Section 148.297  Pediatric Outpatient Adjustment Payments

Pediatric Outpatient 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 outpatient services occurring on or after July 1, 1998, in accordance with this Section. 

a)         To qualify for payments under this Section, a hospital must:

1)         be a children's hospital, as defined in 89 Ill. Adm. Code 149.50(c)(3), and

2)         have a Pediatric Medicaid Outpatient Percentage greater than 80 percent during the Pediatric Outpatient Adjustment Base Period.

b)         Hospitals qualifying under this Section shall receive the following amounts for the Pediatric Outpatient Adjustment Rate Year for dates of services occurring on or after July 1, 1999:

1)         For out-of-state cost reporting hospitals with an MIUR that is less than 75 percent, the product of:

                                                            :

A)        the hospital's MIUR plus 1.15, multiplied by

B)        the number of Pediatric Adjustable Outpatient Services, multiplied by

C)        $169.00.

2)         For Illinois hospitals with an MIUR that is less than 75 percent, the product of:

A)        the hospital's MIUR plus one, multiplied by

B)        the number of Pediatric Adjustable Outpatient Services, multiplied by

C)        $169.00.

3)         For Illinois hospitals with an MIUR that is greater than or equal to 75 percent, the product of:

A)        one and one-half the hospital's MIUR plus one, multiplied by

B)        the number of Pediatric Adjustable Outpatient Services, multiplied by

C)        $169.00.

c)         In addition to the reimbursement rates described in subsection (b) of this Section, hospitals that have an MIUR that is greater than or equal to 80 percent shall receive an additional $229,740.00 during the Pediatric Outpatient Adjustment Rate Year.

d)         Adjustments under this Section shall be paid at least quarterly.                          

e)         Definitions

1)         "Medicaid Inpatient Utilization Rate (MIUR)", as used in this Section, has the same meaning as ascribed in Section 148.120(k)(5), in effect for the rate period October 1, 1996, through September 30, 1997.

2)         "Pediatric Adjustable Outpatient Services" means the number of outpatient services, excluding procedure code 0080, adjudicated through a UB92 billing form and grouped through the Hospital Ambulatory Care Groupings, as defined in Section 148.140(b)(1), during the Pediatric Outpatient Adjustment Base Period. For a hospital, which includes a facility devoted exclusively to caring for children, that is separately licensed as a hospital by a municipality, Pediatric Adjustment Outpatient Services will include psychiatric services (categories of service 27 or 28) for children less than 18 years of age, that are billed through the affiliated general care hospital.

3)         "Pediatric Medicaid Outpatient Percentage" means a percentage that results from the quotient of the total Pediatric Adjustable Outpatient Services for persons less than 18 years of age divided by the total Pediatric Adjustable Outpatient Services for all persons, during the Pediatric Outpatient Adjustment Base Period.

4)         "Pediatric Outpatient Adjustment Base Period" means all services billed to the Department, excluding procedure code  0080, with State Fiscal Year 1996 dates of service that were adjudicated by the Department on or before March 31, 1997.

5)         "Pediatric Outpatient Adjustment Rate Year" means State Fiscal Year 1998 and each State Fiscal Year thereafter.

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