TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 148 HOSPITAL SERVICES
SECTION 148.95 MEDICAID OUTPATIENT UTILIZATION RATE (MOUR) ADJUSTMENT PAYMENTS

 

Section 148.95  Medicaid Outpatient Utilization Rate (MOUR) Adjustment Payments

 

a)         Qualifying Criteria.  Medicaid Outpatient Utilization Rate (MOUR) Adjustment Payments, as described in subsection (b) of this Section, shall be made to an Illinois hospital, excluding hospitals described in 89 Ill. Adm. Code 140.80(j).

 

b)         MOUR Adjustment Payments

 

1)         Each qualifying hospital will receive a payment equal to the product of:

 

A)        The quotient of:

 

i)          the hospital's Medicaid outpatient charges in the MOUR base period

 

ii)         divided by the greater of the hospital's MOUR or 1.6 percent, and

 

B)        2.45 percent.

 

2)         For a hospital that files a combined Medicaid cost report with another hospital after January 1, 2001, and then subsequently closes, the payment described in subsection (b)(1) of this Section shall be multiplied by a fraction, the numerator of which is the number of occupied bed days attributable to the open hospital and the denominator of which is the sum of the occupied bed days of each open hospital and each closed hospital.

 

3)         Payments will be the lesser of the calculation described in subsection (b)(1) or (b)(2) of this Section or $6,750,000.

 

c)         Payment to a Qualifying Hospital

 

1)         For the MOUR adjustment period occurring in State fiscal year 2004, total payments will equal the methodologies described in subsection (b) of this Section multiplied by the proration factor and shall be paid to the hospital within 75 days after the conditions described in subsection (e) of this Section have been met.

 

2)         For the MOUR adjustment period occurring in State fiscal year 2005, total payments will equal the methodologies described in subsection (b) of this Section and shall be paid to the hospital in four equal installments on or before July 15, 2004, October 15, 2004, January 14, 2005 and April 15, 2005.  The sum of the amounts, required prior to the conditions described in subsection (e) being met, shall be paid within 75 days after the conditions in subsection (e) have been met.

 

3)         If a hospital closes during the fiscal year, payments will be prorated based on the number of days the hospital was open during the fiscal year.

 

d)         Definitions

 

1)         "Total outpatient charges" means, for a given hospital, the gross outpatient revenue as reported on form CMS 2552-96, Worksheet G-2, Part I, row 25, column 2, for hospital fiscal years ending in calendar year 2001 as filed in the March 2003 release of the Healthcare Cost Reporting Information System (HCRIS).  If information was not available for hospitals on the HCRIS, the Department may obtain the gross outpatient charges from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees.

 

2)         "MOUR base period" means the 12-month period beginning on July 1, 2000 and ending on June 30, 2001.

 

3)         "MOUR adjustment period" means, beginning June 1, 2004, the one month period beginning on June 1, 2004 and ending June 30, 2004, and beginning July 1, 2004, the 12 month period beginning July 1 of the year and ending June 30 of the following year.

 

4)         "MOUR", for a given hospital, means the ratio of Medicaid outpatient charges to total outpatient charges.

 

5)         "Medicaid outpatient charges" means, for a given hospital, the sum of charges for ambulatory procedure listing services as described in Section 148.140(b), excluding charges for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover charges), as tabulated from the Department's paid claims data for services occurring in the MOUR base year that were adjudicated by the Department through September 12, 2003.

 

6)         "Occupied bed days" means the sum of the number of days that each bed was occupied by a patient for all beds during calendar year 2001, as reported by each hospital on the Annual Survey of Hospitals conducted by the Department of Public Health.  If the sum of a hospital's occupied bed days is not reported on the Annual Survey of Hospitals, then the Department of Public Aid may obtain the sum of occupied bed days from any source available, including, but not limited to, records maintained by the hospital provider, which may be inspected at all times during business hours of the day by the Department or its duly authorized agents and employees.

 

7)         "Proration factor" means a fraction, the numerator of which is 53 and the denominator of which is 365.

 

e)         Payment Limitations:  Payments under this Section are not due and payable until:

 

1)         the methodologies described in this Section receive federal approval from the Centers for Medicare and Medicaid Services in an appropriate State Plan Amendment;

 

2)         the assessment imposed under 89 Ill. Adm. Code 140.80 is determined to be a permissible tax under Title XIX of the Social Security Act; and

 

3)         the assessment described in 89 Ill. Adm. Code 140.80 is in effect.

 

(Source:  Amended at 29 Ill. Reg. 8363, effective June 1, 2005)