Illinois

Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

At A Glance
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MEDICAID REIMBURSEMENT

  • Live Video: Yes
  • Store-and-Forward: Yes
  • Remote Patient Monitoring: Yes
  • Audio Only: Yes

PRIVATE PAYER LAW

  • Law Exists: Yes
  • Payment Parity: Yes

PROFESSIONAL REQUIREMENTS

  • Licensure Compacts: IMLC, PSY
  • Consent Requirements: Yes (Medicaid early intervention)

STATE RESOURCES

  1. Medicaid Program: Illinois Medicaid
  2. Administrator: Illinois Dept. of Healthcare and Family Services
  3. Regional Telehealth Resource Center: Upper Midwest Telehealth Resource Center
Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

Last updated 07/12/2024

Definitions

“Telehealth services” has the meaning given to that term in Section 5 of the Telehealth Act. As used in this Section, “telehealth services” do not include asynchronous store and forward systems, remote patient monitoring technologies, e-visits, or virtual check-ins.

“Interactive telecommunications system” has the meaning given to that term in Section 5 of the Telehealth Act. As used in this Section, “interactive telecommunications system” does not include virtual check-ins.

SOURCE: IL Insurance Code. Sec. 356z.22.  (Accessed July. 2024).

Last updated 07/12/2024

Parity

SERVICE PARITY

An individual or group policy of accident or health insurance shall cover telehealth services, e-visits, and virtual check-ins rendered by a health care professional when clinically appropriate and medically necessary to insureds, enrollees, and members in the same manner as any other benefits covered under the policy. An individual or group policy of accident or health insurance may provide reimbursement to a facility that serves as the originating site at the time a telehealth service is rendered.

SOURCE: IL Insurance Code. Sec. 356z.22.  (Accessed Jul. 2024).

A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed before January 1, 2026 shall provide coverage for medically necessary continuous glucose monitors for individuals who are diagnosed with any form of diabetes mellitus and require insulin for the management of their diabetes. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 shall provide coverage for continuous glucose monitors, related supplies, and training in the use of continuous glucose monitors.  See Requirements section for criteria.

A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage of a one-month supply of continuous glucose monitors, including one transmitter if necessary, as provided under this Section. The provisions of this subsection do not apply to coverage under this Section to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to the federal Internal Revenue Code, 26 U.S.C. 23.

SOURCE: Senate Bill 3414 (2024 Session), (Accessed Jul. 2024).


PAYMENT PARITY

For purposes of reimbursement, an individual or group policy of accident or health insurance shall reimburse an in-network health care professional or facility, including a health care professional or facility in a tiered network, for telehealth services provided through an interactive telecommunications system at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by an in-network or tiered network health care professional or facility.

This subsection applies only to those services provided by telehealth that may otherwise be billed as an in-person service. This subsection is inoperative on and after January 1, 2028, except that this subsection is operative after that date with respect to mental health and substance use disorder telehealth services.

Nothing in this Section is intended to limit the ability of an individual or group policy of accident or health insurance and a health care professional or facility to voluntarily negotiate alternate reimbursement rates for telehealth services. Such voluntary negotiations shall take into consideration the ongoing investment necessary to ensure these telehealth platforms may be continuously maintained, seamlessly updated, and integrated with a patient’s electronic medical records.

SOURCE: IL Insurance Code. Sec. 356z.22. (Accessed Jul. 2024).

Last updated 07/12/2024

Requirements

An individual or group policy of accident or health insurance shall cover telehealth services, e-visits, and virtual check-ins rendered by a health care professional when clinically appropriate and medically necessary to insureds, enrollees, and members in the same manner as any other benefits covered under the policy. An individual or group policy of accident or health insurance may provide reimbursement to a facility that serves as the originating site at the time a telehealth service is rendered.

To ensure telehealth service, e-visit, and virtual check-in access is equitable for all patients in receipt of health care services under this Section and health care professionals and facilities are able to deliver medically necessary services that can be appropriately delivered via telehealth within the scope of their licensure or certification, coverage required under this Section shall comply with all of the following:

  • An individual or group policy of accident or health insurance shall not:
    • require that in-person contact occur between a health care professional and a patient before the provision of a telehealth service;
    • require patients, health care professionals, or facilities to prove or document a hardship or access barrier to an in-person consultation for coverage and reimbursement of telehealth services, e-visits, or virtual check-ins;
    • require the use of telehealth services, e-visits, or virtual check-ins when the health care professional has determined that it is not appropriate;
    • require the use of telehealth services when a patient chooses an in-person consultation;
    • require a health care professional to be physically present in the same room as the patient at the originating site, unless deemed medically necessary by the health care professional providing the telehealth service;
    • create geographic or facility restrictions or requirements for telehealth services, e-visits, or virtual check-ins;
    • require health care professionals or facilities to offer or provide telehealth services, e-visits, or virtual check-ins;
    • require patients to use telehealth services, e-visits, or virtual check-ins, or require patients to use a separate panel of health care professionals or facilities to receive telehealth service, e-visit, or virtual check-in coverage and reimbursement; or
    • impose upon telehealth services, e-visits, or virtual check-ins utilization review requirements that are unnecessary, duplicative, or unwarranted or impose any treatment limitations, prior authorization, documentation, or recordkeeping requirements that are more stringent than the requirements applicable to the same health care service when rendered in-person, except procedure code modifiers may be required to document telehealth.

Deductibles, copayments, coinsurance, or any other cost-sharing applicable to services provided through telehealth shall not exceed the deductibles, copayments, coinsurance, or any other cost-sharing required by the individual or group policy of accident or health insurance for the same services provided through in-person consultation.

An individual or group policy of accident or health insurance shall notify health care professionals and facilities of any instructions necessary to facilitate billing for telehealth services, e-visits, and virtual check-ins.

An individual or group policy of accident or health insurance shall provide coverage for telehealth services for licensed dietitian nutritionists and certified diabetes educators who counsel diabetes patients in the diabetes patients’ homes to remove the hurdle of transportation for diabetes patients to receive treatment, in accordance with the Dietitian Nutritionist Practice Act.

Any policy, contract, or certificate of health insurance coverage that does not distinguish between in-network and out-of-network health care professionals and facilities shall be subject to this Section as though all health care professionals and facilities were in-network.

Health care professionals and facilities shall determine the appropriateness of specific sites, technology platforms, and technology vendors for a telehealth service, as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 and the Mental Health and Developmental Disabilities Confidentiality Act.

Nothing in this Section shall be deemed as precluding a health insurer from providing benefits for other telehealth services, including, but not limited to, services not required for coverage provided through an asynchronous store and forward system, remote patient monitoring services, other monitoring services, or oral communications otherwise covered under the policy.

There shall be no restrictions on originating site requirements for telehealth coverage or reimbursement to the distant site under this Section other than requiring the telehealth services to be medically necessary and clinically appropriate.

The Department may adopt rules, including emergency rules subject to the provisions of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section.

The Department and the Department of Public Health shall commission a report to the General Assembly administered by an established medical college in this State wherein supervised clinical training takes place at an affiliated institution that uses telehealth services, subject to appropriation. The report shall study the insurer telehealth coverage and reimbursement policies to determine if the policies improve access to care, reduce health disparities, promote health equity, have an impact on utilization and cost-avoidance, including direct or indirect cost savings to the patient, and to provide any recommendations for telehealth access expansion in the future. An individual or group policy of accident or health insurance shall provide data necessary to carry out the requirements of this subsection upon request of the Department. The Department and the Department of Public Health shall submit the report by December 31, 2026. The established medical college may utilize subject matter expertise to complete any necessary actuarial analysis.

SOURCE: IL Insurance Code Chap. 215, Sec. 5/356z.22. (Accessed Jul. 2024).

