Ill. Admin. Code tit. 89 § 1200.130

Current through Register Vol. 48, No. 45, November 8, 2024

Section 1200.130 - Supports and Services Not Covered

a) DSCC will not provide financial assistance for the following:

1) Organ transplants and related anti-rejection drugs.

2) Surgery or other treatment that is primarily for cosmetic purposes.

3) Research, experimental or investigational services, drugs and equipment, except as provided in subsection (b).

4) Primary care services required to support general health unrelated to the medically eligible condition, including but not limited to routine well child and dental care, immunizations, nonspecialty infant formula, clothing and diapers.

5) Routine medical and dental treatment.

6) Treatment for acute childhood illnesses.

7) Treatment related to trauma or short-term complications related to the trauma.

8) Supports or services available without charge.

9) Transitional care.

10) Respite care.

11) Unkept appointments, except for good cause shown.

12) Nonmedically necessary items and services provided for the convenience of recipients and/or their families, except for good cause shown.

13) Supports and services not specifically itemized in Section 1200.120.

b) Research, Experimental or Investigational Services, Drugs and Equipment. The DSCC Director or designee shall determine whether services, drugs or equipment are, in fact, research, experimental or investigational based on the criteria set forth in this subsection (b).

1) The affected services, drugs and equipment are medical or professional services, hospital services, drugs, devices or equipment that have not been recognized as having a proven habilitative or rehabilitative value as determined by the professional standards of the applicable medical or healthcare specialty groups, including but not limited to:

A) equipment or appliances that do not have the approval of the Department of Health and Human Services, Food and Drug Administration or other appropriate federal agency (investigational new drugs and devices and investigational services and treatments shall not be deemed to have received federal approval);

B) medical and/or other health related services, including drugs, food supplements, equipment or appliances not reported on, described or discussed in published and recognized professional journals that have an advisory board passing on their publications; and

C) services, drugs, devices, equipment or appliances that have not been recognized by appropriate national professional organizations.

2) If a provider wishes to utilize services, drugs or equipment that is possibly research, experimental or investigational, the provider must provide a written justification for doing so to the DSCC Director or designee who may approve in his/her sole discretion. Other pertinent information from knowledgeable professional sources may be required.

3) If DSCC authorizes services, drugs or equipment later determined by DSCC as research, experimental or investigational and, if the provider has failed to notify DSCC in advance of the possible experimental, research or investigational nature, the provider may be obligated to refund any monies paid by DSCC or the LRA.

c) As used in this Section, acute means an immediate associated consequence of infection, trauma, disease, toxicity or malignancy.

Ill. Admin. Code tit. 89, § 1200.130

Adopted at 42 Ill. Reg. 15460, effective 10/1/2018