Effective for dates of service on or after July 1, 2014,
certain services, although included in the Medical Assistance Program and under
certain circumstances provided in the hospital setting or by an entity
associated with the hospital, are not reimbursed by the Department as hospital
services. In addition, certain services currently provided in the hospital
outpatient and hospital-based clinic setting are subject to fee-for-service
payment methodologies. This means that for these services, hospitals shall be
required to conform to the policies and billing procedures in effect for other
non-hospital providers of services. Payment for these services shall be based
on the same fee schedule that applies to these services when they are provided
in the non-hospital setting. Services not covered or reimbursed as hospital
services are as follows:
a) Private
Duty Nursing Services. Private duty nursing services for hospitalized program
participants are not covered under the Medical Assistance Program. Hospitals
are expected to provide all required nursing services.
b) Sitter Services. Sitter services for
hospitalized program participants are not covered under the Medical Assistance
Program.
c) Dental Services.
Hospitals may not enroll to provide dental services. When dental services are
provided in the outpatient/clinic setting of a hospital, the dentist shall
submit charges to the Department according to the provisions of the Dental
Program.
d) Nurse Anesthetist
Services. Payment for general anesthesia services not reimbursed under 89 Ill.
Adm. Code
140.400 shall be made
only to hospitals that qualify for these payments under the Medicare Program
and shall be made to such hospitals when provided by a hospital employed
non-physician anesthetist (certified registered nurse anesthetist or
"CRNA").
e) Pharmacy Services.
Policy and reimbursement for pharmacy services are described in 89 Ill. Adm.
Code
140.440 through
140.450.
A hospital pharmacy may enroll on a fee-for-service basis for services provided
to a patient in:
1) A specified bed or
special hospital unit which is certified for skilled nursing facility services
under the Medicare Program.
2) A
special hospital unit or separate facility which is administratively associated
with the hospital and is licensed as a long term care facility.
3) The outpatient/clinic setting when the
services provided are not unique to the hospital setting.
f) Medical Transportation Services. A
hospital that owns and operates medical transportation vehicles as a separate
entity (for example, a private corporation) must enroll as a medical
transportation provider. A hospital that owns and operates medical
transportation vehicles that are included on the hospital's cost report as a
cost center of the hospital may not submit a separate claim for transportation
services provided to persons admitted as inpatients. Policy and reimbursements
for medical transportation services is described in 89 Ill. Adm. Code
140.490
through
140.492.
g) Home Health Services. A home health agency
that is administratively associated with a hospital and that is certified for
participation as a home health agency by the Medicare Program may apply for
participation for the provision of home health services. Policy and
reimbursement for home health services is described in 89 Ill. Adm. Code
140.470
through
140.474.
h) Sub-acute Alcoholism and Substance Abuse
Treatment Services. Only acute alcoholism and substance abuse treatment
services (i.e., detoxification) are covered as hospital services. Rules
regarding reimbursement for sub-acute alcoholism and substance abuse treatment
services may be found under Sections
148.340
through
148.390.
i) Hospice Services. Hospice is an
alternative to traditional Medicaid coverage. The Hospice Program is
responsible for all the client's medical needs related to a terminal illness.
If a client chooses the Hospice Program, a physician must certify that the
client is terminally ill and has a life expectancy of six months or less.
Policy and reimbursement for hospice services is described in 89 Ill. Adm. Code
140.469.