A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed before January 1, 2026 shall provide coverage for medically necessary continuous glucose monitors for individuals who are diagnosed with any form of diabetes mellitus and require insulin for the management of their diabetes. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 shall provide coverage for continuous glucose monitors, related supplies, and training in the use of continuous glucose monitors for any individual if the following requirements are met:

  1. the individual is diagnosed with diabetes mellitus;
  2. the continuous glucose monitor has been prescribed by a physician licensed under the Medical Practice Act of 1987 or a certified nurse practitioner or physician assistant with a collaborative agreement with the physician;
  3. the continuous glucose monitor has been prescribed in accordance with the Food and Drug Administration’s indications for use;
  4. the prescriber has concluded that the individual or individual’s caregiver has sufficient training in using the continuous glucose monitor, which may be evidenced by the prescriber having prescribed a continuous glucose monitor, and has attested that the patient will be provided with that training;
  5. the individual either:
    1. uses insulin for treatment via one or more injections or infusions of insulin per day, and only one injection or infusion of one type of insulin shall be sufficient utilization of insulin to qualify for a continuous glucose monitor under this Section; or
    2. has reported a history of problematic hypoglycemia with documentation to the individual’s medical provider showing at least one of the following:
      1. recurrent hypoglycemic events characterized by an altered mental or physical state, despite multiple attempts to adjust medications or modify the diabetes treatment plan, as documented by a medical provider; or
      2. a history of at least one hypoglycemic event characterized by an altered mental or physical state requiring third-party assistance for treatment of hypoglycemia, as documented by the individual’s medical provider, which may be self-reported by the individual; third-party assistance shall not, in any event, be deemed to require that the individual had been admitted to a hospital or visited an emergency department; and
  6. within 6 months prior to prescribing a continuous glucose monitor, the medical provider prescribing the continuous glucose monitor had an in-person or covered telehealth visit with the individual to evaluate the individual’s diabetes control and has determined that the criteria of paragraphs (1) through (5) are met.

Notwithstanding any other provision of this Section, to qualify for a continuous glucose monitor under this Section, an individual is not required to have a diagnosis of uncontrolled diabetes; have a history of emergency room visits or hospitalizations; or show improved glycemic control.

All continuous glucose monitors covered under this Section shall be approved for use by individuals, and the choice of device shall be made based upon the individual’s circumstances and medical needs in consultation with the individual’s medical provider, subject to the terms of the policy.

Any individual who is diagnosed with diabetes mellitus and meets the requirements of this Section shall not be required to obtain prior authorization for coverage for a continuous glucose monitor, and coverage shall be continuous once the continuous glucose monitor is prescribed.

A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage of a one-month supply of continuous glucose monitors, including one transmitter if necessary, as provided under this Section. The provisions of this subsection do not apply to coverage under this Section to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to the federal Internal Revenue Code, 26 U.S.C. 23.

SOURCE: Senate Bill 3414 (2024 Session), (Accessed Jul. 2024).

Insurers are required to include information on the use of telehealth or telemedicine in an electronic provider directory, including but not limited to:

  • whether the provider offers the use of telehealth or telemedicine to deliver services to patients for whom it would be clinically appropriate;
  • what modalities are used and what types of services may be provided via telehealth or telemedicine; and
  • whether the provider has the ability and willingness to include in a telehealth or telemedicine encounter a family caregiver who is in a separate location than the patient if the patient wishes and provides his or her consent

Telehealth may be considered in meeting network adequacy standards.

SOURCE: IL Compiled Statutes, Chapter 215, 124/25. (Accessed Jul. 2024).

Network Adequacy

The print and electronic versions of the provider directories. The directories must include up-to-date, accurate, and complete provider/facility type, location, and contact information required under Section 25 of the Act. Providers available by telehealth or telemedicine must be clearly identified and include information required under the Act.

A description of how health care services to be rendered under the network plan are reasonably accessible and available to beneficiaries, including the type of health care services to be provided by the network plan. The description shall address all of the following:

  •  the availability of telehealth care, including how the use of telemedicine, telehealth, or mobile care services may be used to partially meet the network adequacy standards, if applicable (Section 10(b)(5) of the Act

SOURCE: IL Admin. Code Title 50, Chapter 1 Section 4540.40(c) & (p).  (Accessed Jul. 2024).

Last updated 07/08/2024

Definitions

“Telemedicine” is the use of a telecommunication system to provide medical services for the purpose of evaluation and treatment when the patient is at one medical provider location and the rendering provider is at another location.

Source: IL Admin. Code, Title 89,140.403(a)(9) & IL Dept. of Healthcare and Family Svcs., Handbook for Podiatrists, F-200 (VI), p. 7 (Oct. 2016). (Accessed Jul. 2024).

Telehealth is the use of a telecommunication system to provide medical services between places of lesser and greater medical capability and/or expertise, for the purpose of evaluation and treatment. Medical data exchanged can take the form of multiple formats: text, graphics, still images, audio and video. The information or data exchanged can occur in real time (synchronous) through interactive video or multimedia collaborative environments or in near real time (asynchronous) through “store and forward” applications.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7, p. 25 (June 2021).Handbook for Podiatrists, F-200(220.6) (Oct. 2016) & Handbook for Encounter Clinic Services, D-210.2,  pg. 16-17 (Aug. 2016). (Accessed Jul. 2024).

“Telehealth” means services provided via a telecommunication system.

SOURCE: IL Admin. Code, Title 89,140.403(a)(8). (Accessed Jul. 2024). 

Telepsychiatry: Originating Site: The use of a telecommunication system to provide medical services between places of lesser and greater medical capability and/or expertise, for the purpose of evaluation and treatment. Medical data exchanged can take the form of multiple formats: text, graphics, still images, audio and video. The information or data exchanged can occur in real time (synchronous) through interactive video or multimedia collaborative environments or in near real time (asynchronous) through “store and forward” applications.  The Originating Site is the site where the customer is located.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Community-Based Behavioral Services Providers, 208.3.1 pg. 42 (June 6., 2022). (Accessed Jul. 2024).

 Telemedicine − means the provision of clinical services to patients by physicians or practitioners remotely via electronic communications. The distant-site telemedicine physician or practitioner provides clinical services to the hospital patient either simultaneously, as is often the case with teleICU services, for example, or non-simultaneously, as may be the case with many teleradiology services.  Telemedicine may also include provider-to-provider consultations between Illinois-licensed physicians or practitioners and physicians or practitioners licensed in the United States.

SOURCE: IL Admin Code, Title 77, Chapter 1, Subchp b, Part 250, Sec. 250.310.  (Accessed July. 2024).

Last updated 07/12/2024

Email, Phone & Fax

Audio-Only

Modifier 93 is a new modifier used to identify services that are provided via telephone or other real-time interactive audio-only telecommunication systems. It does not replace modifier GT, which should continue to be used to identify telehealth interactions using both audio and video telecommunications systems. When using modifier 93, the communication during the audio-only service must be of an amount or nature that meets the same key components and/or requirements of a face-to-face interaction. Modifier 93 is effective with dates of service beginning July 1, 2022.

SOURCE: IL Dept. of Healthcare and Family Services, Provider Notice 03/21/2022, Delay in Implementation of Modifier 93 and Place of Service 10 Implementation July 1, 2022. (Accessed Jul. 2024).

Interprofessional Consultation Codes for Psychiatric Services

Specific Interprofessional Consultation codes will be billable for psychiatric services.  See bulletin for specific codes.

SOURCE: IL Dept. of Healthcare and Family Services Provider Bulletin (Feb. 3, 2023).  (Accessed Jul. 2024).

Diabetes Prevention Program (DPP) & Diabetes Self-Management Education and Support (DSMES)

New Modifier 93 – Synchronous Telemedicine Service rendered via telephone or other real-time interactive audio-only telecommunications system, is billable effective with dates of service beginning July 1, 2022. Refer to informational notices dated March 31, 2022, and March 21, 2022.

SOURCE: IL. Dept. of Healthcare and Family Services, Provider Notice 7/29/2022, Billing Update for Diabetes Prevention and Management Programs. (Accessed Jul. 2024).

No reimbursement for telephone.

No reimbursement for FAX.

No reimbursement for text or email.

SOURCE: IL Dept. of Healthcare and Family Services, Handbook for Practitioners Rendering Medical Services, Chapter 200 (June 2021). 220.5.7 p. 25; Handbook for Podiatrists, F-200, 220.6 p. 27 (Oct. 2016); Handbook for Encounter Clinic Services, Chapter D-200 Policy & Procedures, p. 17 (Aug 2016) & IL Administrative Code, Title 89 ,140.403. (Accessed Jul. 2024).

See regulations for exceptions during a public health emergency.

SOURCE: IL Admin. Code, Title 89,140.403. (Accessed Jul. 2024). 

Care Coordination and Support Organization (CCSO)

Care Coordination and Support (CCS) services are reimbursed if certain requirements met, including completing two oral communications with family within the calendar month via telephonic, video or in-person.

