any activities that include Restraint or Seclusion as defined in 405 ILCS 5/1-125 and 405 ILCS 5/1-126;

C)        Traditional psychological, psychiatric, and mental health assessment, such as psychological testing, personality assessment, intellectual assessment, and neuropsychological assessment;

D)        Traditional and atypical clinical interventions for behavioral health needs, such as: psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, family therapy, and counseling;

E)        Activities that are solely educational in nature or for educational purposes;

F)         Activities that are solely vocational or recreational in nature; and

G)        Educational services provided under an individualized family service plan (IFSP) or an individualized educational program (IEP), as required under the federal Individuals with Disabilities Education Act (20 U.S.C. 1400 et seq.).

(Source:  Section 140.465 repealed at 15 Ill. Reg. 17318, effective November 18, 1991; new Section 140.465 added at 48 Ill. Reg. 864, effective December 27, 2023)

Section 140.466  Rural Health Clinics (Repealed)

(Source:  Repealed at 26 Ill. Reg. 4781, effective March 15, 2002)

Section 140.467  Independent Clinics

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.

(Source:  Amended at 23 Ill. Reg. 7122, effective June 1, 1999)

Section 140.469  Hospice

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.

b)         Hospice care is a covered service for all eligible clients, including residents of intermediate and skilled care facilities, when provided by a Medicare certified hospice provider and in accordance with provisions contained in section 1902(a)(13)(B), 1905(o)(1) and 2110(a)(23) of the Social Security Act (42 USC 1396a(a)(13)(B), 1396d(o)(1) and 1397jj(a)(23)).

c)         Covered services include:

1)         Nursing care;

2)         Physician services;

3)         Medical social services;

4)         Short term inpatient care;

5)         Medical appliances, supplies and drugs;

6)         Home health aide services;

7)         Occupational, physical and speech-language therapy services to control symptoms; and

8)         Counseling services.

d)         Reimbursement shall be at the rate established by the Centers for Medicare and Medicaid Services for the specific level of care into which each day of care is classified.  The Medicaid hospice payment rates are calculated based on the annual hospice rates established under section 1814(i)(1)(C)(ii) of the Social Security Act and 42 CFR 418.306. The four levels of care are:

1)         Routine Home Care.  The hospice will be paid the routine home care rate for each day the patient is at home, under the care of the hospice, and not receiving continuous home care.  This rate is paid without regard to the volume or intensity of routine home care services provided on any given day. Effective with dates of service on and after January 1, 2016 and, for patients who have hospice elections on file with a beginning date on or after January 1, 2016, routine home care rates are differentiated between days 1 through 60 and days 61 and beyond.

2)         Continuous Home Care.  The continuous home care rate will be paid when continuous home care is provided.  The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate.  A minimum of eight hours must be provided.  For every hour or part of an hour of continuous care furnished, the hourly rate will be reimbursed to the hospice up to 24 hours a day.

3)         Inpatient Respite Care.  The inpatient rate will be paid each day on which the beneficiary is in the approved inpatient facility and is receiving respite care.  Payment for respite care may be made for a maximum of five days at a time, including the date of admission, but not counting the date of discharge.  Payment for the sixth day and any subsequent days is to be made at the routine home care rate.

4)         General Inpatient Care.  The inpatient rate will be paid when general inpatient care is provided.  None of the other fixed payment rates (i.e., routine home care) will be applicable for a day on which the patient receives hospice inpatient care except for the day of discharge from an inpatient unit.  In which case, the appropriate home care rate is to be paid unless the patient dies as an inpatient.

e)         When the individual resides in an ICF or SNF facility, the Department shall provide payment of an add-on amount to the hospice on routine home care and continuous home care days.  The add-on amount will constitute a portion of the facility rate the State would be responsible for as mandated by 42 CFR 418.1 through 418.205.  The add-on amount for county-owned/operated nursing facilities shall be based on the rates established pursuant to Section 140.530(c)(1).

f)         The hospice shall receive an add-on amount for other physician services such as direct patient care when physician services are provided by an employee of the hospice or under arrangements made by the hospice unless those services are performed on a volunteer basis.  These add-on amounts will be utilized when determining the hospice cap amount.

g)         In accordance with 42 CFR 418.302, effective with service dates on and after January 1, 2016, a service intensity add-on payment may be billed for visits by a social worker or registered nurse as defined in 42 CFR 418.114, when provided during routine home care during the last seven days of life.

h)         Medicaid payment to a hospice provider for care furnished over the period of a year shall be limited by a payment cap as set forth in 42 CFR 418.309.  Any overpayment shall be refunded by the hospice provider.

i)          Effective with dates of service on and after July 1, 2012, the following services will not be covered outside of the hospice program benefit for patients 21 years of age and older electing hospice care. The following services will not be paid separately:

1)         Dental services;

2)         Optometric services and eyewear;

3)         Nursing services provided by registered nurses and licensed practical nurses;

4)         Physical therapy services;

5)         Occupational therapy services;

6)         Speech therapy services;

7)         Audiology services;

8)         General clinic services;

9)         Psychiatric clinic Type A services;

10)         Psychiatric clinic Type B services;

11)         Hospital outpatient physical rehabilitation;

12)         Healthy Kids services;

13)         Mental health rehabilitation option;

14)         Alcohol and substance abuse rehabilitation services;

15)         Medical equipment;

16)         Medical supplies;

17)         Social work services;

18)         Psychological services;

19)         Home health services;

20)         Homemaker services; and

21)         Palliative drugs.

