Section 148.60  Services Not Covered as Hospital Services

Effective for dates of service on or after July 1, 2014, certain services, although included in the Medical Assistance Program and under certain circumstances provided in the hospital setting or by an entity associated with the hospital, are not reimbursed by the Department as hospital services.  In addition, certain services currently provided in the hospital outpatient and hospital‑based clinic setting are subject to fee-for-service payment methodologies.  This means that for these services, hospitals shall be required to conform to the policies and billing procedures in effect for other non-hospital providers of services.  Payment for these services shall be based on the same fee schedule that applies to these services when they are provided in the non-hospital setting.  Services not covered or reimbursed as hospital services are as follows:

a)         Private Duty Nursing Services.  Private duty nursing services for hospitalized program participants are not covered under the Medical Assistance Program.  Hospitals are expected to provide all required nursing services.

b)         Sitter Services.  Sitter services for hospitalized program participants are not covered under the Medical Assistance Program.

c)         Dental Services.  Hospitals may not enroll to provide dental services. When dental services are provided in the outpatient/clinic setting of a hospital, the dentist shall submit charges to the Department according to the provisions of the Dental Program.

d)         Nurse Anesthetist Services.  Payment for general anesthesia services not reimbursed under 89 Ill. Adm. Code 140.400 shall be made only to hospitals that qualify for these payments under the Medicare Program and shall be made to such hospitals when provided by a hospital employed non-physician anesthetist (certified registered nurse anesthetist or "CRNA").

e)         Pharmacy Services.  Policy and reimbursement for pharmacy services are described in 89 Ill. Adm. Code 140.440 through 140.450.  A hospital pharmacy may enroll on a fee-for-service basis for services provided to a patient in:

1)         A specified bed or special hospital unit which is certified for skilled nursing facility services under the Medicare Program.

2)         A special hospital unit or separate facility which is administratively associated with the hospital and is licensed as a long term care facility.

3)         The outpatient/clinic setting when the services provided are not unique to the hospital setting.

f)         Medical Transportation Services.  A hospital that owns and operates medical transportation vehicles as a separate entity (for example, a private corporation) must enroll as a medical transportation provider.  A hospital that owns and operates medical transportation vehicles that are included on the hospital's cost report as a cost center of the hospital may not submit a separate claim for transportation services provided to persons admitted as inpatients.  Policy and reimbursements for medical transportation services is described in 89 Ill. Adm. Code 140.490 through 140.492.

g)         Home Health Services.  A home health agency that is administratively associated with a hospital and that is certified for participation as a home health agency by the Medicare Program may apply for participation for the provision of home health services.  Policy and reimbursement for home health services is described in 89 Ill. Adm. Code 140.470 through 140.474.

h)         Sub-acute Alcoholism and Substance Abuse Treatment Services.  Only acute alcoholism and substance abuse treatment services (i.e., detoxification) are covered as hospital services.  Rules regarding reimbursement for sub-acute alcoholism and substance abuse treatment services may be found under Sections 148.340 through 148.390.

i)          Hospice Services.  Hospice is an alternative to traditional Medicaid coverage.  The Hospice Program is responsible for all the client's medical needs related to a terminal illness.  If a client chooses the Hospice Program, a physician must certify that the client is terminally ill and has a life expectancy of six months or less. Policy and reimbursement for hospice services is described in 89 Ill. Adm. Code 140.469.

(Source:  Amended at 38 Ill. Reg. 15165, effective July 2, 2014)