SOURCE: IL Dept. of Healthcare and Family Services, Care Coordination and Support Organization Provider Handbook (Oct. 5, 2022), p. 56-57.  (Accessed Jul. 2024).

Last updated 07/09/2024

Live Video

POLICY

Recent Legislation Effective Jan. 1, 2024

The Department and any managed care plans under contract with the Department for the medical assistance program shall provide for coverage of mental health and substance use disorder treatment or services delivered as behavioral telehealth services as specified in this Section. The Department and any managed care plans under contract with the Department for the medical assistance program may also provide reimbursement to a behavioral health facility that serves as the originating site at the time a behavioral telehealth service is rendered.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).

The Department of Healthcare and Family Services shall reimburse psychiatrists, federally qualified health centers as defined in Section 1905(l)(2)(B) of the federal Social Security Act, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing, and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services to recipients via telehealth.  The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth. The Department, by rule, shall establish: (i) criteria for such services to be reimbursed, including appropriate facilities and equipment to be used at both sites and requirements for a physician or other licensed health care professional to be present at the site where the patient is located; however, the Department shall not require that a physician or other licensed health care professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services; (ii) a method to reimburse providers for mental health services provided by telehealth; and (iii) a method to reimburse providers for epilepsy treatment services provided by telehealth.

SOURCE: 305 ILCS 5/5-5.25.(b) (Accessed Jul. 2024).

Health insurance providers must include coverage for licensed dietitians, nutritionists, and diabetes educators who counsel diabetes patients, via telehealth, in the patients’ homes to remove the hurdle of transportation for patients to receive treatment.

SOURCE: 215 ILCS 5/356z.22.(g) (Accessed Jul. 2024).

Covered services under the Medical Assistance Programs include telehealth services pursuant to Sectin 140.403.

SOURCE: IL Admin Code, Title 89, Chapter 1, Subch d, Part 140, Sec. 140.3(b)(22) & c(18).  (Accessed Jul. 2024).

Illinois Medicaid will reimburse for live video under the following conditions:

  • A physician or other licensed health care professional or other licensed clinician, mental health professional or qualified mental health professional must be present with the patient at all times with the patient at the originating site;
  • The distant site provider must be a physician, physician assistant, podiatrist or advanced practice nurse who is licensed by Illinois or the state where the patient is located.  For telepsychiatry, it must be a physician who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program;
  • The originating and distant site provider must not be terminated, suspended or barred from the Department’s medical programs;
  • Telepsychiatry: The distant site provider must personally render the telepsychiatry service;
  • Medical data may be exchanged through a telecommunication system.  For telepsychiatry it must be an interactive telecommunication system;
  • The interactive telecommunication system must, at a minimum, have the capability of allowing the consulting distant site provider to examine the patient sufficiently to allow proper diagnosis of the involved body system.  The system must also be capable of transmitting clearly audible heart tones and lung sounds, as well as clear video images of the patient and any diagnostic tools, such as radiographs;
  • Telepsychiatry:  Group psychotherapy is not a covered telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403(b). (Accessed Jul. 2024). 

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

For telepsychiatry services, a staff member meeting the minimum qualifications of a mental health professional (MHP) must be present at all times with the patient at the originating site.

When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 26-27, (June 2021). (Accessed Jul. 2024).

See regulations for requirements during a public health emergency.

SOURCE: IL Admin. Code, Title 89,140.403. (Accessed Jul. 2024). 


ELIGIBLE SERVICES/SPECIALTIES

Appropriate CPT codes must be billed with the GT modifier for telemedicine and telepsychiatry services and the appropriate Place of Service code, 02, telehealth. Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider. Non-enrolled providers rendering services as a distant site provider shall not be eligible for reimbursement from the Department, but may be reimbursed by the originating site provider from their facility fee payment.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7 p. 26, (June 2021),  IL Dept. of Healthcare and Family Svcs, Handbook for Podiatric Services, Ch F-200 Policy and Procedures 220.6.2, p. 27. (Oct. 2016). (Accessed Jul. 2024).

See Encounter Clinic Services Appendices and Handbook Supplement (Sept. 2020) for billing examples.

SOURCE: Handbook for Encounter Clinic Services, Chapter D-200, Sept. 23, 2020 (Accessed Jul. 2024).

There is no reimbursement for group psychotherapy as a telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403. (Accessed Jul. 2024).

Modifier GT – identifies telehealth interactions using both audio and video telecommunications systems.

Modifier 93 (Effective with dates of service beginning July 1, 2022) – identifies telehealth interactions using an audio-only telecommunications system.

The system updates allow providers to bill a service with modifier “GT” or “93” and a service without modifier “GT” or “93” for the same customer, same date of service, and same procedure code and get reimbursed for both services.

SOURCE: Provider Notice Rate Adjustment and Telehealth Billing Guidance (Jan. 9, 2023). (Accessed Jul. 2024).

Interprofessional Consultation for Psychiatric Services

Certain procedure codes for interprofessional consultation is allowed for the delivery of psychiatric services. See memo for codes.

SOURCE: IL HFS Provider Notice (Feb. 3, 2023).  (Accessed Jul. 2024).

Recent Legislation Effective Jan. 1, 2024

Mental Health and Substance Use Disorder

For purposes of reimbursement, the Department and any managed care plans under contract with the Department for the medical assistance program shall reimburse a behavioral health care professional or behavioral health facility for behavioral telehealth services on the same basis, in the same manner, and at the same reimbursement rate that would apply to the services if the services had been delivered via an in-person encounter by a behavioral health care professional or behavioral health facility. This subsection applies only to those services provided by behavioral telehealth that may otherwise be billed as an in-person service.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).

Fee Schedules Indicate telehealth eligible services with appropriate modifiers or service code.

SOURCE: Adaptive Behavior Support Services (Jan. 26, 2022), Dental (Jan. 1, 2023), (Accessed Jul. 2024).

Podiatry

Codes and billing examples for podiatry services.

SOURCE: Handbook for Podiatric Services (Appendices), Appendix F-6 (p. 35). (Accessed Jul. 2024).

Home Health Services

A face-to-face encounter may occur through telehealth.

SOURCE: IL Dept. of Healthcare and Family Svcs., Handbook for Home Health Services. Ch. R-200 Policy and Procedures, R-205.1 p. 19, (May 2016). IL Dept. of Healthcare and Family Svcs., Handbook for Care Coordination and Support Organization Provider (Oct. 5, 2022), p. 31.  IL Admin Code, Title 89, Chapter 1, Subch d, Part 140, 140.471(d)(2)(C). (Accessed Jul. 2024).

POS 10 is a new place of service code that specifies a distant site telehealth service rendered to a patient who is located in their home. It does not replace POS 02. The description for POS 02 has been changed to, “Telehealth Provided Other than in Patient’s Home” and it is still a valid distant site telehealth service POS code. POS 10, when applicable, should be submitted for claims with dates of service beginning April 1, 2022.

SOURCE: Provider Notice Issued 3/21/22: Modifier 93 and Place of Service Code 10 Implementation. (Accessed Jul. 2024).

Community Based Behavioral Services

Effective with dates of service beginning October 1, 2021, providers delivering services via audio or video communication must utilize the appropriate telehealth POS code, consistent with Section 207.3.7, when billing for services.  Providers submitting claims for ‘on-site’ services that include services rendered both by telehealth and face-to-face must exclude the telehealth services from the “roll up” combination of on-site units. Rather, services delivered via telehealth must be billed with the appropriate telehealth modifier (GT or 93) and POS (02 or 10) on a service line separate from other ‘rolled up’ on-site services rendered face-to-face to the same recipient for the same procedure code and modifier combination.

Providers billing a service that was performed via audio or video communication must append the procedure code with appropriate modifier and POS to indicate telehealth as the mode of service delivery.  This coding is needed for HFS to track the mode of service delivery. The modifier and place of service codes are for reporting purposes only and do not affect current payment methodology.  Additional telehealth modifiers and POS have been adopted effective with dates of service beginning July 1, 2022. The table below provides guidance to providers utilizing telehealth on the appropriate telehealth modifiers and POS based upon the date of service. (See manual for additional information).

The new billing instructions apply to any service being billed as a telehealth service, whether it is:

  • A code identified in the Community Based Behavioral Services Handbook that historically could be provided via phone and/or video delivery modes independent of the current public health emergency, or
  • A behavioral health service allowed via telehealth per the current public health emergency telehealth policy stated in the March 20, 2020 provider notice. This list of codes includes the following services from the CBS Fee Schedule: 96110, 96112, 96127 and H1000.

