CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 148 HOSPITAL SERVICES
SECTION 148.430 PERINATAL OUTPATIENT ADJUSTMENT PAYMENTS
Section 148.430 Perinatal Outpatient Adjustment Payments
a) Qualifying Criteria. Perinatal Outpatient Adjustment Payments shall be made to qualifying Illinois general acute care hospitals that were designated as a perinatal center as of January 1, 2005. A hospital not otherwise excluded under subsection (b) of this Section for the perinatal outpatient adjustment period determination shall qualify for payment if the hospital:
1) Is located in a large urban area;
2) Has a Medicaid obstetrical percentage of at least ten percent used for the October 1, 2004 Medicaid percentage adjustment determination as described in Section 148.122;
3) Has a Medicaid intensive care unit percentage of at least three percent; and
4) Has a ratio of ambulatory procedure listing for total Group 3 services, described in Section 148.140(b)(1)(C), to total ambulatory procedure services, as described in Section 148.140(b)(1), of at least 50 percent.
b) The following classes of hospitals are ineligible for Perinatal Outpatient 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) Perinatal Outpatient Adjustment Payments
1) A hospital qualifying under subsection (a) of this Section shall receive payment equal to the product of $550 multiplied by the hospital's ambulatory procedure listing for emergency Level I services described in Section 148.140(b)(1)(C)(i) provided in the perinatal outpatient base period.
2) For a hospital that, as of January 1, 2005, was designated a Level II+ or III perinatal center qualifying under subsection (a) of this Section, the payment calculated in subsection (c)(1) will be multiplied by four.
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 preformed under this subsection (c).
d) Payment to a Qualifying Hospital
1) For the perinatal outpatient 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) "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).
2) "Medicaid intensive care unit percentage" means a fraction, the numerator of which is the number of hospital inpatient days during which Medicaid recipients received intensive care services from the hospital, as determined from the hospital's fiscal year 2002 Medicaid cost report on file with the Department as of July 1, 2004, and the denominator of which is the sum of days of inpatient hospital service provided to recipients of medical assistance under Title XIX of the federal Social Security Act, excluding days for individuals eligible for Medicare under Title XVIII of the Act (Medicaid/Medicare crossover days), as contained in the hospital's cost report on file with the Department as of July 1, 2004, for the hospital's fiscal year ending in 2002.
3) "Outpatient ambulatory procedure listing emergency Level I services" means, for a given hospital, the sum of services for ambulatory procedure listing services as described in Section 148.140(b)(1)(C)(i), 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 perinatal outpatient base period that were adjudicated by the Department through June 30, 2004.
4) "Perinatal outpatient 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) "Perinatal outpatient 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)