We track 50 documented policy changes from Illinois Medicaid - HFS across IL. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original Illinois Medicaid - HFS notice. Use the related links below to narrow results by specialty or state, or create a free alert to get new Illinois Medicaid - HFS updates by email (daily or weekly, your choice, on every plan).
Illinois hospitals must submit Average Commercial Rate (ACR) data for their five highest-volume commercial payers to demonstrate compliance with federal Medicaid managed care payment limits. This data collection is required to maintain directed payment eligibility for calendar year 2027. Data submission is mandatory by July 31, 2026, through a secure portal managed by Milliman.
Illinois Department of Healthcare and Family Services (HFS) is establishing a 2027 Critical Access Pharmacy (CAP) Program that provides enhanced dispensing fee payments to eligible independent pharmacies. Pharmacies must meet specific ownership, location, and prescription volume criteria and complete online attestation between October 1-31, 2026, to qualify for Calendar Year 2027 benefits.
Government-owned ambulance providers in Illinois must submit updated cost reports and signed Intergovernmental Agreements (IGAs) by October 1, 2026 to participate in the Ground Emergency Medical Transportation (GEMT) supplemental payment program for calendar year 2027. Even providers currently participating in 2026 must resubmit; new participants must include signed IGAs from authorized local government officials.
Illinois HFS requires Supportive Living Program providers to keep surveillance camera use rare, individually assessed, and thoroughly documented when privacy is limited, and never a default practice. Cameras may be used in non-resident operational spaces for basic building security or operational purposes, provided placement does not materially reduce resident privacy in HCBS service areas. Cameras are prohibited in resident dining, activity, and therapy rooms or comparable service areas, and in bathrooms, changing areas, and toileting areas under any circumstances, and audio monitoring in resident spaces is prohibited.
Illinois Department of Healthcare and Family Services has published Calendar Year 2026 safety net add-on payment calculations for qualifying hospitals. The add-ons include a tiered safety net program targeting $50M annually for hospitals with Medicaid Inpatient Utilization Rates above 40%, and a low volume add-on for hospitals with fewer than 11,000 inpatient days.
This is an informational notice from the Illinois Department of Financial and Professional Regulation regarding the annual Federal Fiscal Year 2027 Safety Net Determination for enrolled hospitals. The safety net status determination results are now available on the Department's website and are effective January 1, 2027 through December 31, 2027. Billing teams should verify their hospital's safety net status designation for 2027.
Illinois Department of Healthcare and Family Services confirms that Peripheral Artery Disease (PAD) screening testing is already covered as medically necessary under Medicaid fee-for-service and managed care organizations. Public Act 104-0379 mandates this coverage effective January 1, 2027, but no billing changes are needed since coverage already exists.
Illinois Medicaid confirms existing coverage for karyotype and hormone testing to diagnose Klinefelter syndrome, as required by Public Act 104-0073. No billing changes are needed since coverage is already provided under fee-for-service and managed care programs.
Effective October 1, 2026, Illinois Medicaid (both FFS and Managed Care) will cover Wegovy (semaglutide tablets and injection) for MACE reduction in adults with established cardiovascular disease and obesity/overweight, and for MASH treatment with moderate-to-advanced liver fibrosis (F2-F3). Zepbound (tirzepatide) is now covered for moderate-to-severe obstructive sleep apnea in adults with obesity. All three indications require prior authorization. Weight loss alone remains non-covered.
HFS is restarting collections on outstanding advance payments to nursing facilities effective September 1, 2026. Facilities with unpaid advances must sign a renegotiated advance payment agreement by August 15, 2026, or face immediate recoupment of outstanding balances. This applies only to long-term care (LTC) nursing facility providers in Illinois.
Illinois HFS is restarting collections on advance payment agreements for long-term care (LTC) nursing facilities effective September 1, 2026. Providers must execute renegotiated advance payment agreements by August 15, 2026, committing to repay all outstanding balances over 12 months in equal monthly installments. Failure to sign the agreement or make required payments will trigger immediate recoupment of 25% of the outstanding balance monthly for four months, with HFS authorized to withhold FFS claims, supplemental payments, and direct MCO payments to recover amounts owed.
The Illinois All Kids School-Based Dental Program will operate from August 31, 2026 through July 31, 2027. All enrolled dental providers and public health dental hygienists rendering services in school settings during the 2026-2027 school year must attend one of three mandatory informational conference calls (August 5, 7, or 14, 2026) to review program requirements and updates. Failure to participate or complete program requirements will result in non-payment of services.