SOURCE: Medicaid Provider Notice “Use of Modifier GT and Place of Service Code 02 to Specify Telehealth Delivery Mode for Behavioral Health Services” & IL Dept. of Healthcare and Family Svcs., Handbook for Community-Based Behavioral Services Providers, 208.3.1 pg. 23-26 (June 6, 2022). (Accessed Jul. 2024).

The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth.

SOURCE: ILCS 5/5.25, (Accessed Jul. 2024).

Department provides coverage for epilepsy treatment services via telehealth as required under Public Act 102-0207. Coverage is provided under both Medicaid fee-for-service and the managed care plans.

SOURCE: Medicaid Provider Notice “Confirmation of Reimbursement for Epilepsy Specialists via Telehealth (9/24/21)” (Accessed Jul. 2024).

Telehealth services for persons with intellectual and developmental disabilities. The Department shall file an amendment to the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities authorized under Section 1915(c) of the Social Security Act to incorporate telehealth services administered by a provider of telehealth services that demonstrates knowledge and experience in providing medical and emergency services for persons with intellectual and developmental disabilities. The Department shall pay administrative fees associated with implementing telehealth services for all persons with intellectual and developmental disabilities who are receiving services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities.

For dates of service on and after January 1, 2025, the Department shall pay negotiated, agreed upon administrative fees associated with implementing telehealth services for persons with intellectual and developmental disabilities who are receiving Community Integrated Living Arrangement residential services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities. The implementation of telehealth services shall not impede the choice of any individual receiving waiver-funded services through the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities to receive in-person health care services at any time. The Department shall ensure individuals enrolled in the waiver, or their guardians, request to opt-in to these services. For individuals who opt in, this service shall be included in the individual’s person-centered plan. The use of telehealth services shall not be used for the convenience of staff at any time nor shall it replace primary care physician services.

SOURCE: 305 ILCS 5/5-5a.1 as amended by SB 3268.  (Accessed Jul. 2024).

Diabetes Prevention Program (DPP) & Diabetes Self-Management Education and Support (DSMES)

DPP services are provided in-person or via telehealth/virtually during sessions that occur at regular, periodic intervals over the course of one year.

DSMES services may be provided in the home, clinic, hospital outpatient facility, via telehealth, or any other setting as authorized and include: counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control; counseling and skill building to facilitate the knowledge, skill and ability necessary for diabetes self-care; and nutritional counseling services.

SOURCE: Medicaid Provider Notice “Billing Update for Diabetes Prevention and Management Programs (7/29/22)” (Accessed Jul. 2024).

Care Coordination and Support Organization (CCSO)

Care Coordination and Support (CCS) services are reimbursed if certain requirements met, including completing two oral communications with family within the calendar month via telephonic, video or in-person.

SOURCE:  IL Dept. of Healthcare and Family Services, Care Coordination and Support Organization Provider Handbook (Oct. 5, 2022), p. 56-57.  (Accessed Jul. 2024).

Medical Equipment

Effective July 1, 2017, to be eligible for reimbursement by the Department, certain medical equipment and supplies will be subject to a face-to-face encounter. The Department will, at a minimum, require a face-to-face encounter for equipment and supplies for which Medicare requires a face-to-face encounter. The face-to-face patient encounter may occur through telehealth, in compliance with Section 140.403.

SOURCE: IL Admin Code, Title 89, Chapter 1, Subchapter d, Part 140, Sec. 140.475(g)(3). (Accessed Jul. 2024).


ELIGIBLE PROVIDERS

The Department of Healthcare and Family Services required to reimburse psychiatrists, federally qualified health centers, clinical psychologists, clinical social workers, advanced practice registered nurses certified in psychiatric and mental health nursing and mental health professionals and clinicians authorized by Illinois law to provide behavioral health services via telehealth.  The Department shall reimburse epilepsy specialists, as defined by the Department by rule, who are authorized by Illinois law to provide epilepsy treatment services to persons with epilepsy or related disorders via telehealth.

SOURCE: 305 ILCS 5/5.25, (Accessed Jul. 2024).

For telemedicine services, the distant site provider must be a physician, physician assistant, podiatrist, or advanced practice nurse who is licensed by the State of Illinois or by the state where the patient is located.

  • Practitioner Handbook:  When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.  Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider. Non-enrolled providers rendering services as a distant site provider shall not be eligible for reimbursement from the Department, but may be reimbursed by the originating site provider from their facility fee payment.
  • Podiatry Handbook:  Services rendered by an APN can be billed under the collaborating physician’s NPI, or if the APN is enrolled, under the APN’s NPI. When medically appropriate, more than one Distant Site provider may bill for services rendered during the telehealth visit.

For telepsychiatry, the distant site provider must be a physician who is licensed by the State of Illinois or by the state where the patient is located who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program.

  • Practitioner Handbook: To be eligible for reimbursement for telepsychiatry services, physicians must enroll in the correct specialty/sub-specialty in IMPACT.
  • Encounter Clinic Handbook:  Telepsychiatry is not a covered service when rendered by an APN or PA.  Group psychotherapy is not a covered telepsychiatry service.

SOURCE: IL Admin. Code Title 89, 140.403(b); IL Dept. of Healthcare and Family Svcs., Handbook for Podiatrists (physician services only), F-200, F-220.6.2 p. 28 (Oct. 2016); IL Dept Of Healthcare and Family Svcs, Handbook for Providers of Podiatric Services (Oct 2016), p. 27, & Handbook for Practitioner Services. Ch. 200, 220.5.7 p. 26 (June 2021) & Handbook for Encounter Clinic Services. Ch. 200, 210.2.2 pg. 17. (Aug. 2016). (Accessed Jul. 2024).

An encounter clinic serving as the distant site shall be reimbursed as follows:

  • If the originating site is another encounter clinic, the distant site encounter clinic shall receive no reimbursement from the Department.  The originating site encounter clinic is responsible for reimbursement to the distant site encounter clinic; and
  • If the originating site is not an encounter clinic, the distant site encounter clinic shall be reimbursed for its medical encounter.  The originating site provider will receive a facility fee.

See Encounter Clinic Services Appendices supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Admin. Code Title 89, 140.403IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010; Handbook for Encounter Clinic Services. Ch. 200, pg. 17.  Aug. 2016 & IL All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Jul. 2024).

Effective with dates of service beginning October 1, 2021, providers billing a service from the Community Based Behavioral  Services Fee Schedule that was performed via audio or video communication must append the procedure code with modifier GT and use Place of Service Code 02. This coding is needed for HFS to track the mode of service delivery. The GT modifier and Place of Service Code 02 are for reporting purposes only and do not affect current payment methodology.

The new billing instructions apply to any service being billed as a telehealth service, whether it is:

  • A code identified in the Community Based Behavioral Services Handbook that historically could be provided via phone and/or video delivery modes independent of the current public health emergency, or
  • A behavioral health service allowed via telehealth per the current public health emergency telehealth policy stated in the March 20, 2020 provider notice. This list of codes includes the following services from the CBS Fee Schedule: 96110, 96112, 96127 and H1000.

The following providers billing from the Community Based Behavioral Services Fee Schedule are impacted:

  • Community Mental Health Centers
  • Behavioral Health Clinics
  • Physicians
  • Licensed Clinical Psychologists
  • Licensed Clinical Social Workers

SOURCE: Medicaid Provider Notice “Use of Modifier GT and Place of Service Code 02 to Specify Telehealth Delivery Mode for Behavioral Health Services” (Accessed Jul. 2024)

Local education agencies may submit telehealth services as a certified expenditure.

SOURCE: IL Admin. Code Title 89, 140.403(c)(1)(B). (Accessed Jul. 2024).


ELIGIBLE SITES

The Department shall reimburse any Medicaid certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including substance abuse centers licensed by the Department of Human Services’ Division of Alcoholism and Substance Abuse.

SOURCE: ILCS 5/5.25(c), (Accessed Jul. 2024).  

POS 10 is a new place of service code that specifies a distant site telehealth service rendered to a patient who is located in their home. It does not replace POS 02. The description for POS 02 has been changed to, “Telehealth Provided Other than in Patient’s Home” and it is still a valid distant site telehealth service POS code. POS 10, when applicable, should be submitted for claims with dates of service beginning April 1, 2022.