(Source:  Amended at 41 Ill. Reg. 999, effective January 19, 2017)

Section 140.470  Eligible Home Health Care, Nursing and Public Health Providers

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.

b)         Home health care providers must implement an auditable electronic service verification.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.471  Description of Home Health Care Services

a)         Home health services are services provided for participants in their places of residence and are aimed at facilitating the transition from a more acute level of care to the home.

b)         Services provided shall be of a curative or rehabilitative nature and demonstrate progress toward goals outlined in a plan of care.  Services shall be provided for individuals upon direct order of a physician and in accordance with a plan of care established by the physician and reviewed at least every 60 days.

c)         For purposes of this Section, "residence" includes any setting in which normal life activities take place and does not include a hospital, a skilled nursing facility, an intermediate care facility, a specialized mental health rehabilitation facility,or any setting in which payment is or could be made under Medical Assistance programs for inpatient services that include room and board.  The term "residence" includes an intermediate care facility for the mentally retarded only to the extent that home health services are not required to be provided under 89 Ill. Adm. Code 144.

d)         Effective July 1, 2012, to be eligible for reimbursement by the Department, initial certification of intermittent skilled nursing services, home health aide or therapy services must have documentation that a face-to-face encounter was conducted by the practitioner requesting services.  The following conditions must be met for the face-to-face encounter:

1)         The physician responsible for performing the initial certification must document that the face-to-face patient encounter, which is related to the primary reason the patient requires home health services, has occurred no more than 90 days prior to the home health start of care date or within 30 days after the start of the home health care by including the date of the encounter and including an explanation of why the clinical findings of the encounter support that the patient is in need of either intermittent skilled nursing, home health aide or therapy services as defined in Section 140.472.

2)         The face-to-face encounter must be performed by the certifying physician, a nurse practitioner, a clinical nurse specialist who is working in collaboration with the physician in accordance with State law, a certified nurse midwife as authorized by State law, a physician assistant under the supervision of the physician, or, for patients admitted to home health immediately after an acute or post-acute stay, the physician who cared for the patient in an acute or post-acute facility and who has privileges at the facility. 

A)        If the certifying physician does not perform the face-to-face encounter personally, the non-physician practitioner or the physician who cared for the patient in an acute or post-acute facility performing the face-to-face encounter must communicate the clinical findings of that face-to-face patient encounter to the certifying physician. The clinical findings must be incorporated into a written or electronic document in the patient's medical record.

B)        If a face-to-face patient encounter occurred within 90 days prior to the start of care but is not related to the primary reason the patient requires home health services, or the patient has not seen the certifying physician or allowed non-physician practitioner within the 90 days prior to the start of the home health episode, the certifying physician or non-physician practitioner must have a face-to-face encounter with the patient within 30 days after the start of the home health care.

C)        The face-to-face patient encounter may occur through telehealth, in compliance with Section 140.403.

D)        The physician responsible for certifying the patient for home care must document that the face-to-face encounter is related to the primary reason the patient requires home health services, and occurred within the timeframes described in subsection (d)(1).  The documentation must indicate the practitioner who conducted the encounter and the date of the encounter.

(Source:  Amended at 42 Ill. Reg. 4829, effective March 1, 2018)

Section 140.472  Home Health Care Services

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.

(Source:  Amended at 42 Ill. Reg. 4829, effective March 1, 2018)

Section 140.473  Prior Approval for Home Health Care Services

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.

(Source:  Amended at 42 Ill. Reg. 4829, effective March 1, 2018)

Section 140.474  Payment for Home Health Care Services

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. 

b)         Payment to self-employed registered nurses providing in-home nursing services is made at the community rate for those services as determined for each case at the time prior approval is given. 

c)         Payment for in-home shift nursing for children who are under 21 years of age under Section 140.472(b) shall be at the Department's established hourly rate to an agency licensed to provide these services.  The hourly rate for in-home shift nursing care may be adjusted in consideration of the appropriation of funds by the General Assembly.

d)         Payment for medical equipment and supplies will be made in accordance with Section 140.481.

