AUTHORITY: Implementing and authorized by Articles III, IV, V and VI and Section 12-13 of the Illinois Public Aid Code [305 ILCS 5].
SOURCE: Sections 148.10 thru 148.390 recodified from 89 Ill. Adm. Code 140.94 thru 140.398 at 13 Ill. Reg. 9572; Section 148.120 recodified from 89 Ill. Adm. Code 140.110 at 13 Ill. Reg. 12118; amended at 14 Ill. Reg. 2553, effective February 9, 1990; emergency amendment at 14 Ill. Reg. 11392, effective July 1, 1990, for a maximum of 150 days; amended at 14 Ill. Reg. 15358, effective September 13, 1990; amended at 14 Ill. Reg. 16998, effective October 4, 1990; amended at 14 Ill. Reg. 18293, effective October 30, 1990; amended at 14 Ill. Reg. 18499, effective November 8, 1990; emergency amendment at 15 Ill. Reg. 10502, effective July 1, 1991, for a maximum of 150 days; emergency expired October 29, 1991; emergency amendment at 15 Ill. Reg. 12005, effective August 9, 1991, for a maximum of 150 days; emergency expired January 6, 1992; emergency amendment at 15 Ill. Reg. 16166, effective November 1, 1991, for a maximum of 150 days; amended at 15 Ill. Reg. 18684, effective December 23, 1991; amended at 16 Ill. Reg. 6255, effective March 27, 1992; emergency amendment at 16 Ill. Reg. 11335, effective June 30, 1992, for a maximum of 150 days; emergency expired November 27, 1992; emergency amendment at 16 Ill. Reg. 11942, effective July 10, 1992, for a maximum of 150 days; emergency amendment at 16 Ill. Reg. 14778, effective October 1, 1992, for a maximum of 150 days; amended at 16 Ill. Reg. 19873, effective December 7, 1992; amended at 17 Ill. Reg. 131, effective December 21, 1992; amended at 17 Ill. Reg. 3296, effective March 1, 1993; amended at 17 Ill. Reg. 6649, effective April 21, 1993; amended at 17 Ill. Reg. 14643, effective August 30, 1993; emergency amendment at 17 Ill. Reg. 17323, effective October 1, 1993, for a maximum of 150 days; amended at 18 Ill. Reg. 3450, effective February 28, 1994; emergency amendment at 18 Ill. Reg. 12853, effective August 2, 1994, for a maximum of 150 days; amended at 18 Ill. Reg. 14117, effective September 1, 1994; amended at 18 Ill. Reg. 17648, effective November 29, 1994; amended at 19 Ill. Reg. 1067, effective January 20, 1995; emergency amendment at 19 Ill. Reg. 3510, effective March 1, 1995, for a maximum of 150 days; emergency expired July 29, 1995; emergency amendment at 19 Ill. Reg. 6709, effective May 12, 1995, for a maximum of 150 days; amended at 19 Ill. Reg. 10060, effective June 29, 1995; emergency amendment at 19 Ill. Reg. 10752, effective July 1, 1995, for a maximum of 150 days; amended at 19 Ill. Reg. 13009, effective September 5, 1995; amended at 19 Ill. Reg. 16630, effective November 28, 1995; amended at 20 Ill. Reg. 872, effective December 29, 1995; amended at 20 Ill. Reg. 7912, effective May 31, 1996; emergency amendment at 20 Ill. Reg. 9281, effective July 1, 1996, for a maximum of 150 days; emergency amendment at 20 Ill. Reg. 12510, effective September 1, 1996, for a maximum of 150 days; amended at 20 Ill. Reg. 15722, effective November 27, 1996; amended at 21 Ill. Reg. 607, effective January 2, 1997; amended at 21 Ill. Reg. 8386, effective June 23, 1997; emergency amendment at 21 Ill. Reg. 9552, effective July 1, 1997, for a maximum of 150 days; emergency amendment at 21 Ill. Reg. 9822, effective July 2, 1997, for a maximum of 150 days; emergency amendment at 21 Ill. Reg. 10147, effective August 1, 1997, for a maximum of 150 days; amended at 21 Ill. Reg. 13349, effective September 23, 1997; emergency amendment at 21 Ill. Reg. 13675, effective September 27, 1997, for a maximum of 150 days; amended at 21 Ill. Reg. 16161, effective November 26, 1997; amended at 22 Ill. Reg. 1408, effective