Proposed Changes to Medicaid Reimbursement Took Effect April 1 – But Still Awaits CMS Approval

April 5, 2024

Medicaid will "reprocess" claims once the rate adjustments are approved

Earlier this week, the Illinois Department of Healthcare and Family Services (HFS) announced that planned Medicaid rate adjustments would be effective for service dates beginning April 1, 2024. These adjustments impact both the fee-for-service (FFS) program and the Medicaid managed care organizations (MCOs).

The proposed changes will likely boost reimbursements for healthcare professionals by $120.8 million annually but are still subject to approval by the Centers for Medicare and Medicaid Services (CMS):

  • Rates would be adjusted from generally reimbursing at 60% of Medicare to 70% of Medicare, with a reimbursement ceiling set at 100% of Medicare for all services. (The exceptions would be behavioral health and non-cesarian obstetrical services, which are currently reimbursed over 100% of the Medicare rate.)
  • Reimbursement rates for specified mammography procedure codes will be set at 80% of the Medicare rate, though those eligible for participation in the Department’s Breast Cancer Quality Screening and Treatment Initiative; will continue to be paid at 100% of the Medicare rate.

Rates for assistant surgeons, anesthesia services, and any applicable add-ons or bonus payments are not included in the rate adjustments.

All proposed rate changes are subject to approval by CMS.

ISMS has and will continue to strive for increased physician participation in Medicaid by making reimbursements more attractive.

Until Medicaid receives approval, here’s what doctors need to know:

  • Claims with dates of service beginning April 1, 2024, will be rejected with special error code and message: “C93 – Department will reprocess claim.”
  • Medicaid will reprocess these claims once approval is received by CMS.
  • MCOs will be processing claims with updated rates as soon as their systems allow.
  • Rate changes will be reflected on all applicable April 1, 2024 fee schedules, which will be posted once CMS approves the rate updates.
If you have questions, please contact the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims or contact the appropriate MCO. You may also contact the ISMS Health Policy Research and Advocacy team by email.
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