(Source:  Amended at 42 Ill. Reg. 4829, effective March 1, 2018)

Section 140.475  Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices

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

2)         when the Individual Program Plan (IPP) of an individual with developmental disabilities residing in an ICF/MR or a long term care facility identifies the equipment, supplies, prosthetic devices and orthotic devices that are necessary for his or her participation in active treatment as described in 42 CFR 483.440, Condition of Participation:  Active Treatment Service.

c)         Payment shall be made for the repair of prosthetic devices, orthotic devices and medical equipment owned by recipients if the item is out of warranty and the sum of the individual repair parts and the labor does not exceed 75 percent of the cost of a new unit.  Labor charges are to be included in the repair price.  A guarantee of at least 180 days must be provided. Charges shall not include tax, delivery, rebate, packaging or freight.  The Department may agree to assume repair costs of a rented or loaned communication system if such an agreement is required by the manufacturer's or vendor's rental or loan terms.  The Department may deny payment for repairs if evidence indicates that damage has resulted from abuse of the equipment.

d)         Payment shall be made for loaner items issued pending repair or replacement of prosthetic devices, orthotic devices and medical equipment owned by recipients if it is the usual practice of the supplier to provide and charge for such items.

e)         Covered services are:

1)         Non-durable medical supplies for an individual's life maintenance care and treatment;

2)         Durable medical equipment essential to expedite a hospital discharge and to enable the person to be cared for at home;

3)         Prosthetic and orthotic devices, including communication devices, that are essential to enhance functional mobility or medically necessary communication, or are essential for employment;

4)         Respiratory equipment and supplies necessary as a life saving measure or for prevention of a medical emergency, institutionalization, or to facilitate deinstitutionalization;

5)         Repair of durable medical equipment, prosthetic devices and orthotic devices; and

6)         Effective July 1, 2024, pursuant to 305 ILCS 5/5-16.8a, continuous glucose monitors that are:

A)        Ordered by a provider:

i)          who is a licensed physician, a certified nurse practitioner, or a physician assistant who has a collaborative agreement with the physician; and

ii)         who is not required to obtain additional or specific continuing medical education in order to prescribe a continuous glucose monitor;

B)        Not required to have:

i)          an alarm when glucose levels are outside the pre-determined range;

ii)         the capacity to generate predictive alerts in case of impending hypoglycemia; or

iii)        the ability to transmit real-time glucose values and alerts to the patient and designated other persons;

C)        Provided to a patient who has:

i)          diabetes mellitus; and meets the coverage requirement established in Section 356z.59(a) of the Illinois Insurance Code [215 ILCS 5]; or

ii)         gestational diabetes, regardless of suboptimal glycemic control that is likely to harm the patient or the fetus;

D)        Provided to a patient on a case-by-case basis for medical necessity, and approved if appropriate, when the patient has diabetes mellitus but:

i)          does not meet the coverage requirement; or

ii)         is in a population in which continuous glucose monitor usage has not been well-studied;

E)        Provided to a patient who is not required to:

i)          need intensive insulin therapy; or

ii)         have a recent history of emergency room visits or hospitalizations related to hypoglycemia, hyperglycemia, or ketoacidosis; and

F)         Prescribed only with prior authorization when covered under Medical Assistance. Once a continuous glucose monitor is prescribed, the prior authorization shall be approved for a 12-month period.

f)         Payment shall be made for covered services on a prior approval basis, except as provided under Section 140.477.

g)         Effective July 1, 2017, to be eligible for reimbursement by the Department, certain medical equipment and supplies will be subject to a face-to-face encounter. The Department will, at a minimum, require a face-to-face encounter for equipment and supplies for which Medicare requires a face-to-face encounter. A list of medical equipment and supplies subject to a face-to-face encounter will be published on the Department's website. The face-to-face encounter must meet the following conditions:

1)         The face-to-face patient encounter that is related to the primary reason the patient requires medical equipment, supplies or appliances must have occurred no more than six months prior to start of services.

2)         The face-to-face encounter must be performed by the certifying physician, a nurse practitioner or clinical nurse specialist who is working in collaboration with the physician in accordance with State law, a physician assistant under the supervision of the physician, or, for patients admitted to home health immediately after an acute or post-acute stay, the physician who cared for the patient in an acute or post-acute facility.

A)        If the certifying physician does not perform the face-to-face encounter personally, the non-physician practitioner or the physician who cared for the patient in an acute or post-acute facility performing the face-to-face encounter must communicate the clinical findings of that face-to-face patient encounter to the certifying physician. The clinical findings must be incorporated into a written or electronic document in the patient's medical record.

B)        The certifying physician must document that the face-to-face encounter is related to the primary reason the patient requires medical equipment, supplies or appliances and occurred within the timeframes described in subsection (g)(1).  The documentation must indicate the practitioner who conducted the encounter and the date of the encounter.

3)         The face-to-face patient encounter may occur through telehealth, in compliance with Section 140.403.

h)         Starting June 1, 2019, payment for the provision of medical equipment, supplies, prosthetic devices and orthotic devices will only be made to enrolled providers that are accredited by a healthcare accrediting body approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department. Accrediting bodies approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department may be found on the DMEPOS Accreditation website at https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/durable-medical-equipment-prosthetics-orthotics-supplies-dmepos.

(Source:  Amended at 49 Ill. Reg. 1819, effective January 30, 2025)

Section 140.476  Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices for Which Payment Will Not Be Made

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.

