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Proposed Changes In Methods And Standards

State of Illinois Healthcare and Family Services

Proposed Changes in Methods and Standards for Establishing Medical Assistance Payment Rates for Certain Services

The Department of Healthcare and Family Services (HFS) proposes to change the methods and standards by which certain services are reimbursed under the Illinois Medical Assistance Program. This public notice details changes to reimbursement methodologies for two separate Medicaid services.

Performance Based Bonus Payments

Pending budgetary authority, HFS proposes to amend the Illinois Title XIX (Medicaid) State plan to provide bonus payments to qualifying Illinois Health Connect Primary Care Providers. The changes are being made in order to assure that individuals eligible for Medicaid have continued access to necessary medical services.

Effective June 19, 2009, HFS proposes to pay annual bonus payments to qualifying Illinois Health Connect Primary Care Providers (PCPs) for each patient receiving a qualifying service under a bonus measurement. 

Qualifying PCPs - A qualifying PCP is an Illinois Health Connect PCP who meets or exceeds the previous year’s HEDIS 50th percentile benchmark collectively for all the Illinois Health Connect enrollees on their panel roster for a particular measure, or, in the case of developmental screening, the benchmark target set by the Department.  A PCP maybe a qualifying PCP for one or more measurement.

Bonus Measurements -

Immunization Combo 3: Children who receive designated immunizations by age 24 months.

Developmental Screening: Children who receive at least one objective screening by the age of 12 months, between the ages of 12 and 24 months, and between the ages of 24 and 36 months. A bonus will be available for each separate age group.

Asthma management: Patients with persistent asthma, ages 5-9 years, ages 10-17 years and ages 18-56 years who fill an asthma controller medication prescription.

Diabetes Management: Patients with diabetes, ages 18 to 65 years who receive at least one HbA1c test annually.

Breast Cancer Screening: Women ages between ages 40 and 69 who have had a mammogram in the last two years.

If a PCP meets or exceeds the benchmark for a particular measured service, an annual bonus payment will be made for each patient that received the measured service during the previous calendar year. If the PCP does not meet the benchmark, there will not be a bonus payment made for any patients, whether they received the service or not. The annual bonus payments will be $25 per patient. Services measured may change in future years. Implementation of this change will increase spending by approximately $3 million in State fiscal year 2009.

Medicare Advantage Plans

HFS proposes to amend the Illinois Title XIX (Medicaid) State plan to update the methodology used in determining the maximum allowable capitated payment rate for co-insurance and deductibles due to Medicare Advantage Plans, excluding Private Fee-For-Service (PFFS) plans, for enrolled Qualified Medicare Beneficiaries (QMBs). This change is being made to account for the use of more updated cost data. 

Effective July 1, 2009, maximum monthly capitated payments for QMBs enrolled in Medicare Advantage plans, excluding PFFS plans, will be based upon the most recent year for which fee-for-service data is considered complete by the Department. Capitated payment rates will be determined for two categories based upon Age (less than 65, and 65 older). These maximum monthly capitated payment rates will be recalculated every three years. Implementation of this change will increase spending by approximately $1.5 million in State fiscal year 2010. 

Time, place and manner in which interested persons may comment on the proposed changes:

Any interested party may submit comments, data, views, or arguments concerning these proposed changes. All comments must be in writing and should be addressed to: 

Bureau of Program and Reimbursement Analysis

Division of Medical Programs

Healthcare and Family Services

201 South Grand Avenue East

Springfield, Illinois 62763-0001

E-mail address:

Interested persons may review these proposed changes on the Internet HFS Public Notices. Local access to the Internet is available through any local public library. In addition, this material may be viewed at the DHS local offices (except in Cook County). In Cook County, the changes may be reviewed at the Office of the Director, Healthcare and Family Services, 100 West Randolph Street, Chicago, Illinois. The changes may be reviewed at all offices Monday through Friday from 8:30 a.m. until 5 p.m. This notice is being provided in accordance with federal requirements found at 42 CFR 447.205.