December 29, 1997; amended at 22 Ill. Reg. 3083, effective January 26, 1998; amended at 22 Ill. Reg. 11514, effective June 22, 1998; emergency amendment at 22 Ill. Reg. 13070, effective July 1, 1998, for a maximum of 150 days; emergency amendment at 22 Ill. Reg. 15027, effective August 1, 1998, for a maximum of 150 days; amended at 22 Ill. Reg. 16273, effective August 28, 1998; amended at 22 Ill. Reg. 21490, effective November 25, 1998; amended at 23 Ill. Reg. 5784, effective April 30, 1999; amended at 23 Ill. Reg. 7115, effective June 1, 1999; amended at 23 Ill. Reg. 7908, effective June 30, 1999; emergency amendment at 23 Ill. Reg. 8213, effective July 1, 1999, for a maximum of 150 days; emergency amendment at 23 Ill. Reg. 12772, effective October 1, 1999, for a maximum of 150 days; amended at 23 Ill. Reg. 13621, effective November 1, 1999; amended at 24 Ill. Reg. 2400, effective February 1, 2000; amended at 24 Ill. Reg. 3845, effective February 25, 2000; emergency amendment at 24 Ill. Reg. 10386, effective July 1, 2000, for a maximum of 150 days; amended at 24 Ill. Reg. 11846, effective August 1, 2000; amended at 24 Ill. Reg. 16067, effective October 16, 2000; amended at 24 Ill. Reg. 17146, effective November 1, 2000; amended at 24 Ill. Reg. 18293, effective December 1, 2000; amended at 25 Ill. Reg. 5359, effective April 1, 2001; emergency amendment at 25 Ill. Reg. 5432, effective April 1, 2001, for a maximum of 150 days; amended at 25 Ill. Reg. 6959, effective June 1, 2001; emergency amendment at 25 Ill. Reg. 9974, effective July 23, 2001, for a maximum of 150 days; amended at 25 Ill. Reg. 10513, effective August 2, 2001; emergency amendment at 25 Ill. Reg. 12870, effective October 1, 2001, for a maximum of 150 days; emergency expired February 27, 2002; amended at 25 Ill. Reg. 16087, effective December 1, 2001; emergency amendment at 26 Ill. Reg. 536, effective December 31, 2001, for a maximum of 150 days; emergency amendment at 26 Ill. Reg. 680, effective January 1, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 4825, effective March 15, 2002; emergency amendment at 26 Ill. Reg. 4953, effective March 18, 2002, for a maximum of 150 days; emergency amendment repealed at 26 Ill. Reg. 7786, effective July 1, 2002; emergency amendment at 26 Ill. Reg. 7340, effective April 30, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 8395, effective May 28, 2002; emergency amendment at 26 Ill. Reg. 11040, effective July 1, 2002, for a maximum of 150 days; emergency amendment repealed at 26 Ill. Reg. 16612, effective October 22, 2002; amended at 26 Ill. Reg. 12322, effective July 26, 2002; amended at 26 Ill. Reg. 13661, effective September 3, 2002; amended at 26 Ill. Reg. 14808, effective September 26, 2002; emergency amendment at 26 Ill. Reg. 14887, effective October 1, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 17775, effective November 27, 2002; emergency amendment at 27 Ill. Reg. 580, effective January 1, 2003, for a maximum of 150 days; emergency amendment at 27 Ill. Reg. 866, effective January 1, 2003, for a maximum of 150 days; amended at 27 Ill. Reg. 4386, effective February 24, 2003; emergency amendment at 27 Ill. Reg. 8320, effective April 28, 2003, for a maximum of 150 days; emergency amendment repealed at 27 Ill. Reg. 12121, effective July 10, 2003; amended at 27 Ill. Reg. 9178, effective May 28, 2003; emergency amendment at 27 Ill. Reg. 11041, effective July 1, 2003, for a maximum of 150 days; emergency amendment at 27 Ill. Reg. 16185, effective October 1, 2003, for a maximum of 150 days; emergency amendment at 27 Ill. Reg. 16268, effective October 1, 2003, for a maximum of 150 days; amended at 27 Ill. Reg. 18843, effective November 