2)         Equipment required for a resident of a long term care facility, unless the equipment must be made to order for an identified recipient and based on a medical need, or which is identified by the Individual Program Plan (IPP) of an individual with developmental disabilities as necessary to fulfill the requirements for active treatment services.

b)         Items or services that are not medically necessary to treat the recipient's disease, disability, infirmity or impairment.

c)         Prosthetic and orthotic devices inserted or implanted that do not increase physical capacity, overcome a handicap, restore a physiological function, or eliminate a functional disability.

d)         Items or services for which the Department has not granted prior approval where prior approval is required.

e)         Stock orthopedic shoes, unless used in conjunction with a brace.

f)         Items or services for a client who has elected hospice care, when the items or services are related to the terminal illness.

g)         Items or services fabricated, fitted or dispensed without an appropriate license.

(Source:  Amended at 25 Ill. Reg. 12820, effective October 8, 2001)

Section 140.477  Limitations on Equipment, Prosthetic Devices and Orthotic Devices

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.

b)         Replacement of covered equipment, prosthetic devices and orthotic devices is subject to all policies that apply to an original purchase of the same item.  Replacements will not be reimbursed by the Department if the original item is under a warranty that would cover the necessary repairs or replacement.  If the item requires prior approval and if the item was purchased by the Department for the same client within the past 12 months, the Department's original determination of medical necessity will be deemed adequate for the replacement purchase.  In this case, the request for prior approval must contain an explanation of the need for replacement.  The Department may deny payment for replacement of equipment if evidence indicates that breakage or loss has resulted from abuse of the equipment.

(Source:  Amended at 37 Ill. Reg. 10282, effective June 27, 2013)

Section 140.478  Prior Approval for Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices

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.

b)         Post approval may be requested.  Post approval will be granted in circumstances when prior approval could not be requested, such as:

1)         determination of the patient's eligibility for public assistance was delayed;

2)         the medical need arose unexpectedly outside of the Department's normal business hours and prior approval could not be obtained;

3)         other third party resources denied payment.

(Source:  Amended at 25 Ill. Reg. 12820, effective October 8, 2001)

Section 140.479  Limitations, Medical Supplies

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.

d)         The exemptions from prior approval specified in subsection (c) apply only if the quantity ordered by the physician is equal to or less than the Department's maximum allowable quantity.  If the physician has ordered a quantity that exceeds the Department's maximum allowable quantity, the dispensing provider must request prior approval for the entire order.  The Department will not pay for the dispensing of any quantity that is less than the physician's order, unless:

1)         the dispensing provider can document that the ordering physician has confirmed that the excess quantity is not medically necessary; or

2)         the Department has denied the request for prior approval of the excess quantity.

(Source:  Amended at 25 Ill. Reg. 12820, effective October 8, 2001)

Section 140.480  Equipment Rental Limitations

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.

(Source:  Amended at 25 Ill. Reg. 12820, effective October 8, 2001)

Section 140.481  Payment for Medical Equipment, Supplies, Prosthetic Devices and Hearing Aids

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.

b)         Payment for wheelchairs and wheelchair parts and accessories is made for covered items or services at the lesser of the provider's charge or the maximum allowable rate established by the Department. 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 will be calculated based on the Medicare rate for the year the procedure code is first established on the Department's fee schedule minus 6 percent.  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 Manufacturer's Suggested Retail Price (MSRP) minus 10 percent.

c)         Medical supplies are medical items which are not durable or reusable such as surgical dressings, disposable syringes, catheters, urinary bags, etc.  Payment for medical supplies is made for covered items at the lesser of the provider's charge or the maximum allowable rate established by the Department.  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 will be calculated based on the Medicare rate for the year the procedure code is first established on the Department's fee schedule minus 6 percent.  If there is no rate established on the Department's fee schedule, the maximum allowable rate established for each item 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 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.

d)         Payment for Prosthetic and Orthotic Devices.  Prosthetic and orthotic devices include corrective or supportive devices prescribed to artificially replace a missing portion of the body, or to prevent or correct physical deformity or malfunction, or to support a weak or deformed portion of the body.  Payment for prosthetic and orthotic devices is made for covered items or services at the lesser of the provider's charge or the maximum allowable rate established by the Department.  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 will be calculated based on the Medicare rate for the year the procedure code is first established on the Department's fee schedule minus 6 percent.  If there is no rate established on the Department's fee schedule, the maximum allowable rate established for each item shall be the least of:

1)         The average suggested retail price derived from providers' price lists; or

2)         The wholesale price derived from providers' price lists for each item plus 50 percent; or

3)         The Medicare allowable rate for covered Medicare items or services.

e)         Payment for hearing aids shall be made at the lesser of the provider's charge or the maximum allowable rate established by the Department.  The hearing aid shall be priced by the Department at the vendor's actual acquisition cost, without exceeding the Department's upper limits of reimbursement for the item.  Acquisition cost is defined as the actual amount the supplying provider pays for the hearing aids.  Any discounts, rebates or bonuses shall be subtracted when calculating the acquisition cost.  The amount of any rebates or bonuses shall be prorated on all purchases for which the rebate or bonus was earned.  The prorated share shall be subtracted when calculating the acquisition cost of the item. Verification of the vendor's acquisition cost must be attached to the request for reimbursement.  In addition to payment for the acquisition costs, the Department will pay a dispensing fee.  Payment for a dispensing fee shall include reimbursement for fitting, follow-up visits, shipping and retail markup.  The Department shall review and update the maximum allowable rate at least annually.

