Section 148.296  Tertiary Care Adjustment Payments

 

Tertiary Care Adjustment Payments shall be made to all eligible hospitals, excluding county-owned hospitals, as described in Section 148.25(b)(1)(A), and hospitals organized under the University of Illinois Hospital Act, as described in Section 148.25(b)(1)(B), for inpatient admissions occurring on or after July 1, 2002, in accordance with this Section. 

 

a)         Definitions.  The definitions of terms used with reference to calculation of payments under this Section are as follows:

 

1)         "Base Period Claims" means claims for inpatient hospital services with dates of service occurring in the Tertiary Adjustment Base Period that were subsequently adjudicated by the Department through December 31, 1999.  For a general care hospital that includes a facility devoted exclusively to caring for children and that was separately licensed as a hospital by a municipality before September 30, 1998, Base Period Claims for services that may, in 89 Ill. Adm. Code 149.50(c)(3), be billed by a children's hospital shall be attributed exclusively to the children's facility. Base Period Claims shall exclude the following types:

 

A)        Claims for which Medicare was liable in part or in full ("cross-over" claims);

 

B)        Claims for transplantation services that were paid by the Department via form C-13, Invoice Voucher; and

 

C)        Claims for services billed for exceptional care services as described in Section 148.50(c)(2)(A) and (B).

 

2)         "Case Mix Index" (CMI), for a given hospital, means the sum of all Diagnosis Related Grouping (DRG) (see 89 Ill. Adm. Code 149) weighting factors for Base Period Claims divided by the total number of claims included in the sum, but excluding claims:

 

A)        Reimbursed under a per diem rate methodology; and

 

B)        For Delivery or Newborn Care.

 

3)         "Case Mix Adjustment Factor" (CMAF) means the following:

 

A)        For qualifying hospitals located in Illinois that, for Base Period Claims, had a CMI that is greater than the mean:

 

i)          CMI of all Illinois cost-reporting hospitals, but less than that mean plus a one standard deviation above the mean, the CMAF shall be equal to 0.040;

 

ii)         CMI plus one standard deviation above the mean of all Illinois cost reporting hospitals, but less than that mean plus two standard deviations above the mean, the CMAF shall be equal to 0.250;

 

iii)         CMI plus two standard deviations above the mean of all Illinois cost reporting hospitals, the CMAF shall be equal to 0.300.

 

B)        For qualifying hospitals located outside of Illinois that, for Base Period Claims, had a CMI that is greater than the mean:

 

i)          CMI of all out-of-state cost reporting hospitals, but less than that mean plus a one standard deviation above the mean, the CMAF shall be equal to 0.020;

 

ii)         CMI plus one standard deviation above the mean of all out-of-state cost reporting hospitals, but less than that mean plus two standard deviations above the mean, the CMAF shall be equal to 0.125;

 

iii)         CMI plus two standard deviations above the mean of all out-of-state cost reporting hospitals, the CMAF shall be equal to 0.150.

 

4)         "Delivery or Newborn Care" means inpatient hospital care, the claim for which was assigned by the Department to DRGs 370 through 375, 385 through 387, 389, 391 and 985 through 989.

 

5)         "Tertiary Adjustment Base Period" means calendar year 1998.

 

6)         "Tertiary Care Adjustment Rate Period" means, for fiscal year 2001, the three-month period beginning April 1, 2001, and for each subsequent fiscal year, the twelve-month period beginning July 1.

 

b)         Case Mix Adjustment

The Department shall make a Case Mix Adjustment to certain hospitals, as defined in this subsection (b).

 

1)         Qualifying Hospital.  A hospital meeting both of the following criteria shall qualify for this payment:

 

A)        A hospital that had 100 or more Qualified Admissions; and

 

B)        For a hospital located:

 

i)          in Illinois, has a CMI greater than or equal to the mean CMI for Illinois hospitals; or

 

ii)         outside of Illinois, has a CMI greater than or equal to the mean CMI for out-of-state cost-reporting hospitals.

 

2)         Qualified Admission.  For the purposes of this subsection (b), "Qualified Admission" shall mean a Base Period Claim excluding a claim:

 

A)        Reimbursed under a per diem rate methodology; and

 

B)        For Delivery or Newborn Care.

 

3)         Case Mix Adjustment.  Each Qualifying Hospital will receive a payment equal to the product of:

 

A)        The product of the hospital's:

 

i)          number of Qualified Admissions; and

 

ii)         CMAF; and

 

B)        The sum of the hospital's:

 

i)          rate for capital related costs in effect on July 1, 2000; and

 

ii)         the product of the hospital's CMI raised to the second power and the DRG PPS (Prospective Payment System) (see 89 Ill. Adm. Code 149) rate per discharge in effect on July 1, 2000.

 

c)         DRG Adjustment

The Department shall make a DRG Adjustment to certain hospitals, as defined in this subsection (c).

 

1)         Qualifying Hospital.  A hospital that, during the Tertiary Adjustment Base Period, had at least one Qualified Admission shall qualify for this payment.

 

2)         Qualified Admission.  For the purposes of this subsection (c), "Qualified Admission" means a Base Period Claim that was:

 

A)        Assigned by the Department to a DRG that:

 

i)          had been assigned a weighting factor greater than 3.2000; and

 

ii)         for which fewer than 200 Base Period Claims were adjudicated by the Department; and

 

B)        Not a claim:

 

i)          reimbursed under a per diem rate methodology;

 

ii)         for Delivery or Newborn Care; or

 

iii)         for a patient transferred to another facility as described at 89 Ill. Adm. Code 149.25(b)(2).