26, 2003; emergency amendment at 28 Ill. Reg. 1418, effective January 8, 2004, for a maximum of 150 days; emergency amendment at 28 Ill. Reg. 1766, effective January 10, 2004, for a maximum of 150 days; emergency expired June 7, 2004; amended at 28 Ill. Reg. 2770, effective February 1, 2004; emergency amendment at 28 Ill. Reg. 5902, effective April 1, 2004, for a maximum of 150 days; amended at 28 Ill. Reg. 7101, effective May 3, 2004; amended at 28 Ill. Reg. 8072, effective June 1, 2004; emergency amendment at 28 Ill. Reg. 8167, effective June 1, 2004, for a maximum of 150 days; amended at 28 Ill. Reg. 9661, effective July 1, 2004; emergency amendment at 28 Ill. Reg. 10157, effective July 1, 2004, for a maximum of 150 days; emergency amendment at 28 Ill. Reg. 12036, effective August 3, 2004, for a maximum of 150 days; emergency expired December 30, 2004; emergency amendment at 28 Ill. Reg. 12227, effective August 6, 2004, for a maximum of 150 days; emergency expired January 2, 2005; amended at 28 Ill. Reg. 14557, effective October 27, 2004; amended at 28 Ill. Reg. 15536, effective November 24, 2004; amended at 29 Ill. Reg. 861, effective January 1, 2005; emergency amendment at 29 Ill. Reg. 2026, effective January 21, 2005, for a maximum of 150 days; amended at 29 Ill. Reg. 5514, effective April 1, 2005; emergency amendment at 29 Ill. Reg. 5756, effective April 8, 2005, for a maximum of 150 days; emergency amendment repealed by emergency rulemaking at 29 Ill. Reg. 11622, effective July 5, 2005, for the remainder of the 150 days; amended at 29 Ill. Reg. 8363, effective June 1, 2005; emergency amendment at 29 Ill. Reg. 10275, effective July 1, 2005, for a maximum of 150 days; emergency amendment at 29 Ill. Reg. 12568, effective August 1, 2005, for a maximum of 150 days; emergency amendment at 29 Ill. Reg. 15629, effective October 1, 2005, for a maximum of 150 days; amended at 29 Ill. Reg. 19973, effective November 23, 2005; amended at 30 Ill. Reg. 383, effective December 28, 2005; emergency amendment at 30 Ill. Reg. 596, effective January 1, 2006, for a maximum of 150 days; emergency amendment at 30 Ill. Reg. 955, effective January 9, 2006, for a maximum of 150 days; amended at 30 Ill. Reg. 2827, effective February 24, 2006; emergency amendment at 30 Ill. Reg. 7786, effective April 10, 2006, for a maximum of 150 days; emergency amendment repealed by emergency rulemaking at 30 Ill. Reg. 12400, effective July 1, 2006, for the remainder of the 150 days; emergency expired September 6, 2006; amended at 30 Ill. Reg. 8877, effective May 1, 2006; amended at 30 Ill. Reg. 10393, effective May 26, 2006; emergency amendment at 30 Ill. Reg. 11815, effective July 1, 2006, for a maximum of 150 days; amended at 30 Ill. Reg. 18672, effective November 27, 2006; emergency amendment at 31 Ill. Reg. 1602, effective January 1, 2007, for a maximum of 150 days; emergency amendment at 31 Ill. Reg. 1997, effective January 15, 2007, for a maximum of 150 days; amended at 31 Ill. Reg. 5596, effective April 1, 2007; amended at 31 Ill. Reg. 8123, effective May 30, 2007; amended at 31 Ill. Reg. 8508, effective June 1, 2007; emergency amendment at 31 Ill. Reg. 10137, effective July 1, 2007, for a maximum of 150 days; amended at 31 Ill. Reg. 11688, effective August 1, 2007; amended at 31 Ill. Reg. 14792, effective October 22, 2007; amended at 32 Ill. Reg. 312, effective January 1, 2008; emergency amendment at 32 Ill. Reg. 518, effective January 1, 2008, for a maximum of 150 days; emergency amendment at 32 Ill. Reg. 2993, effective February 16, 2008, for a maximum of 150 days; amended at 32 Ill. Reg. 8718, effective May 29, 2008; amended at 32 Ill. Reg. 9945, effective June 26, 2008; emergency amendment