1)         To establish the maximum limit for the acquisition cost of the hearing aid, the Department shall review wholesale prices from available supply catalogs and provider price lists for the most widely accepted brands and types of technology.

2)         To establish the maximum allowable rate for the dispensing fee, the Department shall use an average of available rates charged by audiologists for three hearing aid follow-up visits, not to exceed the Department's maximum allowable rate for a physician visit of low complexity for an established patient, plus the average of available shipping fees charged by the wholesaler for hearing aid shipping and an amount for the retail mark-up, determined by taking 50 percent of the average wholesale price of the hearing aids reviewed.

(Source:  Amended at 42 Ill. Reg. 4829, effective March 1, 2018)

Section 140.482  Family Planning Services

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.

Section 140.483  Limitations on Family Planning Services

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.

Section 140.484  Payment for Family Planning Services

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.

Section 140.485  Healthy Kids Program

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 1396a(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.

2)         The Department strives to achieve these goals by offering the following services at no cost to an eligible child, except as may be limited by a spend down requirement:

A)        periodic and interperiodic health, vision, hearing and dental screening services to meet the health care needs of children (see Section 140.488(a) through (d));

B)        immunizations against childhood diseases (see Section 140.488(e));

C)        diagnostic laboratory procedures as described in Section 140.488(f);

D)        further diagnosis or treatment necessary to correct or ameliorate defects and physical or mental illnesses or conditions which are discovered or determined to have increased in severity by a provider as the result of a periodic or interperiodic health, vision, hearing or dental screening;

E)        effective for dates of service on or after July 1, 2014, referral for dental care beginning at age one; and

F)         assistance in locating a provider, scheduling an appointment and in arranging transportation to and from the source of medical care.

3)         The Department also strives to protect each eligible person's right to freedom of choice regarding participation and selection of a health care provider and the right to continuity of care.

b)         Eligibility.  Services are available to those persons listed in Section 140.3, except that those persons must be under 21 years of age at the time of receiving the services.

c)         Provider Participation.  Providers of Healthy Kids services must be duly licensed or certified according to applicable federal or State law or rule and be enrolled in the Illinois Medical Assistance Program to provide one or more Healthy Kids Program services as authorized in Title XIX of the Social Security Act and the Illinois Medical Assistance Program State Plan (as set forth in Sections 140.11 through 140.835).

d)         Program Activities and Services

1)         Informing Clients.  The Department shall inform eligible persons in writing about the benefits of preventive health care, the services which are available, and procedures by that eligible persons may request and receive assistance in identifying an enrolled provider, scheduling an appointment or arranging transportation to and from the source of medical care.  Effective July 1, 1990, the Department shall also notify Medicaid-eligible pregnant women, postpartum women during the six months after termination of pregnancy, women up to one year postpartum who are breastfeeding their infants or children below the age of five years of their potential eligibility for receiving services through the Special Supplemental Food Program for Women, Infants and Children which is administered by the Illinois Department of Public Health (IDPH).  The informing of eligible persons shall be done as described in the timeliness standards contained in Section 140.487.

2)         Periodic Medical Screenings.  The Department will pay for a series of periodic medical screenings scheduled from a person's birth through age 20.  The periodicity schedule of screenings is contained in Section 140.488.  The Department will pay for additional health screenings when necessary for:

A)        enrollment in school;

B)        enrollment in a licensed day care program, including Headstart;

C)        placement in a licensed child welfare facility, including a foster home, group home or child care institution;

D)        attendance at a camping program;

E)        participation in an organized athletic program;

F)         enrollment in an early childhood education program recognized by the Illinois State Board of Education;

G)        participation in a Women, Infant and Children (WIC) program; or

H)        is requested by a child's parent, guardian or custodian, or is determined to be necessary by social services, developmental, health, or educational personnel.

3)         Dental Screenings

Effective for dates of service on or after July 1, 2014:

A)        A dental screening shall be included as part of the well child visit at the appropriate intervals.

B)        A physician shall refer children to a dentist for routine and periodic preventive dental care within six months after the eruption of the first tooth or by age one.

C)        The periodicity schedule for dental screening services is contained in Section 140.488.  The Department will pay for one dental screening per age period unless a second screening is medically necessary.

4)         Vision Screening

A)        The Department will pay for vision screening services and diagnosis and treatment for defects in vision, including glasses.

B)        The periodicity schedule for vision screenings is contained in Section 140.488.  The Department will pay for one vision screening per age period, except when a second screening is determined to be medically necessary.

5)         Hearing Screening.  The Department will pay for hearing screenings and diagnosis and treatment for defects in hearing, including hearing aids.  The periodicity schedule for hearing screenings is contained in Section 140.488.  The Department will pay for one hearing screening per age period, except when a second screening is determined to be medically necessary.

6)         Immunizations.  The Department will pay for the immunization of eligible children against childhood diseases.  The list of covered immunizations is contained in Section 140.488(b).