SOURCE: Provider Notice Issued 3/21/22: Modifier 93 and Place of Service Code 10 Implementation. (Accessed Jul. 2024).

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

For telepsychiatry services, A physician, licensed health care professional or other licensed clinician, mental health professional (MHP), or qualified mental health professional (QMHP), must be present at all times with the patient at the originating site.

SOURCE: IL Admin. Code Title 89, 140.403(b) &  IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7  p. 25, (June 2021). (Accessed Jul. 2024).

IL Healthcare and Family Services recognizes the following as valid originating sites: physician’s office, podiatrist’s office, local health department, Community Mental Health Center, Encounter Rate Clinics, and outpatient hospital.

For telepsychiatry services, a staff member meeting the minimum qualifications of a mental health professional (MHP) must be present at all times with the patient at the originating site.

SOURCE:  IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, 220.5.7  p. 25, (June 2021). (Accessed Jul. 2024).

See handbook supplement for telehealth billing examples.

SOURCE: All Providers Handbook Supplement (Sept. 2020), pg. 43-45. (Accessed Jul. 2024). 

An encounter clinic is eligible as an originating site and is responsible for ensuring and documenting that the distant site provider meets the department’s requirements for telehealth and telepsychiatry services since the clinic is responsible for reimbursement to the distant site provider.

Enrolled distant site providers may not seek reimbursement from the Department for their services when the originating site is an encounter clinic. The originating site encounter clinic is responsible for reimbursement to the distant site provider.

See Encounter Clinic Services Appendices supplement for telehealth billing examples for encounter clinics.

SOURCE: IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. (June 2021) Ch. 200, p. 25Handbook for Podiatrists, F-200, p. 27 (Oct. 2016); & Handbook for Encounter Clinic Services. Ch. D-200, pg. 17.  Aug. 2016. (Accessed Jul. 2024).

Recent Legislation Effective Jan. 1, 2024

Mental Health and Substance Use Disorder

There shall be no restrictions on originating site requirements for behavioral telehealth coverage or reimbursement to the distant site under this Section other than requiring the behavioral telehealth services to be medically necessary and clinically appropriate.

SOURCE: Illinois 305 ILCS 5/5-47 (Accessed Jul. 2024).


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

Originating site providers may submit claims for a facility fee for each telehealth service encounter using HCPCS Code Q3014/Telehealth Originating Site Facility Fee.

Eligible facilities include:

  • Physician’s office;
  • Podiatrist’s office
  • Local health departments
  • Community mental health centers
  • Outpatient hospitals

SOURCE: IL Handbook for Practitioners Rendering Medical Services, Ch. 200, p. 26 (June 2021) & Handbook for Podiatrists, F-200, p. 27 (Oct. 2016). (Accessed Jul. 2024).

Hospitals Billing with Revenue Code 0780 and HCPCS Code Q3014

HCPCS code Q3014 must be identified on the same revenue line with Revenue Code 0780. If any other procedure code is billed with Revenue Code 0780, the claim will be rejected with error code T55 – Missing/Invalid HCPCS for Revenue Code 0780.

Other services may be billed as necessary on the same outpatient claim with a telehealth facility fee, but the telehealth service must be identified as described in this provider notice. No modifier is required for the telehealth service.

SOURCE: Medicaid Provider Notice “Hospitals Billing as the Telehealth Originating Site”  (Mar. 2, 2021). (Accessed Jul. 2024)

Sites approved as valid originating facility sites were expanded. The March 20, 2020 notice contained a list of sites that included “providers who receive reimbursement for a patient’s room and board, including nursing facilities and Intermediate Care Facilities for the Developmentally Disabled.” For further clarification, this category would also include Family Support Program residential providers, Medically Complex Facilities for Persons with Developmental Disabilities, and Specialized Mental Health Rehabilitation Facilities.

Facility Fee Billing Instructions for Hospice Agencies:

In situations where a hospice patient in a long term care facility is in need of a telehealth service, the hospice may submit charges for the facility fee as an originating telehealth site.

Use Revenue Code 0657 in conjunction with HCPCS code Q3014 and identify the number of Service Units (telehealth occurrences) provided in the billing period.

The telehealth facility fee service cannot be billed separately and must be included on a claim containing the hospice’s usual charges.

Facility Fee Billing Instructions for Hospitals:

Hospitals are already able to bill as a non-institutional provider originating site, as stated in the Handbook for Practitioner Services, topic 202.1.4 – Allowable Fee-for-Service Charges by Hospitals.

All Other Originating Facility Sites – The Department is currently working to implement a facility fee payment system for these sites and additional information will be forthcoming.

SOURCE: Provider Notice Telehealth Expansion Billing Instructions (March 30, 2020). (Accessed Jul. 2024).

 

 

Last updated 02/27/2024

Miscellaneous

The IL Association of Medicaid Health Plans has created a comprehensive billing manual for IL Medicaid Managed Care that includes some information on telehealth policy as it applies to these health plans. The existence of this guide was relayed to IL Medicaid providers by the IL Dept of Healthcare and Family Services in a Provider Notice issued on 11/17/2023.

SOURCE: IL Dept of Healthcare and Family Services, Provider Notice PRN231117a (Nov 17, 2023).   (Accessed Feb. 2024).

Specific documentation requirements apply for telehealth services.  See administrative code for details.

SOURCE: IL Administrative Code, Title 89 ,140.403(d). (Accessed Feb. 2024).

The Department shall file an amendment to the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities authorized under Section 1915(c) of the Social Security Act to incorporate telehealth services administered by a provider of telehealth services that demonstrates knowledge and experience in providing medical and emergency services for persons with intellectual and developmental disabilities. The Department shall pay administrative fees associated with implementing telehealth services for all persons with intellectual and developmental disabilities who are receiving services under the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities.

SOURCE: Illinois 305 ILCS 5/5-5a1.  (Accessed Jul. 2024).

In order to address the growing challenges of providing stable access to healthcare in rural Illinois, by October 1, 2023, the Department shall adopt rules to implement for dates of service on and after January 1, 2024, subject to federal approval, a program to provide at least $3,500,000 in annual financial support to public, critical access hospitals in Illinois, for the delivery of perinatal and obstetrical or gynecological services, behavioral healthcare services, including substance use disorder services, telehealth services, and other specialty services.

SOURCE:  305 ILCS 5/14-12.7. (Accessed Jul. 2024).

Last updated 07/12/2024

Out of State Providers

For medical services, the provider rendering the service at the distant site can be a physician, physician assistant, podiatrist or advanced practice nurse, who is licensed by the State of Illinois or by the state where the patient is located.

For psychiatric services, the provider rendering the service at the distant site must be a physician licensed by the State of Illinois, or by the state where the patient is located, who has completed an approved general psychiatry residency program or a child and adolescent psychiatry residency program.

SOURCE: IL Handbook for Practitioners Rendering Medical Services, Chapter 200, 220.5.7 p. 26, (June 2021); Handbook for Podiatric Services, Chapter F-200 Policy & Procedures, p. 28 (Oct. 2016), & Handbook for Encounter Clinic Services 210.2.2 pg. 17-18 (Aug. 2016). (Accessed Jul. 2024).

Last updated 07/12/2024

Overview

IL Medicaid reimburses for live video telemedicine and telepsychiatry services for specific providers.  Last year, IL Medicaid issued a  provider bulletin specifying that certain Interprofessional Consultation CPT codes are billable for psychiatric services.  IL Medicaid will provide reimbursement for home uterine monitoring, continuous glucose monitoring, and some audio-only services.

The IL Association of Medicaid Health Plans has created a comprehensive billing manual for IL Medicaid Managed Care that includes some information on telehealth policy as it applies to these health plans. The existence of this guide was relayed to IL Medicaid providers by the IL Dept of Healthcare and Family Services in a Provider Notice issued on 11/17/2023.

Last updated 02/27/2024

Remote Patient Monitoring

POLICY

IL Medicaid will cover home uterine monitoring with prior approval and when patient meets specific criteria.  Payment is only for the items and not for the service.

SOURCE: IL Dept. of Healthcare and Family Services, Handbook for Durable Medical Equipment, Chapter M-200, Policy and Procedures for Medical Equipment and Supplies, p. 56 (Sept. 2015). (Accessed Jul. 2024).