at 32 Ill. Reg. 10517, effective July 1, 2008, for a maximum of 150 days; emergency expired November 27, 2008; amended at 33 Ill. Reg. 501, effective December 30, 2008; peremptory amendment at 33 Ill. Reg. 1538, effective December 30, 2008; emergency amendment at 33 Ill. Reg. 5821, effective April 1, 2009, for a maximum of 150 days; emergency expired August 28, 2009; amended at 33 Ill. Reg. 13246, effective September 8, 2009; emergency amendment at 34 Ill. Reg. 15856, effective October 1, 2010, for a maximum of 150 days; emergency expired February 27, 2011; amended at 34 Ill. Reg. 17737, effective November 8, 2010; amended at 35 Ill. Reg. 420, effective December 27, 2010; expedited correction at 38 Ill. Reg. 12618, effective December 27, 2010; amended at 35 Ill. Reg. 10033, effective June 15, 2011; amended at 35 Ill. Reg. 16572, effective October 1, 2011; emergency amendment at 36 Ill. Reg. 10326, effective July 1, 2012 through June 30, 2013; emergency amendment to Section 148.70(g) suspended at 36 Ill. Reg. 13737, effective August 15, 2012; suspension withdrawn from Section 148.70(g) at 36 Ill. Reg. 18989, December 11, 2012; emergency amendment in response to Joint Committee on Administrative Rules action on Section 148.70(g) at 36 Ill. Reg. 18976, effective December 12, 2012 through June 30, 2013; emergency amendment to Section 148.140(b)(1)(F) suspended at 36 Ill. Reg. 13739, effective August 15, 2012; suspension withdrawn from Section 148.140(b)(1)(F) at 36 Ill. Reg. 14530, September 11, 2012; emergency amendment to Sections 148.140(b) and 148.190(a)(2) in response to Joint Committee on Administrative Rules action at 36 Ill. Reg. 14851, effective September 21, 2012 through June 30, 2013; amended at 37 Ill. Reg. 402, effective December 27, 2012; emergency rulemaking at 37 Ill. Reg. 5082, effective April 1, 2013 through June 30, 2013; amended at 37 Ill. Reg. 10432, effective June 27, 2013; amended at 37 Ill. Reg. 17631, effective October 23, 2013; amended at 38 Ill. Reg. 4363, effective January 29, 2014; amended at 38 Ill. Reg. 11557, effective May 13, 2014; amended at 38 Ill. Reg. 13263, effective June 11, 2014; amended at 38 Ill. Reg. 15165, effective July 2, 2014; emergency amendment at 39 Ill. Reg. 10453, effective July 10, 2015, for a maximum of 150 days; emergency expired December 6, 2015; amended at 39 Ill. Reg. 10824, effective July 27, 2015; amended at 39 Ill. Reg. 16394, effective December 14, 2015; amended at 41 Ill. Reg. 1041, effective January 19, 2017; amended at 42 Ill. Reg. 3152, effective January 31, 2018; emergency amendment at 42 Ill. Reg. 13740, effective July 2, 2018, for a maximum of 150 days; emergency amendment to emergency rule at 42 Ill. Reg. 16318, effective August 13, 2018, for the remainder of the 150 days; emergency expired November 28, 2018; amended at 42 Ill. Reg. 22401, effective November 29, 2018; emergency amendment at 43 Ill. Reg. 9813, effective August 26, 2019, for a maximum of 150 days; amended at 44 Ill. Reg. 2545, effective January 22, 2020; amended at 44 Ill. Reg. 18579, effective November 9, 2020; emergency amendment at 44 Ill. Reg. 12832, effective July 17, 2020, for a maximum of 150 days; amended at 44 Ill. Reg. 19767, effective December 11, 2020; amended at 46 Ill. Reg. 5254, effective March 11, 2022; amended at 47 Ill. Reg. 5648, effective April 5, 2023; amended at 47 Ill. Reg. 13121, effective August 25, 2023; amended at 47 Ill. Reg. 16418, effective November 3, 2023; expedited correction at 48 Ill. Reg. 10028, effective November 3, 2023; amended at 48 Ill. Reg. 10834, effective July 12, 2024; amended at 48 Ill. Reg. 15451, effective October 17, 2024; amended at 49 Ill. Reg. 2024, effective February 10, 2025.
