Agencies
Services
Provider Notice issued 12/28/2023
| To: | Long Term Care (LTC) Facilities - Nursing Facilities (NF) |
| Date: | December 28, 2023 |
| Re: | Health Benefits for Immigrant Adults (HBIA) and Seniors (HBIS) 90-Day Nursing Facility Rehabilitation Stay Coverage by Managed Care Organizations (MCOs) |
This notice informs nursing facilities (NFs) that 90-day rehabilitation stays within a nursing facility setting shall be covered only by HealthChoice Illinois managed care organizations (MCOs) for the Health Benefits for Immigrant Adults (HBIA) and Seniors (HBIS) programs.
The transition of most HBIA and HBIS customers from fee-for-service to managed care beginning January 1, 2024, was outlined in a provider notice dated December 28, 2023. The coverage policy for short term nursing facility rehabilitation stays is only applicable to HBIA/HBIS customers assigned to MCOs and is strictly limited to 90 days. HBIA/HBIS individuals do not qualify for regular/federally matched Medicaid except for emergency services due to citizenship/immigration status; therefore, long term care (LTC) services are not covered. Previously, only rehabilitation stays in a hospital setting were covered.
MCOs will be working to educate nursing facilities in their provider networks regarding rehabilitation stays, including medically necessary utilization management requirements. An initial 30-day prior authorization is required. HBIA/HBIS customers will not be entered as an admission in the Medical Electronic Data Interchange (MEDI) or have group care credit (GCC). These customers will not be listed on the patient credit file. NFs should bill using the rehabilitation room and board accommodation revenue codes 0118, 0128, 0138, 0148, or 0158. MCOs will determine what information is required on the claim to bypass the admissions requirements. Any admission transaction for an HBIA or HBIS customer entered in MEDI will be rejected.
It will be the responsibility of the nursing facility and the MCOs to work together to ensure the patient is discharged within 90 days. No payments will be made after 90 days.
Please do not contact the Bureau of Long Term Care or the Department of Human Services (DHS) caseworkers regarding short term rehabilitation stays for these populations.
Any questions regarding this change should be directed to the MCO or the Bureau of Managed Care (BMC) at hfs.MCOOperations@illinois.gov.
Kelly Cunningham, Administrator
Division of Medical Programs