Proposed Changes In Methods And Standards

The Illinois Department of Public Aid (DPA) proposes to change the methods and standards by which certain services are reimbursed under the Illinois Medicaid program. These changes are being made in order to assure that reimbursement for services rendered by these classes of providers are consistent with the State’s fiscal year 2006 budget while maintaining access to necessary medical services. Unless otherwise noted, these changes are effective on July 1, 2005.

The DPA proposes to provide an alternative reimbursement methodology for certain services provided by (a) a government-operated entity that is not a hospital, long term care facility, or cost-reporting clinic and (b) government-employed (including contractually employed) practitioners. The covered services to which this alternative methodology is available include: dental services; rehabilitation services; case management services; home health services; podiatric services; chiropractic services; physical, occupational, and speech therapy services; transportation services, family planning services; optometric services; Healthy Kids services; nurse midwife services; certified nurse practitioner services; respiratory care services; and services provided by a certified local public health department.   

The State or local government agency operating that entity, or employing a practitioner, may elect the alternative methodology by entering into an interagency or intergovernmental agreement, as appropriate, with the DPA that specifies the responsibilities of the two parties with respect to delivery of services by the entity and the funding thereof, including the certification of the expenditure of public funds by the State or local government agency in support of such services. The reimbursement rate shall be cost incurred by the government agency. The cost shall be computed, on a claim-by-claim basis, as the product of the provider’s charge for the service; multiplied by the agency-specific cost-to-charge factor for that service. The cost-to-charge factor shall be quotient of the difference of the government agency’s documented expenditures for the services provided, less any funds derived from a federal funding source and any funds otherwise used as State or local match for other federal funds, divided by the total charges for services provided. The cost-to-charge factor shall be determined annually from charge, expenditure, and reimbursement information certified by the State or local government agency that operated the entity, or employed a practitioner.  

The certification shall be completed at the end of the agency’s fiscal year. It shall be prepared and transmitted in a form and format specified by the DPA. It is estimated that these changes will result in an increase in Medicaid expenditures of $25 million during State fiscal year 2006.  

The DPA, in cooperation with the Illinois Department of Human Services (DHS), proposes to increase by 3.00 percent the rates of reimbursement paid for alcoholism and substance abuse (ASA) rehabilitation services. This change affects all Medicaid-covered ASA services provided by community providers enrolled with the DPA and licensed by the DHS, Division of Alcoholism and Substance Abuse, to provide such services. It is estimated that these changes will result in an increase in Medicaid expenditures of $1.5 million during State fiscal year 2006.

With the exception of pharmacy items provided under the early and periodic, screening, diagnosis, and treatment requirement of the federal Social Security Act, the DPA will no longer reimburse for the following categories of over-the-counter drugs: antacids; antibiotic ointments; anti-fungals; antihistamines; anti-itch ointments; iron supplements; laxatives; lice treatments; pain relief products; proton pump inhibitors; and tear replacement products . It is estimated that these changes will result in a reduction in Medicaid expenditures of $111 million during State fiscal year 2006.

The DPA proposes to change the rates of reimbursement paid by the DHS for certain home- and community-based waiver services provided to persons with a developmental disability. Reimbursement for the following services (DHS program numbers in parentheses) will be increased by 3.00 percent: developmental training (31U, 31A); supported employment (36G, 36U, 39G, 39U); at-home day program (37U); home-based services—service facilitation (55A), home-based services—nursing (55N, 55P); behavioral health therapies (56U, 57G, 57U, 58G, 58U); and, reimbursement for the following services (DHS program numbers in parentheses) will be increased by 3.00 percent: developmental training (31U, 31A); supported employment (36G, 36U, 39G, 39U); at-home day program (37U); home-based services—service facilitation (55A), home-based services—nursing (55N, 55P); behavioral health therapies (56U, 57G, 57U, 58G, 58U); and, certain community supported living arrangements (CSLA)/community integrated living arrangements (CILA) (65H). In addition, reimbursement for certain CILA (60D, 61D) services will be increased by 2.46 percent and community living facility (CLF) (67D) services will be increased by 2.01 percent. It is estimated that these changes will result in an increase in Medicaid expenditures of $17.7 million during State fiscal year 2006.

The DPA proposes to increase the rates of reimbursement paid for non-emergency transportation services provided by a Medicar or service car. The base rate (which includes the first ten miles of each service event) will be increased by $0.50. The rate per mile for each mile in excess of ten, for each service event, will be increased by $0.10. This increase does not apply to providers located in counties (Madison and St. Clair) where rates were increased previously. This changed is deemed necessary under the provisions of 89 Ill. Admin. Code 140.492(i). It is estimated that these changes will result in an increase in Medicaid expenditures of $1.0 million during State fiscal year 2006.

Note: Effective July 1, 2005, the DPA will be renamed the Department of Healthcare and Family Services.

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

Bureau of Program and Reimbursement Analysis

Division of Medical Programs

Illinois Department of Public Aid

201 South Grand Avenue East

Springfield, Illinois 62763-0001

E-mail address: bpra@idpa.state.il.us (prior to July 1, 2005)

Interested persons may review these proposed changes on the Internet at HFS Public Notices (prior to July 1, 2005) or HFS Public Notices (after July 1, 2005). 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, Illinois Department of Public Aid, 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.