SUBPART A: GENERAL PROVISIONS
Section 148.10 Hospital Services
Sections 148.10 through 148.70 contain participation requirements and coverage limitations for hospital services.
(Source: Recodified from 89 Ill. Adm. Code 140.94 at 13 Ill. Reg. 9572)
Section 148.20 Participation
Effective for dates of service on or after July 1, 2014:
a) Payment for hospital inpatient, outpatient and clinic services shall be made only when provided by a hospital, as described in Section 148.25(b), or a distinct part unit, as described in Section 148.25(c), for covered services, as described in Section 148.50.
b) Payment for freestanding emergency center services shall only be made when provided by a freestanding emergency center as defined in Section 148.25(e).
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.25 Definitions and Applicability
Effective for dates of service on or after July 1, 2014:
a) The term "large public hospital" means a hospital:
1) Owned by and located in an Illinois county with a population exceeding three million; or
2) Organized under the University of Illinois Hospital Act; or
3) Maintained by the Illinois Department of Human Services.
b) The term "hospital" means:
1) For the purpose of hospital inpatient reimbursement, any institution, place, building, or agency, public or private, whether organized for profit or not‑for-profit, that:
A) Is subject to licensure by the Illinois Department of Public Health (DPH) under the Hospital Licensing Act.
B) Is organized under the University of Illinois Hospital Act.
C) Is maintained by the State, or any department or agency of the State, when the department or agency has authority under the law to establish and enforce standards for the hospitalization or care facilities under its management and control.
D) Meets all comparable conditions and requirements of the Hospital Licensing Act in effect for the state in which it is located.
2) For the purpose of hospital outpatient reimbursement, the term "hospital" shall, in addition to the definition described in subsection (b)(1), include:
A) An ambulatory surgical treatment facility, as described in 89 Ill. Adm. Code 146.105(a).
B) A free-standing emergency center, as described in subsection (e) of this Section.
3) For the purpose of non hospital-based clinic reimbursement, the term "hospital" shall mean a county-operated outpatient facility owned by and located in an Illinois county with a population exceeding three million.
4) For the purpose of hospital-based clinic reimbursement, the term "hospital" shall mean a hospital-based clinic meeting the provisions of Section 148.40(d) and 89 Ill. Adm. Code 140.461(a).
5) For the purpose of participation, reimbursement and accreditation, the term "Health and Human Services Approved Accreditation Organization (HHS-AAO)" shall mean an accrediting organization recognized by the Secretary of the Department of Health and Human Services as having standards for accreditation that meet or exceed Medicare requirements for the provider and service in question.
c) For the purpose of hospital inpatient reimbursement, the term "distinct part unit" means a unit within a hospital, as defined in subsection (b)(1), that meets the following qualifications:
1) Distinct Part Psychiatric Units. A distinct part psychiatric unit is a functional unit that is enrolled with the Department to provide inpatient psychiatric services (category of service 021).
2) Distinct Part Rehabilitation Units. A distinct part rehabilitation unit is a functional unit that is enrolled with the Department to provide inpatient rehabilitation services (category of service 022).
d) Specialty Hospitals
1) Psychiatric Hospitals. To qualify as a psychiatric hospital, a facility must be:
A) Licensed by the state within which it is located as a psychiatric hospital and be primarily engaged in providing, by or under the supervision of a psychiatrist, psychiatric services for the diagnosis and treatment of mentally ill persons.