Continuous Glucose Monitoring (For Enrolled Pharmacies)

The Department of Healthcare and Family Services’ (HFS) will cover for continuous glucose monitors (CGMs) as required under Public Act 102-1093. Coverage is provided under both Medicaid fee-for-service (FFS) and the HealthChoice Illinois (HCI) managed care plans (MCOs).

The Act requires medically necessary CGMs be provided for individuals diagnosed with type 1 or type 2 diabetes who require insulin for the management of their diabetes. HFS already provides coverage for medically necessary CGMs and insulin, and no program coverage changes are necessary. The criteria for CGM coverage can be found at Criteria and Forms | HFS (illinois.gov) under the Criteria heading.

SOURCE: IL Dept of Healthcare and FamilyServices Provider Notice 7/25/22 Confirmation of Coverage for Continuous Glucose Monitors. (Accessed Jul. 2024).

The Department shall adopt rules to implement the changes made to Section 356z.59 of the Illinois Insurance Code, as applied to the medical assistance program. The rules
shall, at a minimum, provide that:

  1. the ordering provider must be a physician licensed under the Medical Practice Act of 1987 or a certified nurse practitioner or physician assistant with a collaborative agreement with the physician; the ordering provider is not required to obtain continuing medical education in order to prescribe a continuous glucose monitor;
  2. continuous glucose monitors are not required to have an alarm when glucose levels are outside the pre-determined range; the capacity to generate predictive alerts in case of impending hypoglycemia; or the ability to transmit real-time glucose values and alerts to the patient and designated other persons;
  3. the beneficiary is not required to need intensive insulin therapy;
  4. the beneficiary is not required to have a recent history of emergency room visits or hospitalizations related to hypoglycemia, hyperglycemia, or ketoacidosis;
  5. if the beneficiary has gestational diabetes, the beneficiary is not required to have suboptimal glycemic control that is likely to harm the beneficiary or the fetus;
  6. if a beneficiary has diabetes mellitus and the beneficiary does not meet the coverage requirements or if the beneficiary is in a population in which continuous glucose monitor usage has not been well-studied, requests shall be reviewed, on a case-by-case basis, for medical necessity and approved if appropriate; and
  7. prior authorization is required for a prescription of a continuous glucose monitor; once a continuous glucose monitor is prescribed, the prior authorization shall be approved for a 12-month period.

SOURCE: Senate Bill 3414, (2024 Session), (Accessed Jul. 2024).

Community-Integrated Living Arrangements (CILA)

“Remote Monitoring and Supports.” The use of electronic interactive technology (e.g., a device, a product, or system) to provide supports and services, absent of direct care staff, in accordance with the Health Care Affordability Act [305 ILCS 5/12-21.21].  Remote monitoring and supports are meant to increase independence and daily living skills of individuals.

SOURCE: IL Admin. Code, Title 59, Chapter 1, Part 115, Sec. 115.120.  (Accessed Jul. 2024).

CILA agencies may provide remote monitoring and support services in community-integrated living arrangements pursuant to 305 ILCS 5/12-21.21, as determined by DDD.  Remote monitoring and supports (i.e., video, web-cameras, or other interactive technology) may be provided to increase independence and daily living skills of an individual and address an individual’s needs and outcomes identified in their personal plan.  Remote supports and services must be based on an assessment which shall, at a minimum, identify risks important in considering whether remote monitoring and supports are appropriate for the individual.

SOURCE: IL Admin Code, Title 59; Chapter 1, Part 115, Sec. 115.320(C)(7).  (Accessed Jul. 2024).


CONDITIONS

Only for home uterine monitoring.

  • Home uterine monitoring
  • Must be at least 24 weeks gestation; gestation of less than 24 weeks may require additional information
  • Hospitalized for preterm labor at 24-36 weeks
  • Cessation of labor accomplished by administration of tocolytics (terbutaline, procardia, etc.)
  • Discharged to home on oral or subcutaneous tocolytics
  • Multiple gestation pregnancy
  • History of preterm labor and delivery
  • Cervical status change (lengthening or dilation)
  • Cervical effacement
  • Contraction threshold
  • Gravida/para

Pregnancy-Induced Hypertension Monitor

  • Covered for diagnosis of pregnancy-induced hypertension, previous pregnancy induced hypertension or pre-eclampsia
  • Hospitalizations for symptoms related to pregnancy induced; i.e., hypertension, headaches, edema in face, hands and feet
  • Blurred vision
  • Right upper quadrant pain
  • 24-hour urine results greater than 300 mg of total protein
  • Antihypertensive medications
  • Pre-pregnancy and current blood pressure readings.

Will not be covered for patients with a diagnosis of chronic hypertension.

SOURCE: IL Dept. of Healthcare and Family Services, Handbook for Durable Medical Equipment, Chapter M-200, Policy and Procedures for Medical Equipment and Supplies, p. 56 (Sept. 2015). (Accessed Feb. 2024).


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

Last updated 07/09/2024

Store and Forward

POLICY

Although store-and-forward is included within the definitions of telehealth in IL Medicaid manuals and administrative code (see descriptions below), there are no details provided on store-and-forward reimbursement and other areas of policy only indicate that the GT (live video) modifier is required for telehealth services.

SOURCE: Provider Notice Changes to Professional Claims for Telehealth Services. Jan. 10, 2018. (Accessed Jul. 2024). 

The Illinois Medicaid definition encompasses store-and-forward.  “The information or data exchanged can occur in real time (synchronous) through interactive video or multimedia collaborative environments or in near real time (asynchronous) through ‘store-and-forward’ applications.”

SOURCE: IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. 200, p. 24, June 2021; Handbook for Podiatrists, F-200, p. 27 (Oct. 2016); & Handbook for Encounter Clinic Services pg. 16-17 (Aug. 2016). (Accessed Jul. 2024).

IL Admin Code encompasses store-and-forward, addressing that a provider at a distant site can “review the medical case without the patient being present.”

“Asynchronous Store and Forward Technology” means the transmission of a patient’s medical information from an originating site to the provider at the distant site.  The provider at the distant site can review the medical case without the patient being present.  An asynchronous telecommunication system in single media format does not include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (electronic mail).  Photographs visualized by a telecommunication system must be specific to the patient’ s medical condition and adequate for furnishing or confirming a diagnosis and/or treatment plan.  Dermatological photographs (for example, a photograph of a skin lesion) may be considered to meet the requirement of a single media format under this provision.

SOURCE: IL Administrative Code, Title 89 ,140.403. (Accessed Jul. 2024).

Interprofessional Consultation for Psychiatry

Certain codes for Interprofessional Consultation will be allowed.  See bulletin for specific codes.

SOURCE: IL Dept of Healthcare and Family Services Provider Bulletin (Feb. 3. 2023). (Accessed Jul. 2024).

 


ELIGIBLE SERVICES/SPECIALTIES

No Reference Found


GEOGRAPHIC LIMITS

No Reference Found


FACILITY/TRANSMISSION FEE

No Reference Found

Last updated 07/12/2024

Cross State Licensing

A person who engages in the practice of telemedicine without a license or permit issued under this Act shall be subject to penalties provided in Section 59. A person with a temporary permit for health care may treat a patient located in this State through telehealth services in a manner consistent with the person’s scope of practice and agreement with a sponsoring entity.An out-of-state person providing a service to a patient in IL through telemedicine submits himself or herself to the jurisdiction of the courts of IL. (Scheduled to be repealed Jan. 1, 2027).

SOURCE: IL Compiled Statutes, Chapter 225, 60/49.5(e) (Accessed Jul. 2024).

A health care professional treating a patient located in this State through telehealth services must be licensed or authorized to practice in Illinois. A health care professional with a temporary permit for full practice advanced practice registered nurse for health care, a temporary permit for advanced practice registered nurse for health care, or a temporary permit for health care may treat a patient located in this State through telehealth services in a manner consistent with the health care professional’s scope of practice and agreement with a sponsoring entity.

SOURCE: IL Compiled Statutes, Chapter 225, 150/10. (Accessed Jul. 2024).

Any person who was issued a temporary reinstatement permit by the Department pursuant to a proclamation issued by the Secretary or related action by the Director in response to the COVID-19 pandemic may continue to practice under his or her temporary reinstatement permit if he or she submits an application for restoration or reinstatement of his or her license to the Department on or before May 11, 2023. Any such person may continue to practice under his or her temporary reinstatement permit until the Department restores or reinstates the license or denies the application, at which time the temporary reinstatement permit shall expire. If the Department does not restore or reinstate the license or does not deny the application by May 11, 2024, the temporary reinstatement permit shall expire. If the person holding a temporary reinstatement permit does not submit an application for restoration or reinstatement to the Department on or before May 11, 2023, the temporary reinstatement permit shall expire on that date.

