Section 2800.401  Determination of Funding

a)         Upon receipt and review of all information required under Subpart B of this Part, the screening teams shall recommend further evaluation by the full Board for eligibility of applicants who met the criteria set forth in this Section. Patient applications that meet the criteria set forth in this Section and are approved by all three members of the screening team after receipt and review of all information required under Subpart B of this Part shall be given final approval in emergency situations which will be reaffirmed by the full Board at the next scheduled meeting. If there is disagreement among the members of the screening team, the application will be presented to the full Board for discussion at the next meeting.

1)         Patient was legally domiciled in Illinois when the pathophysiological state necessitating the transplantation procedure was originally identified and the patient continues to be legally domiciled in Illinois. (Section 4(b) of the Act.)

2)         Patient has limitations, gaps, or exclusions in his accident and health insurance. (Section 4(b) of the Act.), (i.e., Any difference between the patient's insurance coverage and the costs of an experimental transplantation procedure.  However, if an institution accepts reimbursement for a patient's transplantation procedure from the Illinois Department of Public Aid's Medical Assistance Program, then no limitation, gap or exclusion exists under this program and the rules of this Part).

3)         The center has an established and proven experimental transplantation program approved by the Board under Section 2800.301 of this Part.

4)         The proposed procedure for which payment is requested is not performed prior to July 1, 1985.

b)         If substantial change (e.g., worsening of the condition requiring the transplant, or immediate availability of a donor organ) in the needs of any patient occurs after the applicant has filed the necessary application forms and information, the applicant shall submit a report of the change and may ask for a reevaluation of the patient's status by submitting a new application.

c)         The Board will recommend payment of an award under the Experimental Organ Transplantation Program for applicants receiving a majority vote of the Board members.  The level of the award will be determined by the difference between the patient's insurance coverage and the cost of the procedure, not including professional fees, based upon the cost reports and financial information submitted under Section 2800.203 of this Part. If the amount owed for an approved transplant procedure is less than 5 percent of the total charge for the procedure or less than 5 percent of the $200,000 maximum, full reimbursement will be made on the lesser amount. The Board will recommend funding for professional fees at a maximum level of 10 percent of the award for the procedure. (Section 4(d) of the Act.) The maximum level of payment recommended by the Board for live donor acquisition charges will be $10,000. (Section 4(f) of the Act.)

d)         No one individual applicant shall be eligible to receive more than a total of $200,000 under this program. (Section 4(f) of the Act.)

e)         No payments shall be made for complications or follow-up hospitalization for a donor of an organ transplanted under this program. (Section 4(f) of the Act.)

(Source:  Amended at 12 Ill. Reg. 15550, effective September 16, 1988)