B) Enrolled with the Department as a psychiatric hospital to provide inpatient psychiatric services (category of service 021).
2) Rehabilitation Hospitals. To qualify as a rehabilitation hospital, a facility must be:
A) Licensed by the state within which it is located as a physical rehabilitation hospital.
B) Enrolled with the Department as a rehabilitation hospital to provide inpatient physical rehabilitation services (category of service 022).
3) Children's Hospitals. To qualify as a children's hospital, a facility must be devoted exclusively to caring for children and either be:
A) A hospital licensed by the state within which it is located as a pediatric, psychiatric or children's hospital.
B) A unit within a general hospital that was enrolled with the Department as a children's hospital on July 1, 2013.
C) Effective July 1, 2018, a unit within a general hospital that:
i) Is designated a Perinatal Level III center by the Illinois Department of Public Health as of December 1, 2017;
ii) Is designated a Pediatric Critical Care Center by the State as of December 1, 2017; and
iii) Has a 2017 Medicaid inpatient utilization rate equal to or greater than 45% as of July 1, 2018.
D) Effective July 1, 2018, a unit within a general hospital that:
i) Is designated a Perinatal Level II center by the Illinois Department of Public Health as of December 1, 2017;
ii) Has a 2017 Medicaid Inpatient Utilization Rate greater than 70%; and
iii) Has at least 10 pediatric beds listed on the Illinois Department of Public Health 2015 calendar year hospital profile as of July 1, 2018.
E) For hospitals identified in subsections (d)(3)(B), (d)(3)(C), and (d)(3)(D), units so enrolled shall be reimbursed for all inpatient and outpatient services provided to Medical Assistance recipients who are under 18 years of age, with the exception of obstetric services, normal newborn nursery services, psychiatric services, and physical rehabilitation services, without regard to the physical location within the hospital where the care is rendered.
4) Long Term Acute Care Hospitals. To qualify as a long term acute care hospital, a facility must be licensed by the state within which it is located as an acute care hospital and certified by Medicare as a long term care hospital.
e) The term "freestanding emergency center" means a facility that provides comprehensive emergency treatment services 24-hours per day, on an outpatient basis, and has been issued a license by the Illinois Department of Public Health under the Freestanding Emergency Center Code (77 Ill. Adm. Code 518), as a freestanding emergency center, or a facility outside of Illinois that meets conditions and requirements comparable to those found in the Emergency Medical Services (EMS) Systems Act [210 ILCS 50] in effect for the jurisdiction in which it is located.
f) The term "coordinated care participating hospital" means a hospital, located in a county of the State in which the Department mandates some or all of the beneficiaries of the Medical Assistance Program residing in the area to enroll in a care coordination program as defined in Section 5-30 of the Illinois Public Aid Code (Code) that:
1) Has entered into a contract to provide hospital services to enrollees of the care coordination program.
2) Has not been offered a contract by a care coordination plan that pays not less than the Department would have paid on a fee-for-service basis, but excluding disproportionate share hospital adjustment payments or any other supplemental payment that the Department pays directly.
g) The term "critical access hospital" means a hospital, located in Illinois, that has been designated as a critical care hospital by DPH in accordance with 42 CFR 485, Subpart F.
h) Academic Medical Centers and Major Teaching Hospital Status. Hospitals dedicated to medical research and medical education shall be classified each State fiscal year in 3 tiers based on specific criteria:
1) Tier I. A private academic medical center must:
A) be a hospital located in Illinois that is:
i) under common ownership with the college of medicine of a non-public college or university; or
ii) a freestanding hospital in which the majority of the clinical chiefs of service or clinical department chairs are department chairs in an affiliated non-public Illinois medical school; or
iii) a children's hospital that is separately incorporated and non-integrated into the academic medical center hospital but is the pediatric partner for an academic medical center hospital and that serves as the primary teaching hospital for pediatrics for its affiliated Illinois medical school. A hospital identified in this subsection (h)(i)(A)(iii) is deemed to meet the additional Tier I criteria if its partner academic medical center hospital meets the Tier I criteria;
B) serve as the training site for at least 30 graduate medical education programs accredited by the Accreditation Council for Graduate Medical Education;
C) facilitate the training on the campus or on affiliated off-campus sites of no less than 500 medical students, interns, residents and fellows during the calendar year preceding the beginning of the State fiscal year;
D) perform, either itself or through its affiliated university, at least $12,000,000 in medical research funded through grants or contracts from the National Institutes of Health or, with respect to hospitals described in subsection (h)(1)(A)(ii), have as its affiliated non-public Illinois medical school a medical school that performs, either itself or through its affiliated university, medical research funded using at least $12,000,000 in grants or contracts from the National Institutes of Health; and
E) expend, directly or indirectly, through an affiliated non-public medical school or as part of a hospital system, defined as a hospital and one or more other hospitals or hospital affiliates related by common control or ownership, no less than $5,000,000 toward medical research and education during the calendar year preceding the beginning of the State fiscal year.
