Section 148.434  Outpatient Community Access Adjustment Payments

a)         Qualifying Criteria.  Outpatient Community Access Adjustment Payments, as described in subsection (b) of this Section, shall be made to an Illinois general acute care hospital as described in Section 148.270(c)(1) that was designated as a perinatal center as of January 1, 2005, that had a Medicaid obstetrical percentage used for the October 1, 2004 Medicaid percentage adjustment determination described in Section 148.122 of at least 12.5 percent, that had a ratio of crossover days to total Medicaid days greater than or equal to 25 percent, utilizing information used for the Medicaid Percentage Adjustment Payment described in Section 148.122, and that qualified for Medicaid Percentage Adjustment Payments as described in Section 148.122 on October 1, 2004, 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 Community Access Adjustment Payments

1)         Hospitals qualifying under subsection (a) of this Section shall receive an amount equal to $100 multiplied by the hospital's outpatient ambulatory procedure listing services in the outpatient community access base period.

2)         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 (b).

c)         Payment to a Qualifying Hospital

1)         For the outpatient community access adjustment period for fiscal year 2006, fiscal year 2007 and fiscal year 2008 total payments will equal the methodologies described in subsection (b) 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) being met shall be paid within 100 days after the conditions described in subsection (e) of this Section 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 services" means, for a given hospital, the sum of services 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 community access base period that were adjudicated by the Department through June 30, 2004.

2)         "Outpatient community access 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 community access 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)