SOURCE: IL Compiled Statutes, 20 ILCS 2105/2105-400.  (Accessed Jul. 2024).

An optometrist treating a patient located in this State through telehealth must be licensed under this Act. (To be repealed Jan. 1, 2027).

SOURCE: IL Compiled Statutes Chapter 225, 80/15.4. (Accessed Jul. 2024).

Telemedicine means the performance of any of the activities listed in Section 49, including, but not limited to, rendering written or oral opinions concerning diagnosis or treatment of a patient in Illinois by a person in a different location than the patient as a result of transmission of individual patient data by telephonic, electronic, or other means of communication. “Telemedicine” does not include the following:

  1. periodic consultations between a person licensed under this Act and a person outside the State of Illinois;
  2. a second opinion provided to a person licensed under this Act;
  3. diagnosis or treatment services provided to a patient in Illinois following care or treatment originally provided to the patient in the state in which the provider is licensed to practice medicine; and
  4. health care services provided to an existing patient while the person licensed under this Act or patient is traveling.

This section is scheduled to be repealed on January 1, 2027.

SOURCE: IL Compiled Statutes, Chapter 225, 60/49.5(c). (Accessed Jul. 2024). 

Social Work

A person not a resident of IL is not prohibited from performing social work via telehealth in the state for a nonresident of the state for not more than 5 days in any one month or more than 15 days in any one calendar year, that had a previous established therapeutic relationship with the nonresident, and the person is authorized to perform such services under the laws of the state or country in which the person resides.

A person who is not a resident of this state is not prohibited from performing social work via telehealth in this state for a nonresident of this state currently attending a university or college in this state, that had a previous established therapeutic relationship with the nonresident, and the person is authorized to perform such services under the laws of the state our country in which the person resides.

SOURCE: 225 ILCS 20/4 . (Accessed Jul. 2024).

Dietian (To be repealed January 1, 2028)

No person may provide, offer to provide, or attempt to provide medical nutrition therapy, whether for remuneration, or hold himself or herself out as a licensed dietitian nutritionist or as a qualified provider of nutrition care services, including medical nutrition therapy, unless the person is licensed in accordance with this Act.

This Section does not prohibit the provision of medical nutrition therapy by: a person who is licensed to practice dietetics and nutrition under the law of another state, territory of the United States, or country and has applied in writing to the Department in form and substance satisfactory to the Department for a license as a dietitian nutritionist until (i) the expiration of 6 months after filing the written application, (ii) the withdrawal of the application, or (iii) the denial of the application by the Department.

SOURCE: 225 ILCS 30/15 (a) & (b).  (Accessed Jul. 2024).

Physician & Physician Assistant

The Department may issue a temporary permit to an applicant who is licensed to practice as a physician assistant in another state. The temporary permit will authorize the practice of providing health care to patients in this State, with a collaborating physician in this State, if certain conditions are met.

SOURCE: 225 ILCS 60/66 & 225 ILCS 95/9.7.  (Accessed Jul. 2024).

Last updated 07/12/2024

Definitions

“Telehealth services” means the evaluation, diagnosis, or interpretation of electronically transmitted patient-specific data between a remote location and a licensed health care professional that generates interaction or treatment recommendations. “Telehealth services” includes telemedicine and the delivery of health care services, including mental health treatment and substance use disorder treatment and services to a patient, regardless of patient location, provided by way of an interactive telecommunications system, asynchronous store and forward system, remote patient monitoring technologies, e-visits, or virtual check-ins.

“Virtual check-in” means a brief patient-initiated communication using a technology-based service, excluding facsimile, between an established patient and a health care professional. “Virtual check-in” does not include communications from a related office visit provided within the previous 7 days, nor communications that lead to an office visit or procedure within the next 24 hours or soonest available appointment.

“E-visit” means a patient-initiated non-face-to-face communication through an online patient portal between an established patient and a health care professional.

“Asynchronous store and forward system” means the transmission of a patient’s medical information through an electronic communications system at an originating site to a health care professional or facility at a distant site that does not require real-time or synchronous interaction between the health care professional and the patient.

“Interactive telecommunications system” means an audio and video system, an audio-only telephone system (landline or cellular), or any other telecommunications system permitting 2-way, synchronous interactive communication between a patient at an originating site and a health care professional or facility at a distant site. “Interactive telecommunications system” does not include a facsimile machine, electronic mail messaging, or text messaging.

“Remote patient monitoring” means the use of connected digital technologies or mobile medical devices to collect medical and other health data from a patient at one location and electronically transmit that data to a health care professional or facility at a different location for collection and interpretation.

“Health care professional” includes, but is not limited to, physicians, physician assistants, optometrists, advanced practice registered nurses, clinical psychologists licensed in Illinois, prescribing psychologists licensed in Illinois, dentists, occupational therapists, pharmacists, physical therapists, clinical social workers, speech-language pathologists, audiologists, hearing instrument dispensers, licensed certified substance use disorder treatment providers and clinicians, and mental health professionals and clinicians authorized by Illinois law to provide mental health services, and qualified providers listed under paragraph (8) of subsection (e) of Section 3 of the Early Intervention Services System Act, dietitian nutritionists licensed in Illinois, and health care professionals associated with a facility.

“Facility” includes a facility that is owned or operated by a hospital under the Hospital Licensing Act or University of Illinois Hospital Act, a facility under the Nursing Home Care Act, a rural health clinic, a federally qualified health center, a local health department, a community mental health center, a behavioral health clinic as defined in 89 Ill. Adm. Code 140.453, an encounter rate clinic, a skilled nursing facility, a substance use treatment program licensed by the Division of Substance Use Prevention and Recovery of the Department of Human Services, a school-based health center as defined in 77 Ill. Adm. Code 641.10, a physician’s office, a podiatrist’s office, a supportive living program provider, a hospice provider, home health agency, or home nursing agency under the Home Health, Home Services, and Home Nursing Agency Licensing Act, a facility under the ID/DD Community Care Act, community-integrated living arrangements as defined in the Community-Integrated Living Arrangements Licensure and Certification Act, and a provider who receives reimbursement for a patient’s room and board.

“Established patient” means a patient with a relationship with a health care professional in which there has been an exchange of an individual’s protected health information for the purpose of providing patient care, treatment, or services.

SOURCE: IL Compiled Statutes, Chapter 225, 150/5.  (Accessed Jul. 2024).

Telemedicine means the performance of any of the activities listed in Section 49, including, but not limited to, rendering written or oral opinions concerning diagnosis or treatment of a patient in Illinois by a person in a different location than the patient as a result of transmission of individual patient data by telephonic, electronic, or other means of communication. “Telemedicine” does not include the following:

  1. periodic consultations between a person licensed under this Act and a person outside the State of Illinois;
  2. a second opinion provided to a person licensed under this Act;
  3. diagnosis or treatment services provided to a patient in Illinois following care or treatment originally provided to the patient in the state in which the provider is licensed to practice medicine; and
  4. health care services provided to an existing patient while the person licensed under this Act or patient is traveling.

This section is scheduled to be repealed on January 1, 2027.

SOURCE: IL Compiled Statutes, Chapter 225, 60/49.5(c). (Accessed Jul. 2024). 

Under the Department of Public Health, telemedicine means the provision of clinical services to patients by physicians and practitioners from a distance via electronic communications.  The distant-site telemedicine physician or practitioner provides clinical services to the hospital patient either simultaneously, as is often the case with teleICU services, for example, or non-simultaneously, as may be the case with many teleradiology services.  Telemedicine may also include provider-to-provider consultations between Illinois-licensed physicians or practitioners and physicians or practitioners licensed in the United States.

SOURCE: IL Admin. Code, Title 77, Sec. 250.310(a)(8) (Accessed Jul. 2024). 

“Teledentistry” means the use of telehealth systems and methodologies in dentistry and includes patient care and education delivery using synchronous and asynchronous communications under a dentist’s authority as provided under this Act.

SOURCE: IL Code 225, Sec. 25/4. (Accessed Jul. 2024).

