Informational Notice To: Participating Physicians, Chiropractors, Podiatrists, Optometrists, Advance Practice Nurses, Federally Qualified Health Centers (FQHC), Encounter Rate Clinics (ERC), Rural Health Clinics (RHC) and Hospitals
Re: Cost Sharing
As a result of Public Act 097-0689 (pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, changes were made to the participant cost-sharing for Medicaid, All Kids and Illinois Healthy Women.
Cost Sharing Requirements for Medicaid and All Kids
Effective with dates of service on or after July 16, 2012, the department will be implementing new co-payment amounts for services. The co-pay chart included with this notice identifies the co-payment amounts and will replace the copayment information in Appendix 12, 13 and 14 of Chapter 100, General Policy and Procedures Handbook. Note: Residents of nursing homes, intermediate care facilities for the developmentally disabled and supportive living facilities do not pay co-pays. The following services are exempt from copayments: well-child visits, immunizations, preventive services, services provided under the Breast & Cervical Cancer (BCC) program and diagnostic services.
Cost Sharing Requirements for Illinois Healthy Women
Effective with dates of service on or after July 16, 2012, the department will be implementing new co-payment amounts for certain services rendered to participants enrolled in Illinois Healthy Women. The following identifies the services and co-payment amounts.
There are no co-pays for your family planning (birth control) medical services and contraceptive methods. Providers must bill for family planning services using the appropriate evaluation and management CPT Code along with modifier FP. Diagnosis coding should document the family planning service provided, as shown in the V25 series from the ICD-9-CM.
Family planning-related medical services will require a $3.65 co-pay for office visits. Family planning-related medical services may include follow-up for: abnormal pap findings, HPV vaccinations, sexually transmitted infections, urinary tract, vaginal, other lower genital tract and genital skin infections. Refer to the Practitioner Handbook, Topic A-223.2 for additional services that may be subject to a copayment.
Prescriptions, except for contraceptive (birth control) methods, will require a $2.00 co-pay for each generic prescription and $3.65 for each name brand prescription.
Collection of Co-payments
The department will automatically deduct the co-payment from the provider’s reimbursement. When billing the department, providers should bill their usual and customary charge and should not report the co-payment on the claim. Providers will be responsible for collecting co-payments from the participant. Providers may choose not to charge a co-payment, but if co-payments are charged, the co-payment amount cannot exceed the amounts shown on the chart.
Federal regulations stipulate that a provider cannot deny services to an individual covered under a Title XIX or Title XXI program due to the person’s inability to pay a co-payment. This requirement does not apply to the All Kids Premium Level 2. Providers may apply their office policies relating to the co-payments to participants covered under the All Kids Premium Level 2.
Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565 .
Theresa A. Eagleson, Administrator
Division of Medical Programs