Illinois Department of Human Services has re-assessed Managed Care Organization (MCO) provider assessment fees for fiscal years 2026 and 2027 using updated 2023 member month data and newly including FIDE SNP member months. Tax tier rates have been adjusted, with FY2026 Tier 1 at $115.00 per member month and FY2027 Tier 1 at $116.90 per member month. Any over- or underpayments from the initial assessment have been recalculated and will be distributed across remaining FY2027 monthly installment payments beginning October 2026.
Illinois Department of Healthcare and Family Services (HFS) has updated hospital provider assessment repayment policies, allowing hospitals with unpaid assessment obligations to enter into renegotiated repayment agreements with terms of up to 72 months in equal monthly installments. Effective immediately, HFS will no longer accept new tax deferral plans (as of July 1, 2026), and hospitals must comply with repayment agreements or face immediate collection action including asset liens and payment recoupment from MCOs and state agencies.
Effective August 1, 2026, providers must add modifier U1 (negative screening) or U2 (positive screening with follow-up plan) to CPT code 96127 for behavioral health screenings. Claims submitted without one of these modifiers will be rejected with error code L54. This applies to Illinois Medicaid FFS and HealthChoice Illinois MCO plans. Depression screening codes G8431 and G8510 continue unchanged.
This policy establishes a new admission processing workflow for residents transitioning from conventional Supportive Living Program (SLP) units to Dementia Care Units (DCU) within the same facility. Billing teams must enter a discharge in MEDI for the conventional SLP with a transfer destination code, then submit a new admission Transition Audit Number (TAN) for the DCU with the same date to prevent service gaps and claim denials.
Illinois HFS clarified that hospital-based family planning services are covered under the Family Planning Program and must be billed directly to the Department rather than patients. Hospitals should reference the Hospital Services (837I) tab on the HFS Medicaid fee schedule to identify covered procedures including screening mammograms, ultrasounds, colposcopies, LEEP, hysteroscopies, D&Cs, tubal ligations, and vasectomies. Eligible individuals receive these services at no out-of-pocket cost.
Illinois hospitals subject to inpatient and outpatient assessments for fiscal year 2027 (July-December 2026) must remit monthly assessment payments via ACH/wire transfer with specific formatting requirements. Assessment remittance notices have been mailed with due dates and amounts.
Illinois HFS updated renal dialysis billing effective June 1, 2026, requiring specific revenue codes (0821, 0831, 0841, 0851) with condition codes 74 (home dialysis) or 80 (long-term care). Home-based CAPD/CCPD services now pay at full facility rates instead of 3/7th rate. A new $95.00 add-on payment per treatment day applies for nursing facility residents receiving dialysis; providers must rebill prior claims to receive this add-on.
Illinois Medicaid is implementing a new Third-Party Liability Electronic Database System (TED) effective May 1, 2026, changing how providers handle Medicare primary billing and third-party insurance recovery. When Medicaid identifies Medicare as primary or retroactive third-party coverage, providers will receive notices requiring them to rebill the primary carrier within specific timeframes.
Illinois is launching new Advanced Communication Engine (ACE) member edits for HealthChoice Illinois Medicaid managed care claims starting April 23, 2026. Claims will be automatically rejected before reaching MCOs if they contain incorrect Medicaid RIN, date of birth, or eligibility dates, requiring providers to verify member information in MEDI before submitting claims.
Hospital claims held since October 2025 and January 2026 have been released as of March 23, 2026. Claims past the 180-day timely filing limit can be rebilled using override forms or by calling for systematic override, but must be submitted within 180 days of this notice (by October 14, 2026).
Illinois is transitioning Medicare-Medicaid Alignment Initiative (MMAI) members to Dual Eligible Special Needs Plans (D-SNPs). When the MEDI system shows both a FIDE SNP and HCI plan, providers must submit claims to the FIDE SNP, not the HCI plan listed in the Managed Care Organization section.
Illinois HFS has implemented rate increases for ICF/IID and MC/DD facilities effective January 1, 2026, including $0.80/hour wage increases for direct support personnel and updated wages for non-executive direct care staff per federal Bureau of Labor Statistics averages. The state has repriced all claims paid at lower rates and will distribute adjustment vouchers; billing teams must ensure updated per diem rates are applied to all new and adjusted claims, and pass through payment adjustments to developmental training providers within 10 days.
Illinois MMAI plans are transitioning to Dual Eligible Special Needs Plans (FIDE SNPs) effective January 1, 2026. Providers must establish contracts with the new FIDE SNP plans (Aetna, Humana, Meridian/Wellcare, Molina) as Blue Cross Blue Shield was not selected and will no longer serve dual eligible members.
