CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 148 HOSPITAL SERVICES
SECTION 148.420 OBSTETRICAL CARE ADJUSTMENT PAYMENTS
Section 148.420 Obstetrical Care Adjustment Payments
a) Qualifying Criteria. Obstetrical Care Adjustment Payments shall be made to a qualifying Illinois hospital that provided obstetrical care in the obstetrical base period. A hospital not otherwise excluded under subsection (b) of this Section shall qualify for payment for the rate year 2006 determination.
b) The following classes of hospitals are ineligible for Obstetrical Care 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).
c) Obstetrical Care Adjustment Payments
1) A hospital qualifying under subsection (a) of this Section shall receive payments equal to the product of $550 multiplied by the qualifying hospital's Medicaid obstetrical days provided during the obstetrical care base period.
2) A hospital qualifying under subsection (a) of this Section that qualified for disproportionate share payment adjustments as described in Section 148.120 as of October 1, 2004, with a Medicaid obstetrical percentage greater than ten percent and a Medicaid emergency care percentage greater than 40 percent, shall receive payments equal to the product of $650 multiplied by the qualifying hospital's Medicaid obstetrical days provided during the obstetrical care base period.
3) A hospital qualifying under subsection (a) of this Section located in the St. Louis metropolitan statistical area, with more than 500 Medicaid obstetrical days, shall receive payments equal to the product of $1,800 multiplied by the qualifying hospital's Medicaid obstetrical days provided during the obstetrical care base period.
4) A large urban hospital qualifying under subsection (a) of this Section that has a Medicaid obstetrical percentage greater than 25 percent and is in a county with an eligibility growth percentage rate greater than 60 percent between the years 1998 and 2003 shall receive payments equal to the product of $600 multiplied by the qualifying hospital's Medicaid obstetrical days provided within the obstetrical care base period.
5) A rural hospital as described in Section 148.25(g)(3) qualifying under subsection (a) designated as a Level II perinatal center as of January 1, 2005, with a MIUR greater than 34 percent in State fiscal year 2002 and a Medicaid obstetrical percentage greater than 15 percent, shall receive payment equal to the product of $400 multiplied by the hospital's Medicaid obstetrical days provided within the obstetrical care base period multiplied by 6.
6) 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 obstetrical care 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) "Emergency care percentage" means a fraction, the numerator of which is the total Category 3 ambulatory procedure listing services, excluding services for individuals eligible for Medicare, provided by the hospital in State fiscal year 2003 contained in the Department's data base adjudicated through June 30, 2004, and the denominator of which is the total ambulatory procedure listing services, excluding services for individuals eligible for Medicare, provided by the hospital in State fiscal year 2003 contained in the Department's data base adjudicated through June 30, 2004.
2) "Growth percentage" means, for a given hospital, the percentage of change in the growth of Medicaid clients within the county where the hospital is located from 1998 to 2003.
3) "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.
4) "Medicaid obstetrical 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, with a Diagnosis Related Grouping (DRG) of 370 through 375, excluding days for individuals eligible for Medicare under Title XVIII of the Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for admissions occurring in the obstetrical base period the Department adjudicated through June 30, 2004.
5) "Medicaid obstetrical percentage" means the percentage used in the October 1, 2004 Medicaid percentage adjustment determination as described in Section 148.122.
6) "Obstetrical care 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.
7) "Obstetrical care base period" means the 12-month period beginning on July 1, 2002 and ending on June 30, 2003.
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)