Section 140.2 Medical Assistance Programs

Section 140.2  Medical

Assistance Programs

a)         Under the Medical Assistance Programs, the Department pays

participating providers for necessary medical services, specified in Section

140.3 through 140.7 for:

1)         persons eligible for financial assistance under the Aid to the

Aged, Blind or Disabled-State Supplemental Payment (AABD-SSP) and Temporary

Assistance to Needy Families (TANF) programs (Medicaid-MAG);

2)         persons who would be eligible for financial assistance but who

have resources in excess of the Department's eligibility standards and who have

incurred medical expenses greater than the difference between their income and

the Department's standards (Medicaid-MANG);

3)         individuals under age 18 who do not qualify for TANF/TANF-MANG

and infants under age one year (see Section 140.7);

4)         pregnant women who would not be eligible for TANF/TANF-MANG if

the child were born and who do not qualify as mandatory categorically needy

(see Section 140.9);

5)         persons who are eligible for Title IV-E adoption

assistance/foster care assistance from another State and who are living in Illinois;

6)         noncitizens who have an emergency medical condition (see 89 Ill.

Adm. Code 120.310); however, payment is not included for care and services

related to an organ transplant procedure;

7)         persons eligible for medical assistance under the Aid to the

Aged, Blind or Disabled (AABD) program who reside in specified Supportive

Living Facilities (SLFs), as described at 89 Ill. Adm. Code 146, Subpart B;

8)         persons

eligible for FamilyCare as described in 89 Ill. Adm. Code 120.32;

9)         beginning

January 1, 2014, persons eligible as ACA Adults as described in 89 Ill. Adm.

Code 120.10(h); and

10)         beginning

January 1, 2014, persons eligible as Former Foster Care as described in 89 Ill.

Adm. Code 120.10(i)

g Facilities (SLFs), as described at 89 Ill. Adm. Code 146, Subpart B;

8)         persons

eligible for FamilyCare as described in 89 Ill. Adm. Code 120.32;

9)         beginning

January 1, 2014, persons eligible as ACA Adults as described in 89 Ill. Adm.

Code 120.10(h); and

10)         beginning

January 1, 2014, persons eligible as Former Foster Care as described in 89 Ill.

Adm. Code 120.10(i).

b)         "Necessary medical care" is that which is generally

recognized as standard medical care required because of disease, disability,

infirmity or impairment.

c)         The Department may impose prior approval requirements, as

specified by rule, to determine whether the medical care is necessary and

eligible for payment from the Department in individual situations.  Such

requirements shall be based on recommendations of technical and professional

staff and advisory committees.

d)         When recipients are entitled to Medicare benefits, the

Department shall assume responsibility for their deductible and coinsurance

obligations, unless the recipients have income and/or resources available to

meet these needs.  The total payment to a provider from both Medicare and the

Department shall not exceed either the amount that Medicare determines to be a

reasonable charge or the Department standard for the services provided,

whichever is applicable.

e)         The Department shall pay for services and items not allowed by

Medicare only if they are provided in accordance with Department policy for

recipients not entitled to Medicare benefits

om both Medicare and the

Department shall not exceed either the amount that Medicare determines to be a

reasonable charge or the Department standard for the services provided,

whichever is applicable.

e)         The Department shall pay for services and items not allowed by

Medicare only if they are provided in accordance with Department policy for

recipients not entitled to Medicare benefits.

f)         The Department may contract with qualified practitioners,

hospitals and all other dispensers of medical services for the provision and

reimbursement of any and all medical care or services as specified in the

contract on a prepaid capitation basis (i.e., payment of a fixed amount per

enrollee made in advance of the service); volume purchase basis (i.e., purchase

of a volume of goods or services for a price specified in the contract);

ambulatory visit basis (i.e., one comprehensive payment for each visit

regardless of the services provided during that visit) or per discharge basis

(i.e., one comprehensive payment per discharge regardless of the services

provided during the stay).  Such contracts shall be based either on formally

solicited competitive bid proposals or individually negotiated rates with

providers willing to enter into special contractual arrangements with the

State.

g)         The Department may require that recipients of medical

assistance under any of the Department's programs exercise their freedom of

choice by choosing to receive medical care under the traditional fee for

service system or through a prepaid capitation plan or under one of the other

alternative contractual arrangements described in subsection (f) of this

Section.  The categories of recipients who may choose or be assigned to an

alternative plan will be specified in the contract.  Recipients required to

make such a choice will be notified in writing by the Department.  If a

recipient does not choose to exercise his/her freedom of choice, the Department

may assign that recipient to a prepaid plan

arrangements described in subsection (f) of this

Section.  The categories of recipients who may choose or be assigned to an

alternative plan will be specified in the contract.  Recipients required to

make such a choice will be notified in writing by the Department.  If a

recipient does not choose to exercise his/her freedom of choice, the Department

may assign that recipient to a prepaid plan.  Under such a plan, recipients

would obtain certain medical services or supplies from a single source or

limited source.  The Department will notify recipients in writing if they are

assigned to a prepaid plan. Recipients enrolled in or assigned to a prepaid

plan will receive written notification advising them of the services which they

will receive from the plan.  Covered services not provided by the plan will be

reimbursed by the Department on a fee for service basis.  Recipients will

receive a medical eligibility card, which will apply to such services.

h)         The Department may enter into contracts for the provision of

medical care on a prepaid capitation basis from a Health Maintenance

Organization (HMO) whereby the recipient who chooses to receive medical care

through an HMO must stay in the HMO for a certain period of time, not to exceed

six months (the enrollment period).  Upon written notice, the recipient may

choose to disenroll from such an HMO at any time within the first month of each

enrollment period. The Department will send the recipient a notice at least 30

days prior to the end of the enrollment period, which gives the recipient a

specified period of time in which to inform the Department if the recipient

does not wish to re-enroll in the HMO for a new enrollment period.  The

recipient may then disenroll at the end of the enrollment period only if the

recipient responds to the notice and indicates in writing a choice to

disenroll.  Failure to respond to the notice will result in automatic

re-enrollment for a new enrollment period

eriod of time in which to inform the Department if the recipient

does not wish to re-enroll in the HMO for a new enrollment period.  The

recipient may then disenroll at the end of the enrollment period only if the

recipient responds to the notice and indicates in writing a choice to

disenroll.  Failure to respond to the notice will result in automatic

re-enrollment for a new enrollment period.  Recipients shall also be allowed to

disenroll at any time for cause.

i)          The Department may enter into contracts for the provision of

medical care on a prepaid capitation basis from a Health Maintenance

Organization whereby the recipient who chooses to receive medical care through

an HMO may choose to disenroll at any time, upon written notice.

j)          The Department shall pay for services under the Maternal and

Child Health Program, a primary health care program for pregnant women and

children (see Subpart G).

k)         Services

covered for persons who are confined or detained as described in 89 Ill. Adm.

Code 120.318(b) shall be limited as described in Section 140.10.