Illinois hospitals are subject to inpatient and outpatient assessments for fiscal year 2026 (January-June). Assessment remittance notices have been mailed with payment due dates, and facilities must pay via ACH Credit/Wire Transfer using specific formatting requirements.
Illinois is transitioning from MMAI to FIDE SNP plans effective January 1, 2026, requiring new member verification processes. Billing teams must verify patient enrollment using new contract numbers and health plan portals since state systems are still being updated.
Effective November 1, 2025, pharmacies can no longer use dummy NPIs for emergency contraception billing and must instead use the Illinois Department of Public Health standing order NPI. The policy also confirms coverage for pharmacist-provided contraceptive services and adds coverage for home pregnancy tests.
Illinois hospital providers are now subject to mandatory inpatient and outpatient assessments for fiscal year 2026, with monthly payments due July 2025 through December 2025. Assessment remittance notices have been mailed and payments must be made via ACH Credit/Wire Transfer using specific formatting requirements.
The Illinois Department of Healthcare and Family Services (HFS) has implemented a more frequent provider revalidation requirement mandated by CMS. High-risk providers, providers without an NPI, laboratory providers, and ABA providers must now complete revalidation within a two-year cycle instead of the previous five-year cycle. Providers who revalidated or newly enrolled between April 30, 2025 and April 30, 2026 are exempt from this accelerated timeline.
Illinois Department of Healthcare and Family Services announces two major Medicaid eligibility changes: (1) Federal law eliminates Medicaid coverage for most lawfully present noncitizens effective October 1, 2026, with limited exceptions for green card holders, certain entrants from Cuba/Haiti, COFA migrants, and children under 19 and pregnant women; (2) New federal work requirements for ACA Adults (ages 19-64 with income up to 138% FPL) effective January 1, 2027, with specific exemptions for medically frail, caregivers, veterans, pregnant women, foster youth, and others. Billing teams must identify affected patient populations and implement eligibility verification procedures before both dates.
Illinois Department of Financial and Professional Regulation has reissued the Dental Office Reference Manual (DORM) with updates to dental benefits covered coding. Providers must review the updated DORM and Exhibits A-C for coding changes to ensure accurate billing and payment from the Department.
Illinois Medicaid is implementing HIPAA-compliant changes requiring hospitals and ambulatory surgical treatment centers to submit both HCPCS/CPT codes and APL ICD-9 CM procedure codes on claims, while eliminating several state-specific billing practices. Multiple billing form requirements are changing including spenddown reporting, Medicare crossover claims, and physician identification fields.
Illinois Healthcare and Family Services has updated billing requirements for anesthesia services. The Handbook for Providers of Physician Services Topic 283.1 has been completely rewritten with new billing guidelines that providers must review and implement.
Illinois Medicaid (HFS) will soon require providers to report NPI numbers for pay-to providers (payees) instead of the current 1-digit payee codes. Payees must obtain unique NPIs and share them with billing providers to avoid claim denials and payment issues.
Illinois Medicaid has posted the 2011 Disproportionate Share determination notice and required forms on their website. Hospitals must complete and submit these forms by specified deadlines to maintain qualification for various reimbursement programs including Disproportionate Share, Medicaid Percentage Adjustment, Critical Hospital Adjustment, and County Trauma Center Adjustment payments.
The federal implementation of ICD-10 coding conversion from ICD-9 has been delayed from the original October 1, 2014 date. Healthcare providers should continue using ICD-9 codes until further notice and will be informed when a new implementation date is announced.
Illinois Medicaid is resuming mandatory provider revalidation every 5 years after waiving this requirement during the Public Health Emergency. All Illinois Medicaid providers must complete revalidation to continue receiving payments, with enrollment breaks affecting payments if not completed on time.
Illinois Medicaid's PERM audit found that long-term care facilities are submitting claims with unenrolled ordering providers and missing NPIs for ICF services. A new claim edit will be implemented to automatically reject claims from unenrolled providers, and all ICF claims must include the ordering provider's NPI.
Effective October 13, 2026, a new federal rule restricts Medicaid coverage of gender affirming care for youth. Illinois HFS will bridge the coverage gap using state-only funds through the end of state fiscal year 2027 (June 30, 2027), with future funding decisions deferred to the budget process. Billing teams must continue following existing billing instructions while HFS handles federal compliance on the back end by not claiming federal matching dollars on affected claims.
