As we have been sharing over the past few weeks, there will be a change October 1 regarding Medicaid’s ability to reimburse doctors who are not currently enrolled as Medicaid physicians.  Below, we have tried to simplify the issue and outline who will be affected.  Please note, we are the last state in the nation to move into compliance with this requirement.  Here is the last provider notice put out by HFS, outlining the issue.  The information below comes from Sherri Schneider (Arc board president) and my discussions with HFS staff, who have been very response to our inquiries.  

FACT:
 
Effective October 1, 2019, IL Medicaid will begin to follow the federal regulation that states that IL Medicaid will only pay for prescriptions written by an IL Medicaid enrolled provider. IL Medicaid has been out of compliance since 2012 and now must comply.
 
WHAT THIS MEANS:
 
If the prescribing doctor is NOT enrolled with IL Medicaid, IL Medicaid will not pay for the item/service to include: drugs, durable medical equipment, diapers, referrals to another doctor…etc.
 
WHO DOES THIS AFFECT:
 
Any person who is eligible for Traditional Medicaid.
 
This does NOT YET apply to individuals enrolled in a Medicaid MCO. (Managed Care Organization). They will be following this requirement at a later date. 
 
This does apply to individuals that are “dual eligible” (having both Medicare and IL Medicaid.)  The requirement that physicians be enrolled will extend to crossover claims (where Medicare is primary and Medicaid is secondary).  To receive the 20% payment from Medicaid, the prescribers will need to be enrolled with IL Medicaid.
 
EXCEPTION:  Drugs filled by Medicare Part D. IL Medicaid does not pay secondary to Medicare Part D, except in a very limited circumstance which is described below.  When a pharmacy bills Medicare Part D, the Medicare Part D plan is responsible for the entire cost of the drug, even if the member is dual eligible for both Medicare and Medicaid. IL Medicaid allows Medicare Part D copay only billing for a very small subset of individuals who are not eligible for a waiver, and live in a specific type of supported living arrangement.  This policy would apply to those claims. 
                                           
WHAT HAS IL MEDICAID DONE TO GET THIS WORD OUT:
 
IL  Medicaid has sent Provider Notices to pharmacies and doctor offices. They have updated their provider manual. They have explained that they were able to identify doctors who are not enrolled with IL Medicaid but, in the past, IL Medicaid has paid their prescriptions. These doctors received more notices.
 
 
WHAT HAPPENS IF I GO TO THE PHARMACY AND MEDICAID WILL NOT PAY FOR MY DRUG:
 
IL Medicaid has explained that there will be a one-time (per drug) over ride for the first month. To get an over-ride, one would need to call: 877-782-5565. 
 
NOW WHAT:
 
This leaves families with several options:

  • Change to a doctor that is enrolled with IL Medicaid.  As we are aware, there is a lack of available IL Medicaid enrolled doctors.  Many IL Medicaid doctors are not seeing new patients.  It is very difficult for individuals with an Intellectual and Developmental disability or Autism to change to a new doctor.  To find a doctor who is currently enrolled with traditional IL Medicaid, you may call: 800-226-0768  
  •  The current non-Medicaid doctor can enroll with IL Medicaid.  A physician can register in Impact to become a Medicaid enrolled provider.  After Medicaid enrollment, this doctor can choose to accept Medicaid patients or choose not to see Medicaid patients but his/her prescriptions will be paid by IL Medicaid for patients eligible for IL Medicaid.

We will continue to share information as we receive it and continue to try to advocate for families to get more information and minimize the disruption.  We understand this is a big change.  We are the final state in the country to transition.