Section 140.439  Critical Access Care Pharmacy Payment

a)         To be eligible to receive a Critical Access Care Pharmacy Payment (CAP Payment), a pharmacy provider must:

1)         Attest to meeting all the following criteria for the entire previous fiscal quarter:

A)        Pharmacy is physically located within Illinois;

B)        Pharmacy is brick and mortar, meaning the pharmacy location is open to the public, recipients present at the pharmacy to fill prescriptions, and the majority of the pharmacy's business is not mail order based;

C)        Pharmacy owners have an ownership or control interest in fewer than 10 pharmacies; and

D)        Pharmacy is located in a county with fewer than 50,000 residents, or is located in a county with 50,000 or more residents and in an area within Illinois that is designated as a Medically Underserved Area by the Health Resources & Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services.

2)         Submit an attestation to the Department within 30 calendar days after the end of the fiscal quarter in a form and manner prescribed by the Department.

b)         CAP Payments for a fiscal year will be made quarterly and may not exceed the lesser of $10,000,000 or the total amount specifically appropriated to the Department for CAP Payments.

c)         All CAP Payment calculations shall be based on "CAP-Eligible Claims", which are defined as pharmacy claims:

1)         Billed by an eligible CAP to a Managed Care Organization (MCO) contracted with the Department for HealthChoice Illinois, or its successor program, for dates of service during the quarter being calculated;

2)         Paid for by the MCO; and

3)         For which a paid encounter claim record exists in the Department's Electronic Data Warehouse (EDW) prior to 90 calendar days after the end of the quarter being calculated.

d)         Individual CAP Payments will be made to individual pharmacy providers that meet the requirements of subsection (a).  Individual CAP Payment amounts are calculated using the total number of the individual pharmacy's CAP-Eligible Claims for the quarter being calculated multiplied by the lesser of:

1)         The individual payment amount; or

2)         The Department's dispensing fee for the medical assistance program in effect on April 1, 2018.

e)         The "individual payment amount" is equal to one quarter of the total amount appropriated for the CAP Program for a fiscal year divided by the total number of CAP-Eligible Claims for the quarter for all CAP pharmacies.

f)         To ensure the proper distribution of CAP Payments under this Section, the Department may conduct audits in accordance with 89 Ill. Adm. Code 140.30.

g)         Definitions.  For purposes of this Section, an "ownership or control interest" shall have the same meaning as a person with an ownership or control interest as defined in 42 CFR 455.101.

(Source:  Added at 43 Ill. Reg. 2227, effective February 4, 2019)