This provider notice confirms continued Medicaid coverage (both FFS and MCOs) for RSV immunizations during the 2026-2027 RSV season (October 1 through March 31). Coverage includes monoclonal antibodies (Beyfortus and Enflonsia) for eligible infants under 8 months, Beyfortus for high-risk children 8-19 months, maternal RSV vaccine (Abrysvo) for pregnant individuals at 32-36 weeks gestation, and adult RSV vaccines (Abrysvo, mResvia, Arexvy) for seniors 75+ and specified high-risk populations. Prior authorization is not required for these covered immunizations.
Illinois Department of Human Services has re-assessed Managed Care Organization (MCO) Provider Assessment fees for fiscal years 2026 and 2027 based on updated member month data and now includes FIDE SNP member months. MCO organizations must remit adjusted assessment payments with any over/underpayments redistributed across remaining 2027 monthly installments starting October 2026. Tax tier rates have increased for FY 2027 (Tier 1: $116.90, Tier 2: $0.90, Tier 3: $5.60).
Effective September 1, 2026, Medicaid will limit COVID At-Home Rapid Antigen Test Kits to 8 units per beneficiary per rolling 365-day calendar year across both Fee-for-Service (FFS) and Managed Care Organization (MCO) plans. Billing teams must implement quantity controls in their systems to enforce this new annual limit and prevent claim denials for excess quantities.
Illinois requires Long Term Care facilities to attest on their 2026 cost report that they do not participate in hold harmless arrangements for health care-related taxes, where the state or government provides direct/indirect payment, offset, or waiver guaranteeing tax relief. This is a compliance attestation requirement under federal Medicaid rules (42 CFR § 433.68(f)(3)) and prohibits arrangements involving redistribution of Medicaid payments among providers.
Illinois HFS has issued new recommended screening guidelines for Tardive Dyskinesia in patients prescribed antipsychotic medications, developed in accordance with Public Act 104-009. Providers should access the screening guidelines training slide deck posted on the HFS website to understand the evidence-based assessment and treatment recommendations.
The manufacturer of brand-name Focalin XR (dexmethylphenidate extended-release) capsules has discontinued production. Illinois Medicaid has designated generic dexmethylphenidate ER capsules as preferred while continuing to list brand-name Focalin XR as preferred on the PDL until inventory is depleted. This change applies to both Fee-For-Service and Managed Care Organizations effective July 24, 2026.
Illinois Medicaid has temporarily moved insulin glargine-yfgn (a biosimilar) to preferred status on the PDL due to an intermittent supply shortage of Lantus SoloStar pens. This change applies to both Fee-For-Service and Managed Care Organization plans effective July 24, 2026. Lantus vials remain unaffected and preferred. The biosimilar preferred status is temporary and will be reversed once the shortage resolves.
This is a compliance reminder for Long-Term Care facilities participating in Illinois's Supportive Living Program (SLP). Pre-admission screenings must only be requested when a potential resident is expected to move in within 90 days; premature screening requests are creating unnecessary re-screening delays and burden on families. Facilities must ensure screening requests align with actual admission timelines and comply with the 90-day rule for waitlisted individuals.
Illinois Department of Healthcare and Family Services (HFS) now covers medically necessary habilitative services for early-acquired speech-language disorders, including stuttering, for children under age 21 through Medicaid fee-for-service and HealthChoice Illinois managed care organizations. This coverage became effective July 1, 2026, and is mandated by Public Act 104-0528. The policy also confirms that rehabilitative services for stuttering were already covered under prior guidance.
The Illinois Department of Financial and Professional Regulation has posted Directed Payment calculation reports for July through September 2026 on its Hospital Reimbursement Notifications Website. Participating hospitals must access these reports to review their quarterly directed payment amounts and ensure accurate reimbursement reconciliation.
Network, contract and program news from the payers we track.
Illinois has launched the Medicaid Technical Assistance Center (MTAC) to provide training, technical assistance, and educational resources to help healthcare providers successfully engage with the Illinois Medicaid program.
The Illinois Medicaid Fee-for-Service Non-Emergency Transportation vendor has changed its name from First Transit to Transdev, with updated contact numbers for customers (877-725-0569) and providers (866-503-9040).
Illinois is launching a new online application process for Healthcare Transformation Collaboratives funding, with up to $150 million available in fiscal year 2022.
Illinois Department of Healthcare and Family Services is accepting Letters of Intent for Healthcare Transformation Collaboratives funding, with up to $150 million available per fiscal year for healthcare provider collaborations.
This is a Provider Notice about the Illinois CHIPRA Quality Demonstration Project offering free participation opportunities for up to 200 primary care practices to enhance their medical home capabilities through 2014.
The Illinois Department of Healthcare and Family Services announced a grant funding opportunity for dental clinics to increase dental access for low-income and Medicaid beneficiaries.
Get alerts for changes like this
Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.