Section 148.424  Outpatient Utilization Payments

a)         Qualifying Criteria.  Outpatient Utilization Payments, as described in subsection (b) of this Section, shall be made to an Illinois hospital, excluding:

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).

b)         Outpatient Utilization Adjustment Payments

1)         A rural hospital, as described in Section 148.25(g)(3) and qualifying under subsection (a) of this Section shall receive an amount equal to 1.7 multiplied by the hospital's outpatient ambulatory procedure listing payments for services provided during the outpatient utilization adjustment base period.

2)         An urban hospital, as described in Section 148.25(g)(4) and qualifying under subsection (a) of this Section shall receive an amount equal to 0.45 multiplied by the hospital's outpatient ambulatory procedure listing payments for services provided during the outpatient utilization adjustment base period.

3)         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 (b).

c)         Payment to a Qualifying Hospital

1)         For the outpatient utilization adjustment period for fiscal year 2006, fiscal year 2007 and fiscal year 2008 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 the seventh State business day of September, December, March and May.  The sum of the amounts required prior to the conditions described in subsection (e) of this Section being met shall be paid within 100 days after the conditions described in subsection (e) 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.

d)         Definitions

1)         "Outpatient ambulatory procedure listing payments" means, for a given hospital, the sum of payments for ambulatory procedure listing services as described in Section 148.140(b)(1), excluding payments 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 outpatient access base period that were adjudicated by the Department through June 30, 2004.

2)         "Outpatient utilization 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)         "Outpatient utilization base period" means the 12-month period beginning on July 1, 2002 and ending June 30, 2003.

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:  Added at 30 Ill. Reg. 383, effective December 28, 2005)