CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 148 HOSPITAL SERVICES
SECTION 148.416 CROSSOVER PERCENTAGE ADJUSTMENT PAYMENTS
Section 148.416 Crossover Percentage Adjustment Payments
a) Qualifying Criteria. Crossover Percentage Adjustment Payments shall be made to qualifying hospitals as defined in this subsection (a). A hospital not otherwise excluded under subsection (b) of this Section shall qualify for payment if it is an Illinois general acute care hospital as described in Section 148.270(c)(1), excluding any hospital defined as a cancer center hospital, located in an urban area, that provided over 500 days of inpatient care to Medicaid recipients, that had a ratio of crossover days to total Medicaid days, utilizing information used for the Medicaid percentage adjustment determination described in Section 148.122, effective October 1, 2004, of greater than 40 percent and that did not qualify for Medicaid Percentage Adjustment Payments as described in Section 148.122 on October 1, 2004.
b) The following classes of hospitals are ineligible for Crossover Percentage Adjustment Payments associated with the qualifying criteria listed in subsection (a) of this Section:
1) County-owned hospitals as described in Section 148.25(b)(1)(A).
2) Hospitals organized under the University of Illinois Hospital Act, as described in Section 148.25(b)(1)(B).
3) A hospital owned or operated by a State agency, as described in Section 148.25(b)(6).
4) Cancer center hospitals.
c) Crossover Percentage Adjustment Payments
1) Each qualifying hospital's crossover days will be divided by its total Medicaid days to determine the crossover percentage ratio.
2) Each hospital qualifying under subsection (a) of this Section, located in an other urban area as described in subsection (e)(5) of this Section, shall receive payment equal to $140 multiplied by the hospital's total Medicaid days (including Medicaid/Medicare crossovers).
3) Each hospital qualifying under subsection (a) of this Section located in a large urban area as described in subsection (e)(4) of this Section, with a crossover percentage less than 55 percent, shall receive payment equal to $350 multiplied by the hospital's total Medicaid days (including Medicaid/Medicare crossovers).
4) Each hospital qualifying under subsection (a) located in a large urban area as described in subsection (e)(4) of this Section, with a crossover percentage ratio equal to or greater than 55 percent, shall receive payment equal to $1,400 multiplied by the hospital's total Medicaid days (including Medicaid/Medicare crossovers).
5) A hospital that enrolled to provide Medicaid services during State fiscal year 2003 shall have its utilization and associated reimbursements annualized prior to the payment calculations being performed under this subsection (c).
d) Payment to a Qualifying Hospital
1) For the crossover percentage adjustment period for fiscal year 2006, fiscal year 2007 and fiscal year 2008 total payments will equal the methodologies described in subsection (c) of this Section and shall be paid to the hospital in four equal installments on or before the seventh State business day of September, December, March and May. The sum of the amounts required prior to the conditions described in subsection (f) of this Section being met shall be paid within 100 days after the conditions described in subsection (f) have been met.
2) 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.
e) Definitions
1) "Cancer center hospital" means an Illinois hospital that has received the approval of the American College of Surgeons Commission on Cancer as of June 16, 2005 and provides more than 15 percent of the hospital Medicaid days in State fiscal year 2003 for treating patients with cancer. To be counted as cancer days, the Department will identify cancer days with any claim that contains an ICD-9-CM diagnosis code of 140.0 through 208.9 and 230.0 through 234.9 provided to recipients of medical assistance under Title XIX of the federal Social Security Act, as tabulated from the Department's paid claims data for admissions occurring in the State fiscal year 2003 base period that were adjudicated by the Department through June 30, 2004. To determine if 15 percent of the hospital Medicaid days were for treating cancer patients, the cancer days will be divided by the total Medicaid days provided to recipients of medical assistance under Title XIX of the federal Social Security Act, as tabulated from the Department's paid claims data for admissions occurring in the State fiscal year 2003 base period that were adjudicated by the Department through June 30, 2004.
2) "Crossover percentage adjustment period" means, beginning August 1, 2005, the 11-month period beginning on August 1, 2005 and ending June 30, 2006, and beginning July 1, 2006, the 12-month period beginning July 1 of the year and ending June 30 of the following year.
3) "Crossover percentage base period" means the information utilized in the Medicaid percentage adjustment determination as described in Section 148.122 for October 1, 2004.
4) "Large urban area" means an area located within a metropolitan statistical area, as defined by the U.S. Office of Management and Budget, 725 17th Street N.W., Washington D.C. 20503, in OMB Bulletin 04-03, dated February 18, 2004, with a population in excess of 1,000,000, and with an urban hospital as described in Section 148.25(g)(4).
5) "Other urban area" means an area located within a metropolitan statistical area, as defined by the U.S. Office of Management and Budget, 725 17th Street N.W., Washington D.C. 20503, in OMB Bulletin 04-03, dated February 18, 2004, with a city with a population greater than 50,000 or with a total population in excess of 100,000, and with an urban hospital as described in Section 148.25(g)(4).
6) "Total Medicaid days" means, for a given hospital, the sum of days of inpatient hospital service provided to recipients of medical assistance under Title XIX of the federal Social Security Act, including days for individuals eligible for Medicare under Title XVIII of the Act (Medicaid/Medicare crossover days), as tabulated from the Department's Medicaid percentage adjustment determination as described in Section 148.122 for October 1, 2004.
f) 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: Added at 30 Ill. Reg. 383, effective December 28, 2005)