Ill. Admin. Code tit. 89, § 118.780 - Kidney Transplantation for Noncitizens with End-Stage Renal Disease
Pursuant to Public Act 98-0651, which amended Section 5-5 of the Public Aid Code, effective for dates of outpatient services and inpatient discharges on and after October 1, 2014, notwithstanding Section 1-11 of the Code and any citizenship or immigration requirements under Title 89, any noncitizen is eligible for kidney transplantation when each of the following criteria are met:
a) The noncitizen:
1) has end-stage renal disease;
2) is enrolled with the Department with
coverage limited to renal dialysis services;
3) is not eligible for comprehensive medical
benefits under any government funded or private insurance plan;
4) otherwise meets the income, asset, and
categorical requirements of the medical assistance program; and
5) meets the residency requirements of
Section 5-3 of the Code.
b) Providers, including transplant centers,
providing kidney transplantation services under this Subpart shall be
pre-certified by the Department and meet all provider requirements consistent
with 89 Ill. Adm. Code
148.82.
Only providers, including transplant centers, enrolled in the medical
assistance program, and located in the State of Illinois and St. Louis, MO
shall be allowed to perform the kidney transplantation and conduct the
medically necessary care identified in subsection (c).
c) The kidney transplantation procedure shall
be medically necessary, and providers shall be prior approved and certified by
the Department to perform kidney transplantation and services under this
section. Only medically necessary services associated with kidney
transplantation shall be covered, including but not limited to donor and
recipient transplant surgeries (including facility, surgical, and anesthesia
services), recommended, to the extent covered under the medical assistance
program, pre-op evaluation and screening, assessment for evaluation of
recipient's ability to comply with medical and follow-up instructions,
acquisition and harvesting of kidney to be transplanted, hospitalization,
medical follow-up and testing, rehabilitative and home nursing services,
pharmacy costs, including anti-rejection and anti-infective medicines, and
incidental costs for care of complications in the peri-operative
period.
d) Requests for repeat
kidney transplantation shall be considered in exceptional circumstances and
shall require prior approval by the Department.
e) Transplantation of organs other than
kidneys shall not be a covered service under this Subpart.
f) Clinical trials shall not be a covered
service under this Subpart.
g)
Experimental procedures shall not be a covered service under this
Subpart.
h) Reports, including
patient's progress, kidney function tests, complications, if any, and a list of
current medications shall be submitted to the Department from the transplant
center and transplant surgeon at three months after surgery and at the
anniversary date of transplantation annually for five years.
i) Payment for services rendered under this
Subpart shall be at a single bundled rate, which shall be payment in full for
all medically necessary services associated with the transplantation under this
Subpart, with the exception of immunosuppressant drugs. The bundled rate shall
have two components. First, the inpatient stay during which the transplant
takes place will be priced using the Department's hospital rate methodology
(see 89 Ill. Adm. Code
149.100)
and, second, the Department will add $15,000 to this price to cover all
ancillary services covered in subsection (c) except drugs covered through
pharmacy as appropriate and related to the transplant. These two components
will comprise the single bundled rate for transplant for the first year (12
months) from the date of kidney transplant.
j) Drugs paid for under this Subpart shall be
subject to all the Department's pharmaceutical protocols and procedures,
including but not limited to placement on the prior approval list, preferred
drug list, genetic drug preference, and utilization controls, except:
1) drugs may not be shipped to any address
outside the State of Illinois; and
2) immunosuppressant drugs shall be paid for
at the Department's prevailing rates under 89 Ill. Adm. Code 140 to a pharmacy
provider approved specifically for this program. Immunosuppressant drugs paid
for under this Subpart shall be covered by the Department if medically
necessary and as long as the noncitizen remains eligible under this
Subpart.
Notes
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