Current through Register Vol. 48, No. 38, September 20, 2024
The following implements cost sharing in compliance with
42
USC 1396o (section 1916 of the Social
Security Act):
a) Each recipient, with
the exception of those classes of recipients identified in subsection (d),
shall be required to pay a copayment of $2.00 for generic legend drugs and
over-the-counter drugs billed to the Department, and for other services, with
the exception of those services identified in subsection (e), the nominal
copayment amount as defined at
42
CFR 447.54. For dates of service beginning
July 1, 2012 through March 31, 2013 the nominal copayment amount is $3.65.
Beginning with dates of service on April 1, 2013 through August 31, 2019, the
nominal copayment amount is $3.90.
Beginning with dates of service on or after September 1, 2019, recipients will
no longer be required to pay a copayment for medical assistance services.
Specific copayment amounts are described and updated on the Department's Web
site for the following non-institutional medical services:
1) Office visits to enrolled practitioners
for services reimbursed under the Illinois Public Aid Code.
2) Each brand name legend drug billed to the
Department.
3) Each encounter
billed to the Department by an Encounter Rate Clinic (ERC), Federally Qualified
Health Center (FQHC) or Rural Health Clinic (RHC), but excluding behavioral
services provided by these facilities. For dates of service beginning July 1,
2013 through August 31, 2019, copayments for behavioral health services
provided by these facilities are no longer excluded and shall be required to be
paid by recipients with the exception of those classes of recipients identified
in subsection (d).
b) In
each instance in which a copayment is payable, the Department will reduce the
amount payable to the affected provider by the respective amount of the
required copayment.
c) No provider
of services listed in subsection (a) may deny service to an individual who is
eligible for service on account of the individual's inability to pay the cost
of a copayment.
d) The following
individuals receiving medical assistance are exempt from the copayment
requirement set forth in subsection (a):
1)
Pregnant women, including a postpartum period of 60 days.
2) Children under 19 years of age.
3) All non-institutionalized individuals
whose care is subsidized by the Department of Children and Family Services or
the Department of Corrections.
4)
Hospice patients.
5) Individuals
residing in hospitals, nursing facilities, and intermediate care facilities for
the developmentally disabled who, as a condition of receiving services, are
required to pay all of their income, except an authorized protected amount for
personal use, for the cost of their care. For the purpose of this subsection
(d)(5), the protected amount shall be no greater than the protected amount
authorized for personal use under 89 Ill. Adm. Code
146.225(c).
6) Residents of a State-certified,
State-licensed, or State-contracted residential care program where residents,
as a condition of receiving care in that program, are required to pay all of
their income, except an authorized protected amount for personal use, for the
cost of their residential care program. For the purpose of this subsection
(d)(6), the protected amount shall be no greater than the protected amount
authorized for personal use under 89 Ill. Adm. Code
146.225(c).
7) Individuals enrolled in the "Health
Benefits for Person with Breast or Cervical Cancer" program under 89 Ill. Adm.
Code
120.500.
8) American Indians or Alaskan
Natives.
e) The
following medical services are exempt from any copayments:
1) Renal dialysis treatment.
2) Radiation therapy.
3) Cancer chemotherapy.
4) Insulin.
5) Services for which Medicare is the primary
payer.
6) Emergency services as
defined at
42 USC
1396u-2(b)(2) (section
1932(b)(2) of the Social Security Act) and
42 CFR
438.114(a).
7) Any pharmacy compounded drugs.
8) Any prescription (legend drug) dispensed
or administered by a hospital, clinic or physician.
9) Family planning services and supplies
described in
42
USC 1396d(a)(4)(C) (section
1905(a)(4)(C) of the Social Security Act), including contraceptives and other
pharmaceuticals for which the State claims or could claim federal financial
participation at the enhanced rate under
42 USC
1396b(a)(5) (section
1903(a)(5) of the Social Security Act) for family planning services and
supplies.
10) Other therapeutic
drug classes as specified by the Department.
11) Preventive services as described in
section 4106(b) of the Affordable Care Act.
