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Elizabeth M. Whitehorn, Director

Provider Notice Issued 04/02/2024

Date:   April 2, 2024

To:       Enrolled Physicians; Physician Assistants; Advanced Practice Registered Nurses; Local Health Departments; Federally Qualified Health Centers; Rural Health Clinics; Encounter Rate Clinics; Licensed Clinical Social Workers, Licensed Clinical Psychologists, Licensed Marriage and Family Therapists, Licensed Clinical Professional Counselors, Independent Labs, Imaging Providers, Podiatrists, Audiologists, Independent Diagnostic Testing Facilities, Pharmacists, Portable X-ray Providers,  School Based Health Centers, and Dentists and Optometrists providing medical services

Re:      Practitioner Proposed Rate Adjustments for April 1, 2024, and Claim Reprocessing

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This notice informs providers of planned rate adjustments by the Department of Healthcare and Family Services (HFS) for practitioner services. These rate adjustments will be effective for service dates beginning April 1, 2024, and impact both the fee-for-service (FFS) program and the Medicaid managed care organizations (MCOs).

The Public Notice dated March 13, 2024, outlined these rate updates. The proposed changes are estimated to result in a $120.8 million annual increase to providers:

·Practitioner rates are being adjusted from initial pricing at 60% of the Medicare rate when the procedure code was first opened for coverage, to 70% of the January 1, 2024, Medicare rate.

·A reimbursement ceiling is being set at 100% of the Medicare rate. Services reimbursing above 100% of Medicare due to fluctuations in Medicare rates over time will be reduced to pay at 100% of Medicare.  Behavioral health and non-cesarian obstetrical services that are currently reimbursed over 100% of the Medicare rate will not be reduced.

·Reimbursement rates for specified mammography procedure codes will be set at 80% of the Medicare rate, though providers eligible for participation in the Department’s Breast Cancer Quality Screening and Treatment Initiative will continue to be paid at 100% of the Medicare rate in accordance with 89 Ill. Admin. Code 140.400(c).

Assistant surgeon rates, rates for anesthesia services, and any applicable add-on rates or bonus payments are not included in this rate update. Reimbursement rates for pharmacists, licensed clinical social workers, licensed clinical psychologists, licensed marriage and family therapists, and licensed clinical professional counselors will be adjusted accordingly consistent with current rate setting methodologies. SMART Act rate reductions continue to apply.

The proposed rate changes are subject to approval by the federal Centers for Medicare & Medicaid Services (CMS). Until HFS receives approval, FFS claims with dates of service beginning April 1, 2024, will be rejected with special error code and message, “C93 – Department will reprocess claim”. HFS will reprocess these claims at the time it obtains rate increase approval from CMS. MCOs will be processing claims with updated rates as soon as their systems allow.

 

Rate changes will be reflected on all applicable April 1, 2024, fee schedules, which will be posted as soon as the rate updates are approved by federal CMS.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or the appropriate MCO.                          

 

Kelly Cunningham, Administrator
Division of Medical Programs