Date: October 6, 2022
To: All Medical Assistance Program Providers
Re: COVID-19 Limited Treatment Coverage of Oral Medications and Monoclonal Antibody Administration for the Uninsured Population
This notice informs providers of HFS coverage limitation for COVID-19 medication treatment services for uninsured persons via the HFS COVID-19 Uninsured Testing Program.
HFS continues to offer coverage for testing and testing-related services, including COVID-19 home testing kits. HFS has added vaccine administration through its COVID-19 Uninsured Program for all uninsured persons (see COVID-19 Fee Schedule for procedure codes), retroactive to the specific vaccine administration effective date.
For certain uninsured persons who qualify, HFS will cover the following limited COVID-19 medication treatment services, retroactive to the specific treatment effective date:
- Oral antivirals for the treatment of COVID-19 obtained from an enrolled pharmacy
- Monoclonal antibody administration when covered for the date of service and administered by an eligible provider, as identified in the COVID-19 Fee Schedules.
Due to limitations on federal matching funds, HFS coverage of oral medications and monoclonal antibody administration under the Uninsured Testing Program is confined to a particular subset of the uninsured population, including those uninsured who would generally meet the residency, citizenship, and income requirements for Medicaid coverage. Providers should follow these steps at the time an uninsured person presents for services:
- Check the MEDI system to verify if the person has an existing Recipient Identification Number (RIN) assigned.
- If a RIN is found, the "Special Information" under the "COVID-19 Testing" eligibility in MEDI will show "Title XIX".
- This uninsured population will have medication treatment coverage and are eligible to have their oral antiviral medication billed through the HFS fee-for-service (FFS) pharmacy point-of-sale system or monoclonal antibody administration billed to HFS through the fee-for-service (FFS) claims processing system.
- Those with a "Special Information" message of "State-funded" are not eligible, and medication treatment services are not billable to HFS.
Pharmacy claims may be submitted effective September 30th, 2022. However, professional claims for monoclonal antibody administration should be held until further notification that HFS claims processing updates have been completed.
At this time, the COVID Uninsured Portal is still not operational (please refer to August 2, 2022, provider notice) however, many uninsured patients may already have a Recipient Identification Number (RIN) in MEDI. If a provider identifies an existing RIN for an eligible uninsured customer, the provider must bill a claim to HFS through the provider's usual claim submittal process outside the portal. Providers will continue to bill through their usual claim submittal process even when the COVID uninsured portal is back online.
All claims for the uninsured population must contain a diagnosis code indicating the patient encounter was for the purposes of COVID testing, COVID vaccine administration, and/or COVID medication treatment. Paid claims with no COVID or COVID-related diagnosis code are subject to post-payment review and recoupment.
Additional coverage options are available to the uninsured population who do not fall under Title XIX. The Emergency Medical for Noncitizens program will cover COVID-19 oral medications and monoclonal antibody administration for noncitizens who are ineligible for treatment services under the Uninsured Testing Program and meet the Emergency Medical income threshold. The Health Benefits for Immigrant Adults and Health Benefits for Immigrant Seniors programs also cover COVID-19 oral medications and monoclonal antibody administration. Illinois residents can apply for these medical programs in one of the following ways:
1) Go online to www.ABE.Illinois.gov
2) Contact a Community Service Agency (help is available in 59 languages)
3) Call 800-843-6154
4) Mail in a Paper Application
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5564.
Kelly Cunningham, Administrator
Division of Medical Programs