Section 148.50  Covered Hospital Services

a)         The Department shall pay hospitals for the essential provision of inpatient, outpatient, and clinic diagnostic and treatment services not otherwise excluded or limited which are provided by a hospital, as described in Section 148.25(b), or a distinct part unit, as described in Section 148.25(c), and which are provided in compliance with hospital licensing standards. Payment may be made for the following types of care subject to the special requirements described in Section 148.40:

1)         General/specialty services;

2)         Psychiatric services;

3)         Rehabilitation services; and

4)         End-Stage Renal Disease Treatment (ESRDT) services.

b)         Certain programs are administered as hospital covered services with certain restrictions.  These programs include hospital residing long term care services, subacute alcoholism and substance abuse treatment services, and the transplant program.

c)         Hospital Residing Long Term Care Services

1)         Long term care services are not considered by the Department to be hospital services unless the hospital is enrolled with the Department specifically to provide hospital residing long term care services as a hospital-based long term care facility. Hospital residing long term care is care provided by hospitals to non-acute patients requiring chronic, skilled nursing care when a skilled nursing facility bed is not available, or non-acute care provided by hospitals that is not routinely performed within a skilled setting, such as ventilator care, when appropriate placements are not available to discharge the patient. Hospitals may not utilize the following beds or facilities for hospital services unless the hospital is enrolled with the Department to provide hospital residing long term care:

A)        A special unit or specified beds which are certified for skilled nursing facility services under the Medicare Program; or

B)        A special unit or separate facility administratively associated with the hospital and licensed as a long term care facility.

2)         There are three categories of service for hospital residing long term care.  These categories are as follows:

A)        Skilled Care – Hospital Residing (category of service 37)

Reimbursement is available for hospitals providing hospital residing long term care when the patients' needs reflect routine skilled care and the inability to place the patient is due to unavailability of a skilled nursing bed.  Reimbursement for this type of care is at the average statewide rate for skilled nursing care.  For a hospital to be eligible for such reimbursement, the following criteria must be met:

i)                    The hospital must document its attempt to place the patient in at least five appropriate facilities.

ii)                   Documentation (form DPA 3127) must be attached to the appropriate claim form and submitted to the Department.

iii)                 Reimbursement is limited to services provided after the minimum number of contacts have been made.  Reimbursement will not be made for services which were billed as acute inpatient care and denied as not being medically necessary.  Reimbursement will be made for up to a maximum of 31 days before additional documentation must be submitted to extend the eligibility for additional reimbursement.

B)        Exceptional Care – Hospital Residing (category of service 38)

Reimbursement is available for hospitals providing hospital residing long term care when the level of care is not routinely performed within a skilled setting, such as ventilator care, and the patient cannot be placed in a skilled nursing facility because the level of care is not available.  Exceptional care is defined by the Department as the level of care required by persons who are medically stable and ready for discharge from a hospital but who require a multi-disciplinary level of care for physician, nurse, and ancillary specialist services with exceptional costs related to extraordinary equipment and supplies that have been determined to be a medical necessity.  This includes, but is not limited to, persons with acquired immune deficiency syndrome (AIDS) or a related condition, head injured persons, and ventilator dependent persons. Reimbursement for this type of care is at the average statewide rate for exceptional care.  For a hospital to be eligible for such reimbursement, the following criteria must be met:

i)                    The hospial must document its attempt to place the patient in at least five appropriate facilities.

ii)                   Documentation (form DPA 3127) must be attached to the appropriate claim form and submitted to the Department.

iii)         Reimbursement is limited to services provided after the minimum number of contacts have been made. Reimbursement will not be made for services which were billed as acute inpatient care and denied as not being medically necessary.  Reimbursement will be made for up to a maximum of 31 days before additional documentation must be submitted to extend the eligibility for additional reimbursement.

C)        DD/MI Non-Acute Care – Hospital Residing (category of service 39)

Reimbursement is available for hospitals providing hospital residing long term care when the pre-admission screening agent has not completed the assessment, planning or discharge process.  Reimbursement for this type of care is at the average statewide DD/MI rate.  For a hospital to be eligible for such reimbursement, the following criteria must be met:

i)          The hospital must document that the pre-admission screening agent has not completed the assessment, planning or discharge process.

ii)         Reimbursement is limited to a maximum of three non-acute level of care days.  Reimbursement will not be made for services which were billed as acute inpatient care and denied as not being medically necessary.

d)         Subacute Alcoholism and Substance Abuse Treatment Services

1)         Subacute alcoholism and other substance abuse treatment is a covered service for clients under Title XIX (Medicaid) and for children 13 to or through 18 years of age in Family and Children Assistance cases in the City of Chicago.

2)         Only acute alcoholism and substance abuse treatment services (detoxification) are covered as hospital services.  Regulations regarding reimbursement for subacute alcoholism and substance abuse treatment services may be found under Sections 148.340 through 148.390.

e)         Transplant Program

The Medical Assistance Program provides for payment for organ transplants only when provided by a certified transplantation center as described in Section 148.82.  Payment for kidney and cornea transplants does not require enrollment as an approved transplantation center.  Payment for kidney and cornea transplants is made in accordance with the appropriate methodology described in Sections 148.160, 148.170, 148.250 through 148.300, or 89 Ill. Adm. Code 149.100 and 149.150.  Kidney acquisition costs shall be reimbursed in accordance with 89 Ill. Adm. Code 149.150(c)(5).  Payment for bone marrow, heart, liver, pancreas, kidney/pancreas and other types of transplant procedures may be covered and reimbursed in accordance with Section 148.82 provided the hospital is certified by the Department to perform the transplant.

(Source:  Amended at 18 Ill. Reg. 3450, effective February 28, 1994)