Optometrists (To be repealed January 1, 2027)

“Telehealth” means the evaluation, diagnosis, or interpretation of patient-specific data that is transmitted by way of an interactive telecommunication system between a remote location and an optometrist located at a distant site that generates interaction or treatment recommendations for a patient located at a remote location. “Telehealth” includes the performance of any of the activities set forth in Sections 3 and 15.1.

“Interactive telecommunications system” means an audio and video system permitting 2-way, real-time interactive communication between a patient located at a remote location and an optometrist located at a distant site.

An optometrist may not provide telehealth services unless the optometrist has established a provider-patient relationship with the patient. In this subsection, “provider-patient relationship” means a relationship in which the optometrist has provided services to the patient at an in-person consultation no more than 3 years prior to the date on which telehealth services are provided. An in-person consultation is not required for new conditions relating to a patient with whom the optometrist has a provider-patient relationship unless the optometrist deems an in-person consultation is necessary to provide appropriate care. An optometrist may treat a patient through telehealth in the absence of a provider-patient relationship when, in the professional judgment of the optometrist, emergency care is required.

SOURCE: IL Compiled Statutes Chapter 225, 80/9.  IL Compiled Statutes Chapter 225, 80/15.4. (Accessed Jul. 2024).

Dietian (Scheduled to be repealed January 1, 2028)

“Telehealth” or “telepractice” means the delivery of services under this Act by using electronic communication, information technologies, or other means between an individual licensed under this Act in one location and a patient or client in another location, with or without an intervening healthcare provider. “Telehealth” or “telepractice” includes direct, interactive patient encounters, asynchronous store-and-forward technologies, and remote monitoring. Telehealth or telepractice is not prohibited under this Act provided that the provision of telehealth or telepractice services is appropriate for the client and the level of care provided meets the required level of care for that client. Individuals providing services regulated by this Act via telepractice shall comply with and are subject to all licensing and disciplinary provisions of this Act.

SOURCE:  225 ILCS 30/10. (Accessed Jul. 2024).

Last updated 07/12/2024

Licensure Compacts

Member of the Interstate Medical Licensure Compact.

SOURCE: Interstate Medical Licensure Compact. The IMLC. (Accessed Jul. 2024).

Member of Psychology Interjurisdictional Compact.

SOURCE: Psychology Interjurisdictional Compact. Legislative Updates. (Accessed Jul. 2024).

* See Compact websites for implementation and license issuing status and other related requirements.

Last updated 07/12/2024

Miscellaneous

A health care professional may engage in the practice of telehealth services in Illinois to the extent of his or her scope of practice as established in his or her respective licensing Act consistent with the standards of care for in-person services. This Act shall not be construed to alter the scope of practice of any health care professional or authorize the delivery of health care services in a setting or in a manner not otherwise authorized by the laws of this State.

Telehealth services shall be consistent with all federal and State privacy, security, and confidentiality laws, rules, or regulations.

A health care professional with a temporary permit for full practice advanced practice registered nurse for health care, a temporary permit for advanced practice registered nurse for health care, or a temporary permit for health care may treat a patient located in this State through telehealth services in a manner consistent with the health care professional’s scope of practice and agreement with a sponsoring entity.

“Health care professional” includes, but is not limited to, physicians, physician assistants, optometrists, advanced practice registered nurses, clinical psychologists licensed in Illinois, prescribing psychologists licensed in Illinois, dentists, occupational therapists, pharmacists, physical therapists, clinical social workers, speech-language pathologists, audiologists, hearing instrument dispensers, licensed certified substance use disorder treatment providers and clinicians, and mental health professionals and clinicians authorized by Illinois law to provide mental health services, and qualified providers listed under paragraph (8) of subsection (e) of Section 3 of the Early Intervention Services System Act, dietitian nutritionists licensed in Illinois, and health care professionals associated with a facility.

SOURCE: IL Compiled Statutes, Chapter 225, 150/5 & IL Compiled Statutes Chapter 225, 150/15. (Accessed Jul. 2024).

An optometrist may practice optometry through telehealth and must be licensed in the state to treat a patient in the state.

An optometrist practicing optometry through telehealth is subject to the same standard of care and practice standards that are applicable to optometric services provided in a clinic or office setting.

An optometrist may not provide telehealth services unless the optometrist has established a provider-patient relationship with the patient.

An in-person consultation is not required for new conditions relating to a patient with whom the optometrist has a provider-patient relationship unless the optometrist deems an in-person consultation is necessary to provide appropriate care. An optometrist may treat a patient through telehealth in the absence of a provider-patient relationship when, in the professional judgment of the optometrist, emergency care is required.

SOURCE: IL Compiled Statutes Chapter 225, 80/15.4. (Accessed Jul. 2024).

Occupational therapy may be provided via technology or telecommunication methods, also known as telehealth, however the standard of care shall be the same whether a patient or recipient is seen in person, through telehealth, or other method of electronically enabled health care.  Included in the definition of occupational therapy services are virtual interventions, including simulated, real-time, and near-time technologies, consisting of telehealth and mobile technology.

SOURCE:  Illinois 225 ILCS 75/1. (Accessed Jul. 2024).

Hospitals & Ambulatory Care Facilities

The medical staff shall be organized in accordance with written bylaws, rules and regulations approved by the governing board.  The bylaws, rules and regulations shall specifically provide, but are not limited to:

establishing a procedure for granting telemedicine privileges, based upon the privileging decisions of a distant-site hospital or telemedicine entity that has a written agreement that meets Medicare requirements;

General Acute or Critical Access Hospitals without a licensed pediatric unit or board certified or board eligible pediatrician in the hospital or on call 24 hours a day, 7 days a week that provide limited inpatient or observation services to pediatric patients (neonate (less than 28 days of age) to 14 years old):

  • Shall have a written agreement with a children’s hospital or hospital with a licensed pediatric unit. The agreement shall include provider-to-patient and/or provider-to-provider consultations that meet the telemedicine requirements provided in subsections (a)(2) through (a)(8) remotely via electronic communications, whether synchronous or asynchronous, and specify other information including communication frequency, equipment, education, transfers, case reviews, and critical criteria for emergency transfers;

If a hospital enters into agreement for telemedicine services with a distant-site hospital or distant-site entity, the governing body of the hospital whose patients are receiving the telemedicine services may choose, in lieu of the hospital performing the credentialing and privileging requirements, to rely upon the credentialing and privileging decisions made by the distant-site hospital when making recommendations on privileges for the individual distant-site physicians and practitioners providing the services.  The hospital’s governing body ensures, through its written agreement with the distant-site hospital, that the distant-site hospital meets the Conditions of Participation for Hospitals for credentialing and privileging of physicians and practitioners.

SOURCE:  IL Admin Code, Title 77, Chapter 1, Subch b, Part 250, Sec. 250.310.  (Accessed Jul, 2024).

Veterinarian Medicine

Telemedicine occurs when either the animal who is receiving the care is located in the State when receiving telemedicine treatment or the veterinarian providing the care to the animal is located in the State when providing telemedicine treatment, pursuant to the provisions of Section 5. Telemedicine may only be used when a veterinarian has an established veterinarian-client-patient relationship.

A veterinarian shall not substitute telehealth, teleadvice, telemedicine or teletriage when a physical examination is warranted or necessary for an accurate diagnosis of any medical condition or creation of an approprariate treatment plan.

SOURCE: IL 225 ILCS 115/4.5. (Accessed Jul, 2024).

Last updated 07/12/2024

Online Prescribing

An optometrist treating a patient through telehealth must perform at least a minimum eye examination as required by 68 Ill. Adm. Code 1320.90 before prescribing eyeglasses or contact lenses to the patient. Nothing in this Section authorizes an eye examination that:

  • does not assess the ocular health and visual status of a patient, or
  • consists solely of objective refractive data or information generated by an automated testing device, including an autorefractor, in order to establish a medical diagnosis or to determine a refractive error.

To be repealed Jan. 1, 2027.

SOURCE: Illinois Consolidated Statute 225, 80/15.4. (Accessed Jul. 2024).

A person age 18 or older must be evaluated by a hearing instrument professional in person or via telehealth before receiving a prescription for a hearing aid. A person age 18 or older may not waive evaluation by a hearing instrument professional unless he or she is replacing a lost or stolen hearing aid that is subject to warranty replacement.

SOURCE:  Illinois 225 ILCS 50/4.6.  (Accessed Jul. 2024).

Last updated 07/12/2024

Professional Boards Standards

No Reference Found