 

3)         DRG Adjustment Rates.  For each Qualified Admission, a Qualifying Hospital will receive a payment equal to the product of:

 

A)        The hospital's DRG PPS rate per discharge in effect on July 1, 2000; and

 

B)        The weighting factor assigned to the DRG to which the Qualified Admission was assigned by the Department; and

 

C)        The constant 1.400.

 

d)         Children's Hospital Adjustment

The Department shall make a Children's Hospital Adjustment to certain hospitals, as defined in this subsection (d).

 

1)         Qualifying Hospital.  A children's hospital, as defined at 89 Ill. Adm. Code 149.50(c)(3), shall qualify for this payment.

 

2)         Qualified Days.  For the purposes of this subsection (d), "Qualified Day" means a day of care that was provided in a Base Period Claim, excluding a claim:

 

A)        For Delivery or Newborn Care;

 

B)        Assigned by the Department to a DRG with an assigned weighting factor that is less than 1.0000; or

 

C)        For hospital inpatient psychiatric services as described at Section 148.40(a) or hospital inpatient physical rehabilitation services as described at Section 148.40(b).

 

3)         Children's Hospital Adjustment.  A Qualifying Hospital shall receive a payment equal to the product of:

 

A)        The sum of Qualified Days from the hospital's Base Period Claims; and

 

B)        For Illinois hospitals with:

 

i)          more than 5,000 Qualified Days, $670.00; or

 

ii)         5,000 or fewer Qualified Days, $300.00.

 

C)        For out of state hospitals with:

 

i)          more than 1,000 Qualified Days, $670.00; or

 

ii)         1,000 or fewer Qualified Days, $300.00.

 

e)         Primary Care Adjustment

The Department shall make a Primary Care Adjustment to certain hospitals, as defined in this subsection (e).

 

1)         Qualifying Hospital.  A hospital located in Illinois that has at least one Qualifying Resident shall qualify for this payment.

 

2)         Qualifying Residents.  For purposes of this subsection (e), "Qualifying Residents" means the number of primary care residents, as reported on form HCFA 2552-96, Worksheet E-3, Part IV, line 1, column 1, for hospital fiscal years ending September 30, 1997, through September 29, 1998), used in the fiscal year 2002 Tertiary Care Adjustment Rate Period.

 

3)         Qualified Admission.  For the purposes of this subsection (e), "Qualified Admission" shall mean a Base Period Claim excluding a claim:

 

A)        For hospital inpatient psychiatric services as described at Section 148.40(a) or hospital inpatient physical rehabilitation services as described at Section 148.40(b) and reimbursed under a per diem rate methodology; and

 

B)        For Delivery or Newborn Care.

 

4)         Primary Care Adjustment.  A Qualifying Hospital will receive a payment equal to the product of:

 

A)        The number of Qualifying Admissions during the Tertiary Adjustment Base Period;

 

B)        $4,675.00; and

 

C)        The quotient of:

 

i)          the number of Qualifying Residents,

 

ii)         divided by the number of Qualifying Admissions.

 

f)          Long Term Stay Hospital Adjustment

The Department shall make a Long Term Stay Hospital Adjustment to certain hospitals, as defined in this subsection (f).

 

1)         Qualifying Hospital.  A long term stay hospital, as defined at 89 Ill. Adm. Code 149.50(c)(4), that had a CMI that was greater than or equal to the mean CMI for all long term stay hospitals, shall qualify for this payment.

 

2)         Qualified Days.  For the purposes of this subsection (f), "Qualified Day" means a day of care that was provided in a Base Period Claim, excluding claims for hospital inpatient psychiatric services as described at Section 148.40(a) or hospital inpatient physical rehabilitation services as described at Section 148.40(b).

 

3)         Long Term Stay Hospital Adjustment Rates.  A Qualifying Hospital will receive  payments equal to the product of:

 

A)        The number of Qualified Days from all Base Period Claims; and

 

B)        A constant that:

 

i)          for a hospital that had a CMI that was greater than or equal to the mean CMI for all long term stay hospitals plus one standard deviation above the mean, $300.00; or

 

ii)         for a hospital that had a CMI that was greater than or equal to the mean CMI for all long term stay hospitals, but less than one standard deviation above that mean, $5.00.

 

g)         Rehabilitation Hospital Adjustment

The Department shall make a Rehabilitation Hospital Adjustment to certain hospitals as defined in this subsection (g).

 

1)         Qualifying Hospital.  A hospital that qualifies for the Rehabilitation Hospital Adjustment under the Critical Hospital Adjustment Payments (CHAP) program, as defined in Section 148.295(b), shall qualify for this payment.

 

2)         Qualified Admission.  For the purposes of this subsection (g), "Qualified Admission" shall mean a Medicaid level I rehabilitation admission in the CHAP rate period, as defined in Section 148.295, for fiscal year 2001.

 

3)         Rehabilitation Hospital Adjustment.  A Qualifying Hospital shall receive payment as follows:

 

A)        For a hospital that had fewer than 60 Qualified Admissions, $100,000.00.

 

B)        For a hospital that had 60 or more Qualified Admissions, $350,000.00.

 

h)         Tertiary Care Adjustment

 

1)         The total annual adjustment to an eligible hospital shall be the sum of the adjustments for which the hospital qualifies under subsections (a) through (g) of this Section multiplied by 0.455.

 

2)         A total annual adjustment amount shall be paid to the hospital during the Tertiary Care Adjustment Rate Period in installments on, at least, a quarterly basis.

 

 

(Source:  Amended at 26 Ill. Reg. 17775, effective November 27, 2002)