7)         Diagnostic Procedures

A)        Lead Screening

i)          The Department requires that lead screening shall be performed in compliance with the Lead Poisoning Prevention Act [410 ILCS 45].  Children between the ages of six months to six years should be screened for lead poisoning at priority intervals. Screenings and medical follow up shall be performed in accordance with the "Guidelines for the Detection and Management of Lead Poisoning for Physicians and Health Care Providers", published by the Illinois Department of Public Health.  These guidelines recommend that those children at highest risk be screened on a regular basis.  High risk environmental situations include housing built before 1978, housing that is being renovated or remodeled, or that is in deteriorating condition.  Children six years and older shall also be screened, when medically indicated or appropriate.

ii)         The Department will pay for lead screening as indicated in subsection (d)(7)(A)(i) or as required for admission by a day care center, day care home, preschool, nursery school, kindergarten, or other child care facility or educational facility licensed by the State.

iii)        The Department will pay for epidemiological study of the child's living environment when the child has been diagnosed as having an elevated blood lead level for the purpose of identifying the source of lead exposure.

B)        The Department will pay for the administration of all other medically necessary diagnostic procedures performed during or as the result of medical screenings.

8)         Treatment.  The Department shall pay for necessary medical care (see Section 140.2), diagnostic services, treatment or other measures medically necessary (e.g., medical equipment and supplies) to correct or ameliorate defects, and physical and mental illnesses and conditions which are discovered or determined to have increased in severity by medical, vision, hearing or dental screening services.

9)         Assistance Services.  The Department shall, upon request, provide assistance to eligible children and their parent, guardian or custodian to locate a provider, schedule an appointment or arrange transportation to and from the source of medical care.

10)         Timeliness Standards.  The timeliness standards in Section 140.487 will govern the completion of required activities and services.

e)         Reimbursement to Providers

1)         Fee-for-service.  Provider's enrolled in the Maternal and Child Health Program, as described in Subpart G, will receive enhanced rates for certain services, as described in Section 140.930(a)(1).  Payment will be made at the provider's usual and customary charges or the established Department rates (see Section 140.400), whichever is less, for providers not enrolled in the Maternal and Child Health Program.  Reimbursement for the administration of immunizations to an eligible person will be made at rates established by the Department.  The provider will receive replacement vaccines as explained in subsection (e)(3).

2)         Claims.  Claims for reimbursement shall be submitted on the form and in a manner specified by the Department.

3)         Vaccine Replacement Program.  When a provider administers an immunization to an eligible child, the vaccines are replaced to the provider through the Vaccine Replacement Program which is administered jointly by the Department and the IDPH.  Providers must be annually certified for participation in the Vaccine Replacement Program by IDPH before receiving replacement vaccines.  Information on the Vaccine Replacement Program and certification procedures (set forth at 42 CFR 51b), may be obtained by contacting:

Immunization Vaccine Replacement Program

Illinois Department of Public Health

525 West Jefferson Street

Springfield, Illinois 62761

f)         Limitations on Services.  Services under the Healthy Kids Program shall only be available to persons in the age groups from birth through age 20. Coverage of and payments for services shall be consistent with the requirements of section 1905 of the Social Security Act (42 USC 1396d) as it relates to the Early and Periodic Screening, Diagnosis and Treatment Program.

g)         Record Requirements.  The provider shall comply with record requirements as set forth in Section 140.28.

(Source:  Amended at 38 Ill. Reg. 23623, effective December 2, 2014)

Section 140.486  Illinois Healthy Women

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.

c)         Payment of services under this Section shall be made to participating providers in accordance with this Part.

(Source:  Old Section repealed at 15 Ill. Reg. 298, effective December 28, 1990; new Section added at 28 Ill. Reg. 11161, effective August 1, 2004)

Section 140.487  Healthy Kids Program Timeliness Standards

These timeliness standards for required Healthy Kids services or activities apply regardless of the source from which medical or dental care is provided.

a)         Activity 1:  Informing Eligible Families

1)         Description:

The Department shall inform eligible families in writing about the Healthy Kids Program, including:  the importance of preventive health care; the services which are available; how to request assistance in identifying a willing and qualified provider or how to request assistance in obtaining transportation to and from health care appointments; and that the services are available at no cost to an eligible recipient, except as may be limited by a spenddown requirement.

2)         Timeliness Standards:

A)        At the time of application for public assistance, the applicant will be informed orally by the intake worker and in writing.

B)        An applicant determined to be eligible for benefits shall be informed by mail within sixty (60) calendar days of the date of the determination of eligibility for Medicaid services.

C)        All eligible persons shall be informed annually by mail.

b)         Activity 2:  Notification of a Scheduled Health, Vision, Hearing and Dental Screening Periods

1)         Description:

Eligible persons shall be notified in writing of scheduled health, vision, hearing and dental screening periods.

2)         Timeliness Standard:

The child or the caretaker relative (89 Ill. Adm. Code 101.20) shall receive notification of the next scheduled health, vision, hearing and dental screening periods not less than 10 working days before the date on which the screening period begins as determined by the child's birthday, the Periodicity Schedule and the most recent date of the child's eligibility for services.

c)         Activity 3:  Administration of a Health, Vision, Hearing, or Dental Screening

1)         Description:

A health, vision, hearing or dental screening shall be performed by a provider who is enrolled with the Illinois Medical Assistance Program.

