Section 149.25  General Provisions

a)         Basis of Payment

1)         Payment on a Per Discharge Basis

A)        Under the DRG PPS, hospitals are paid a predetermined amount per discharge for inpatient hospital services furnished to persons receiving coverage under the Medicaid Program.

B)        The DRG prospective payment rate for each discharge (as defined in subsection (b) below) is determined according to the methodology described in Sections 149.100 and 149.150, as appropriate.  An additional payment is made, in accordance with Sections 149.105 and 149.125, as appropriate.  The rates paid shall be those in effect on the date of admission.

2)         Payment in Full

A)        The DRG prospective payment amount paid for inpatient hospital services is the total Medicaid payment for the inpatient operating costs (as described in subsection (a)(3) below) incurred in furnishing services covered under the Medicaid Program.

B)        Except as provided for in subsection (b) below, the full DRG prospective payment amount, as determined under Sections 149.100 and 149.150, as appropriate, is made for each stay during which there is at least one Medicaid eligible day of care.

3)         Inpatient Operating Costs.  The DRG PPS provides a payment amount for inpatient operating costs, including:

A)        Operating costs for routine services (as described in 42 CFR 413.53(b), revised as of September 1, 1990), such as the costs of room, board, and routine nursing services;

B)        Operating costs for ancillary services, such as radiology and laboratory services furnished to hospital inpatients;

C)        Special care unit operating costs (intensive care type unit services as described in 42 CFR 413.53(b), revised as of September 1, 1990);

D)        Malpractice insurance costs related to services furnished to inpatients; and

E)         Hospital-based physician costs as described in Section 149.75(h)(1)(A).

4)         Excluded Costs/Services.  The following inpatient hospital costs are excluded from the DRG prospective payment amounts:

A)        Transplantation cost, including acquisition cost incurred by approved transplantation centers as described in 89 Ill. Adm. Code 148.82. Kidney and cornea transplant costs shall be reimbursed under the appropriate methodology described in Sections 149.100 and 149.150 or in 89 Ill. Adm. Code 148.160, 148.170 or 148.250 through 148.300.

B)        Costs of psychiatric services incurred by a provider enrolled with the Department to provide those services (category of service 21).  Such services shall be reimbursed under 89 Ill. Adm. Code 148.270(b).

C)        Costs of nonemergency psychiatric services incurred by a provider that is not enrolled with the Department to provide those services (category of service 21).  Such services shall not be eligible for reimbursement.

D)        Costs of emergency psychiatric services exceeding the maximum of three days emergency treatment incurred by a provider that is not enrolled with the Department to provide those services (DRGs 424-432).  Such services exceeding the maximum of three days shall not be eligible for reimbursement.

E)         Costs of physical rehabilitation services incurred by a provider enrolled with the Department to provide those services (category of service 22).  Such services shall be reimbursed under 89 Ill. Adm. Code 148.270(b).

F)         Costs of rehabilitation for drug and alcohol abuse (DRG 436 and that part of DRG 437 apportioned to rehabilitation).  Such services shall be reimbursed under 89 Ill. Adm. Code 148.340 through 148.390.

5)         Additional Payments to Hospitals.  In addition to payments based on the DRG prospective payment rates, hospitals will receive payments for the following:

A)        Atypically long or extraordinary costly (outlier) cases, as described in Section 149.105.

B)        Certain costs excluded from the prospective payment rate under subsection (a)(4) above.

C)        The cost of serving a disproportionately high share of low income patients (as defined and determined in Section 149.125(a)(2)).

D)        Specific inpatient payment adjustments (as defined and determined in Section 149.125(a)(3)).

b)         Discharges and Transfers

1)         Discharges.  A hospital inpatient is considered discharged when any of the following occurs:

A)        The patient is formally released from the hospital except when the patient is transferred to another hospital or a distinct part unit as described in Section 149.50(d) (see subsection (b)(2) below).

B)        The patient dies in the hospital.

2)         Transfers.  A hospital inpatient is considered transferred when the patient is placed in the care of another hospital or a distinct part unit as described in Section 149.50(d).

3)         Payment in Full to the Discharging Hospital.  The hospital discharging an inpatient (subsection (b)(1)(A) above) is paid in full, in accordance with subsection (a)(2) above unless the discharging hospital or distinct part unit is excluded from the DRG PPS as described in Section 149.50(b), (c) and (d). In the event the discharging hospital or distinct part unit is excluded or exempted from the DRG PPS, that hospital or distinct part unit shall receive payment in full in accordance with 89 Ill. Adm. Code 148.160, 148.170 or 148.250 through 148.300.

4)         Payment to a Hospital Transferring an Inpatient to Another Hospital or District Part Unit

A)        A hospital reimbursed under the DRG PPS that transfers an inpatient, under the circumstances described in subsection (b)(2), is paid a per diem rate for each day of the patient's stay in that hospital but the total reimbursement shall not exceed the amount that would have been paid under Section 149.100 if the patient had been discharged.  The per diem rate is determined by dividing the appropriate prospective payment rate (as determined under Section 149.100) by the geometric length of stay for the specific DRG to which the case is classified.

B)        Except, if a discharge is classified into DRGs 385 or 985 (neonates, died or transferred to another acute care facility) or DRG 456 (burns, transferred to another acute care facility), and the hospital is reimbursed under the DRG PPS, the transferring hospital is paid in accordance with subsection (a)(2).

C)        A transferring hospital reimbursed under the DRG PPS may qualify for an additional payment for extraordinarily high cost cases that meet the criteria for cost outliers as described in Section 149.105.

D)        A hospital or distinct part unit excluded from the DRG PPS, as described in Section 149.50(b), (c) or (d), that transfers an inpatient under the circumstances described in subsection (b)(2) of this Section, is reimbursed in accordance with 89 Ill. Adm. Code 148.160, 148.170 or 148.250 through 148.300.

c)         Admission Prior to September 1, 1991.  With respect to admissions prior to September 1, 1991, hospitals will receive their per diem reimbursement rate that was in effect July 1, 1991, for each covered day of care provided through the discharge of the patient.

d)         DRG Classification System

1)         The Department will utilize the DRG Grouper, as described in Section 149.5(c)(1), modified to handle additional DRGs and revised ICD-9-CM codes, as defined by the Department, to place claims into DRG payment classifications.

2)         The Department will define additional DRGs that, for hospitals designated as Level III perinatal centers by the Illinois Department of Public Health, replace DRG 385 (neonates, died or transferred to another acute care facility), DRG 386 (extreme immaturity or respiratory distress syndrome, neonate), DRG 387 (prematurity with major problems) and DRG 389 (full term neonate with major problems).

(Source:  Amended at 19 Ill. Reg. 10674, effective July 1, 1995)