Date: March 8, 2019
To: Enrolled Pharmacies
Re: Critical Access Pharmacies’ (CAP) Self-Attest Criteria
Per Public Act 100-0587 and recently adopted rules at 89 Ill. Admin. Code Section 140.439, HFS is required to make quarterly payments to Critical Access Pharmacies (CAPs). A CAP is defined as an Illinois-based brick and mortar pharmacy whose owners have an ownership or control interest in fewer than 10 pharmacies and is a) located in a county with fewer than 50,000 residents; or b) located in an area designated as a Medically Underserved Area by the Health Resources & Services Administration (HRSA). A brick and mortar pharmacy is defined as a pharmacy that is open to the public, where participants present at the pharmacy to fill prescriptions, and the majority of the pharmacy’s business is not mail-order based.
CAPs will receive quarterly payments based on the total number of managed care encounter claims that have been accepted by the Department (CAP-eligible claims) from the Department’s contracted managed care plans. The payments will be based on the lesser of:
1) the total number of a CAP’s CAP-eligible claims multiplied by the Department’s dispensing fee that was in effect as of April 1, 2018, or
2) the Individual Payment Amount, which is equal to one-quarter of the total amount appropriated for the CAP for a fiscal year, divided by the total number of CAP-eligible claims for the quarter for all CAP pharmacies.
The program began July 1, 2018, with the first payments to be made based on CAP-eligible claims for dates of service in the 4th quarter of fiscal year 2018.
To be eligible to receive payments, providers must self-attest to meeting the CAP criteria. Providers may attest using the Department’s MEDI site. Providers will initially be allowed to attest to the first three quarters (April-June, July-September, October-December 2018) beginning with the first quarter of calendar year 2019. After that, providers must attest within 30 days after the end of each quarter.
Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.