Section 148.426  Outpatient Complexity of Care Adjustment Payments

a)         Qualifying Criteria.  Outpatient Complexity of Care Adjustment Payments, as described in subsection (b) of this Section, shall be made to Illinois hospitals located in an urban area as described in Section 148.25(g)(4), 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 Complexity of Care Adjustment Payments

1)         Each hospital qualifying under subsection (a) of this Section will receive a payment equal to the product of 2.55, multiplied by the hospital's emergency care percentage, multiplied by the hospital's ambulatory procedure listing payments.

2)         Each children's hospital qualifying under subsection (a) of this Section, with a Medicaid inpatient utilization rate greater than 90 percent used for the October 1, 2004 Medicaid percentage adjustment determination described in Section 148.122, shall have the adjustment, as calculated in subsection (b)(1), multiplied by 2.

3)         Each cancer center hospital qualifying under subsection (a) of this Section shall have the adjustment, as calculated in (b)(1), multiplied by 3.

4)         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 complexity of care 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)         "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)         "Emergency care percentage" means a fraction, the numerator of which is the total Group 3 ambulatory procedure listing services as described in Section 148.140(b)(1)(C), 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 as described in Section 148.140(b)(1), 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.

3)         "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 complexity of care base period that were adjudicated by the Department through June 30, 2004.

4)         "Outpatient complexity of 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.

5)         "Outpatient complexity of care 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)