Section 118.780  Kidney Transplantation for Noncitizens with End-Stage Renal Disease

Pursuant to Public Act 98-0651, which amended Section 5-5 of the Public Aid Code, effective for dates of outpatient services and inpatient discharges on and after October 1, 2014, notwithstanding Section 1-11 of the Code and any citizenship or immigration requirements under Title 89, any noncitizen is eligible for kidney transplantation when each of the following criteria are met:

a)         The noncitizen:

1)         has end-stage renal disease;

2)         is enrolled with the Department with coverage limited to renal dialysis services;

3)         is not eligible for comprehensive medical benefits under any government funded or private insurance plan;

4)         otherwise meets the income, asset, and categorical requirements of the medical assistance program; and

5)         meets the residency requirements of Section 5-3 of the Code.

b)         Providers, including transplant centers, providing kidney transplantation services under this Subpart shall be pre-certified by the Department and meet all provider requirements consistent with 89 Ill. Adm. Code 148.82. Only providers, including transplant centers, enrolled in the medical assistance program, and located in the State of Illinois and St. Louis, MO shall be allowed to perform the kidney transplantation and conduct the medically necessary care identified in subsection (c).

c)         The kidney transplantation procedure shall be medically necessary, and providers shall be prior approved and certified by the Department to perform kidney transplantation and services under this section. Only medically necessary services associated with kidney transplantation shall be covered, including but not limited to donor and recipient transplant surgeries (including facility, surgical, and anesthesia services), recommended, to the extent covered under the medical assistance program, pre-op evaluation and screening, assessment for evaluation of recipient's ability to comply with medical and follow-up instructions, acquisition and harvesting of kidney to be transplanted, hospitalization, medical follow-up and testing, rehabilitative and home nursing services, pharmacy costs, including anti-rejection and anti-infective medicines, and incidental costs for care of complications in the peri-operative period.

d)         Requests for repeat kidney transplantation shall be considered in exceptional circumstances and shall require prior approval by the Department.

e)         Transplantation of organs other than kidneys shall not be a covered service under this Subpart.

f)         Clinical trials shall not be a covered service under this Subpart.

g)         Experimental procedures shall not be a covered service under this Subpart.

h)         Reports, including patient's progress, kidney function tests, complications, if any, and a list of current medications shall be submitted to the Department from the transplant center and transplant surgeon at three months after surgery and at the anniversary date of transplantation annually for five years.

i)          Payment for services rendered under this Subpart shall be at a single bundled rate, which shall be payment in full for all medically necessary services associated with the transplantation under this Subpart, with the exception of immunosuppressant drugs. The bundled rate shall have two components. First, the inpatient stay during which the transplant takes place will be priced using the Department's hospital rate methodology (see 89 Ill. Adm. Code 149.100) and, second, the Department will add $15,000 to this price to cover all ancillary services covered in subsection (c) except drugs covered through pharmacy as appropriate and related to the transplant. These two components will comprise the single bundled rate for transplant for the first year (12 months) from the date of kidney transplant.

j)          Drugs paid for under this Subpart shall be subject to all the Department's pharmaceutical protocols and procedures, including but not limited to placement on the prior approval list, preferred drug list, genetic drug preference, and utilization controls, except:

1)         drugs may not be shipped to any address outside the State of Illinois; and

2)         immunosuppressant drugs shall be paid for at the Department's prevailing rates under 89 Ill. Adm. Code 140 to a pharmacy provider approved specifically for this program. Immunosuppressant drugs paid for under this Subpart shall be covered by the Department if medically necessary and as long as the noncitizen remains eligible under this Subpart.

(Source:  Added at 46 Ill. Reg. 14541, effective August 8, 2022)