Proposed Changes In Methods And Standards

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. 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.

Effective October 1, 2005, the HFS will increase, to $90.00, the rate paid to encounter rate clinics providing comprehensive health care for women and infants. It is estimated that these changes will result in an increase in annual Medicaid expenditures of $115,000.

Effective January 1, 2006, the HFS proposes to change the rates of reimbursement for services, except for psychiatric diagnostic, evaluative and therapeutic procedures (CPT codes 90801-90899), provided by advanced practice nurses enrolled in the Illinois Medicaid program to be the same as those paid to an enrolled physician providing the same service. (The HFS does not allow advanced practice nurses to bill for psychiatric services.) It is estimated that these changes will result in an increase in annual Medicaid expenditures of $1.4 million.

Effective January 1, 2006, the HFS proposes to increase certain rates of reimbursement paid for Medicaid mental health rehabilitation services. This change affects Medicaid-covered mental health services provided by community providers enrolled with the HFS and certified through the Department of Children and Family Services, the Department of Human Services, or the Department of Corrections, to provide such services in the Illinois Medicaid program. The proposed changes are:

Services for which the minimum staff qualification is a licensed practitioner of the healing arts (LPHA) (excluding physicians and licensed nurses) shall increase by 8.1 percent. Services for which the minimum staff qualification is a registered nurse (RN) or a licensed practical nurse (LPN) shall increase by 6.4 percent. Except for Crisis intervention–Pre-hospitalization screening (HCPCS code T1023), services for which the minimum staff qualification is a mental health professional (MHP) shall increase by 5.4 percent.

The allowance for services provided off-site shall be increased from the current 11 percent to 16 percent.

An additional allowance may be reimbursed for certain services when the service has been delivered (a) off-site, but only when the off-site location is not a hospital, and (b) by more than one individual:

$50.00 per hour for Intensive family-based services (HCPCS code H0046 modified with TF).

$12.50 per quarter hour for Crisis intervention (HCPCS code H2011).

$125.00 per event for Crisis intervention–Pre-hospitalization screening (HCPCS code T1023).

It is estimated that these changes will result in an increase in annual expenditures of $10.5 million.

Pending federal approval, the HFS will allow local education agencies to certify expenditures incurred for the provision of medically necessary services to children enrolled in the State’s Medicaid or KidCare programs when such services are not part of, or related to the development of, an individual education plan. This change will be allowed for services that were provided on or after June 26, 2004. If approved, this change will result in an annual increase of $1.5 million in federal funding for participating school districts.

Pending federal approval, HFS will amend its Title XXI State Children’s Health Insurance Program effective September 1, 2005, to change claiming federal financial participation under Title XXI for the costs of services provided during the prenatal period to beneficiaries because of a failure to meet citizenship or immigration status requirements or because of federal policy regarding inmates of public institutions. This change affects only HFS’ claim for federal reimbursement. The State will continue to cover prenatal services after September 1, 2005, to the same extent as it did previously. No medical provider or individual recipient will be adversely affected by this change.

Any interested party may submit comments, data, views, or arguments concerning these proposed. 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: bpra@idpa.state.il.us

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.