2)         Timeliness Standard:

A health, vision, hearing or dental screening shall occur, to the extent possible, during the next scheduled screening period as determined by the child's birthday, the most recent date of the child's eligibility and the periodicity schedules for screenings.

d)         Activity 4:  Diagnosis

1)         Description:

Diagnosis is the provider's assessment of a child's current state of health or disease.

2)         Timeliness Standards:

A)        The diagnosis shall be made at the conclusion of the screening, except that the diagnosis may be deferred until the provider receives the results of laboratory tests when such tests are required to establish the diagnosis.

B)        The provider shall orally inform the adult responsible for the child of the diagnosis immediately or within 24 hours, unless prohibited by confidentiality rules.  In such cases, the provider shall inform the child of the diagnosis within 24 hours and inform the responsible adult only with the child's written consent.

C)        If the provider suspects that a child has been abused or neglected as defined in the Abused and Neglected Child Reporting Act (Ill. Rev. Stat. 1989, ch. 23, pars. 2051 thru 2061.7), the provider shall immediately make a report to the Illinois Department of Children and Family Services.

e)         Activity 5:  Referral for Treatment

1)         Description:

When a provider determines that a child is in need of treatment for a condition discovered or determined to have increased in severity during a screening, the provider shall arrange to provide the needed treatment directly or shall refer the client for treatment.  Referral for treatment shall include one or more of the following actions:  informing the client (or client's caretaker) of the type of provider from whom treatment should be sought; or providing the client (or client's caretaker) with the name and address of a provider qualified to provide the needed treatment; or making an appointment for the client with a provider qualified to provide the needed treatment.

2)         Upon request of an eligible person or notification by a qualified provider of an eligible person's need for referral assistance as the result of a screening, the Department shall refer the eligible person to a willing and qualified provider for treatment of a diagnosed or suspected condition, whether or not the treatment needed is a covered service.  The eligible person shall be consulted about the referral, except when such consultation may jeopardize the health and safety of the child (e.g., cases of suspected child abuse or neglect).  In making the referral, the Department shall first consider referral of the eligible person to other Federal and State-funded programs (e.g., services to crippled children and alcohol/drug abuse intervention) when such programs may be capable of treating or arranging treatment for the condition.

3)         Timeliness Standard:

Referral, as defined above, shall be made within thirty (30) days of the request or identification of need, except that such referral shall be made immediately when the child is in imminent danger.

f)         Activity 6:  Treatment

1)         Description:

Treatment is the provision of health care needed to correct or ameliorate defects and physical and mental illnesses and conditions discovered or determined to have increased in severity by a qualified provider as the result of a screening.

2)         Timeliness Standard:

Treatment consistent with recognized standards of medical or dental practice shall begin no more than sixty (60) days after the diagnosis of the child's condition, unless medically contraindicated, except that treatment shall begin sooner when the diagnosed condition requires it.

g)         Activity 7:  Scheduling and Transportation Assistance

1)         Description:

Upon oral or written request of a recipient, the Department shall provide assistance to identify a provider, to schedule an appointment with a provider or to arrange transportation to and from the source of medical or dental care.

2)         Timeliness Standards:

A)        The Department shall determine the recipient's need for the requested assistance within ten (10) working days of the request.

B)        The Department shall arrange or provide the needed assistance in time to assure that the recipient receives services within the periodicity schedule or the treatment timeliness standard (Section 140.488).

h)         Activity 8:  Coordination with the Women, Infant and Children (WIC) Special Supplemental Food Program

1)         Description:

The Department shall inform Medicaid-eligible pregnant women, postpartum women during the six (6) months after termination of their pregnancy, women up to one (1) year postpartum who are breastfeeding their infants and children below the age of five (5) years in writing of the availability of WIC Program benefits and procedures for accessing WIC services.

2)         Timeliness Standards

A)        The Department shall in writing inform individuals found eligible for Medicaid services and who are also eligible for WIC Program services of the availability of WIC Program benefits and procedures for accessing such services within sixty (60) days of such persons being determined eligible for Medicaid services.

B)        The Department shall also annually notify such persons in writing of the availability of WIC Program benefits and procedures for accessing such services.

(Source:  Amended at 15 Ill. Reg. 298, effective December 28, 1990)

Section 140.488  Periodicity Schedules, Immunizations and Diagnostic Laboratory Procedures

a)         Health Screening Periodicity Schedule.  Eligible clients may receive one periodic health screening during each of the following time periods, except a second screening may be given as explained in Section 140.485(d)(2):

1)         birth to two weeks;

2)         two weeks to one month;

3)         one to two months;

4)         two to four months;

5)         four to six months;

6)         six to nine months;

7)         nine to 12 months;

8)         12 to 15 months;

9)         15 to 18 months;

10)         18 to 24 months;

11)         two to three years;

12)         three to four years;

13)         four to five years;

14)         five to six years;

15)         six to eight years;

16)         eight to 10 years;

17)         10 to 12 years;

18)         12 to 14 years;

19)         14 to 16 years;

20)         16 to 18 years; and

21)         18 to 21 years.

b)         Vision Screening Periodicity Schedule

1)         Vision screening using age appropriate methods shall be part of all periodic or interperiodic health screenings.

