Section 149.125  Special Treatment of Certain Facilities

a)         General Rules

1)         Sole Community Hospitals.  Hospitals defined as sole community hospitals shall, under subsection (b) below, shall have the choice of being reimbursed under the DRG PPS methodology, as described in Sections 149.5 through 149.150, or the Department's Alternate Reimbursement methodology as described in 89 Ill. Adm. Code 148.250 through 148.300, in accordance with the provisions of 89 Ill. Adm. Code 148.40(f) through (h).

2)         Hospitals that Serve a Disproportionate Share of Low Income Patients. The Department shall make additional payments to hospitals that serve a disproportionate share of low income patients.  The criteria and methodologies for such additional payments are set forth in 89 Ill. Adm. Code 148.120.

3)         Specific Inpatient Payment Adjustments.  The Department shall make specific additional payments to applicable hospitals as set forth in 89 Ill. Adm. Code 148.290.

b)         Criteria for Classification as a Sole Community Hospital.  "Medicaid Sole Community Provider" means a hospital that meets one of the following criteria:

1)         Medicare Program Designation

A)        For the rate period described in 89 Ill. Adm. Code 148.25(g)(2)(A), any hospital designated as a "sole community provider" by the U.S. Department of Health and Human Services for purposes of reimbursement under the federal Medicare Program effective September 1, 1992.

B)        For the rate period described in 89 Ill. Adm. Code 148.25(g)(2)(B), any hospital designated as a "sole community provider" by the U.S. Department of Health and Human Services for purposes of reimbursement under the federal Medicare program effective 90 days prior to the date of admission.

2)         Primary Service Area Designation

A)        Any rural hospital, as described in 89 Ill. Adm. Code 148.25(g)(3), that serves 55 percent or more of the Medicaid patients residing within the hospital's primary service area for the provision of inpatient hospital services.

B)        "Primary service area" means the geographic area defined by U.S. Postal Service Zip Codes in which 50 percent or more of a hospital's inpatients reside.

3)         The determination of sole community provider status under this subsection (b) shall be made prior to the rate period, as described in 89 Ill. Adm. Code 148.25(g)(2).

4)         The data used to make this determination will be from the Illinois Health Care Cost Containment Council (IHCCCC) for the most recent four quarters for which information is available.

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