2)         Beginning at age three through 20 years, the Department will pay for one vision screening performed by a qualified provider per year for an eligible child.  However, the Department will pay for other such screenings when medically necessary, regardless of a child's age or medical history.

c)         Hearing Screening Periodicity Schedule

1)         Hearing screening using age appropriate methods shall be part of all periodic or interperiodic health screenings.

2)         Beginning at age one year for children at high risk for hearing problems and age three years for all other children, the Department will pay for one hearing screening performed by a qualified provider per year for an eligible child.  However, the Department will pay for other such screenings when medically necessary, regardless of a child's age or medical history.

d)         Dental Screenings Periodicity Schedule

1)         Effective for dates of service on or after July 1, 2014, the dental periodicity schedule is available at the Department's website at http://www2.illinois.gov/hfs/MedicalProvider/MedicaidReimbursement/

Pages/Dental.aspx.  Examination of a child's oral cavity, including the status of the teeth and gums, shall be part of each periodic or interperiodic health screening.

2)         Effective for dates of service on or after July 1, 2014, beginning at age one through 20 years, the Department will pay for one clinical oral examination and one oral prophylaxis not more frequently than once every six months performed by an enrolled dentist.  However, the Department will pay for additional services when medically necessary, regardless of a child's age or medical history.

e)         Immunizations.

1)         Immunizations for children that are recommended by the Advisory Committee on Immunization Practices (ACIP) are covered without cost sharing under 89 Ill. Adm. Code 140.402(d)(2).  Current ACIP child vaccine recommendations can be found at https://www.cdc.gov/ vaccines/hcp/imz-schedules/child-adolescent-age.html.

2)         In compliance with section 1905(a)(13)(B) of the Social Security Act (42 U.S.C. 1396(d), and pursuant to 89 Ill. Adm. Code 140.402(e)(11), adult vaccines recommended by ACIP are also covered without cost sharing.  Current ACIP adult vaccine recommendations are listed at https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html.

f)         Diagnostic Laboratory Procedures.  The Department will pay for covered diagnostic laboratory procedures as medically necessary including but not limited to:

1)         Urinalysis, routine (ph specific gravity protein tests for reducing substances such as glucose), with microscopy;

2)         Urinalysis routine without microscopy;

3)         Chemical, qualitative, any number of constituents;

4)         Cholesterol, serum; total;

5)         Cholesterol, serum; total and ester;

6)         Lead Screening, Blood Lead;

7)         Gonadotropin, chorionic quantitative pregnancy test;

8)         Gonadotropin, chorionic qualitative pregnancy test;

9)         Hematocrit;

10)         Hemoglobin Colorimetric;

11)         Sickle RBC, reduction slide method;

12)         Hemoglobin Electrophoresis;

13)         Sickle Hemoglobin;

14)         Tuberculosis intradermal;

15)         TB Tine Test;

16)         Syphilis Test, qualitative;

17)         GC Culture Test, bacterial screening only;

18)         Culture presumptive, pathogenic organisms screening only;

19)         Culture, multiple organisms;

20)         Urine culture colony count;

21)         Urine bacteria count, commercial kit;

22)         Urine bacteria culture, identification, in addition to colony count and commercial kit;

23)         Chlamydia Culture;

24)         Pap Smear, Cytopathology;

25)         Epidemological study of a child's living environment when a child has been diagnosed as having an abnormally high blood lead level;

26)         Denver Developmental Screening Test; and

27)         Other developmental tests that may be approved by the Department.

(Source:  Amended at 49 Ill. Reg. 3081, effective February 26, 2025)

Section 140.490  Medical Transportation

a)         Payment for medical transportation shall be made to an individual, public, private or not-for-profit transportation carrier, whose operators are properly licensed, who provides the appropriate form of transportation and who bills and receives payment from the general public and other third party payors (except for private autos pursuant to subsection (a)(5)).  Eligible providers to be considered for payment include:

1)         Ambulance providers who hold a valid license, permit or certification from the state where the business is headquartered or from the Secretary of State (see Section 3-401 of the Illinois Vehicle Title and Registration Law [625 ILCS 5/3-401] and Section 8-101 of the Illinois Vehicle Code [625 ILCS 5/8-101]) and pass health/safety inspections annually by the Department of Public Health (see the Emergency Medical Services (EMS) Systems Act [210 ILCS 50]).  Out-of-state ambulance providers who provide services within Illinois must be in compliance with the EMS Systems Act [210 ILCS 50].  Vehicles operated by municipalities must meet the certification requirements contained in 77 Ill. Adm. Code 535, Subpart C, by July 1, 1987.  The Department will grant exceptions to this requirement if the municipality can demonstrate that the Illinois Department of Public Health has granted a waiver or exception to such requirement.