2) Tier II. A public academic medical center must:
A) be a hospital located in Illinois that is a primary teaching hospital affiliated with:
i) University of Illinois School of Medicine at Chicago;
ii) University of Illinois School of Medicine at Peoria;
iii) University of Illinois School of Medicine at Rockford;
iv) University of Illinois School of Medicine at Urbana; or
v) Southern Illinois University School of Medicine in Springfield; and
B) contribute no less than $2,500,000 toward medical research and education during the calendar year preceding the beginning of the State fiscal year.
3) Tier III. A major teaching hospital must:
A) be an Illinois hospital with 100 or more interns and residents or with a ratio of interns and residents to beds greater than or equal to 0.25; and
B) support at least one graduate medical education program accredited by the Accreditation Council for Graduate Medical Education.
i) Children's Specialty Hospital. To qualify as a children's specialty hospital, a facility must be:
1) an Illinois hospital as defined in subsection (d)(3)(A) and have fewer than 50 total inpatient beds; or
2) a cost reporting hospital, as defined in subsection (d)(3)(A), located outside of Illinois and have fewer than 50 total beds and an average length of stay greater than 20 days in State fiscal year 2013, as contained in the Department's claims data warehouse.
(Source: Amended at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.30 General Requirements
Effective for dates of service on or after July 1, 2014:
a) For the purpose of hospital inpatient, hospital outpatient and hospital-based clinic reimbursement, the following requirements must be met by a hospital to qualify for enrollment in the Illinois Medical Assistance Program:
b) The hospital must be certified for participation in the Medicare Program (Title XVIII) unless the provisions of subsection (c) apply.
c) If not eligible for or subject to Medicare certification, the hospital must be accredited by The Joint Commission (TJC) or another Health and Human Services Approved Accreditation Organization.
d) The hospital must agree to accept the Department's basis for reimbursement.
(Source: Amended at 39 Ill. Reg. 10824, effective July 27, 2015)
Section 148.40 Special Requirements
Effective for dates of discharge on or after July 1, 2014:
a) Inpatient Psychiatric Services
1) Payment for inpatient hospital psychiatric services shall be made only to:
A) A hospital that is a general hospital, as defined in Section 148.25(b), with a functional unit, as defined in Section 148.25(c)(1), that specializes in, and is enrolled with the Department to provide, psychiatric services; or
B) A hospital, as defined in Section 148.25(b), that holds a valid license as, and is enrolled with the Department as, a psychiatric hospital, as defined in Section 148.25(d)(1).
2) Inpatient psychiatric services are those services provided to patients who are in need of short-term acute inpatient hospitalization for active treatment of an emotional or mental disorder.
3) Federal Medicaid regulations preclude payment for patients over 20 or under 65 years of age in any Institution for Mental Diseases (IMD). Therefore, psychiatric hospitals may not receive reimbursement for services provided to patients over the age of 20 and under the age of 65. In the case of a patient receiving psychiatric services immediately preceding his or her 21st birthday, psychiatric services shall be reimbursable by the Department until the earliest of the following:
A) The date the patient no longer requires the services.
B) The date the patient reaches 22 years of age.
4) A psychiatric hospital must be accredited by TJC or another Health and Human Services Approved Accreditation Organization to provide services to program participants under 21 years of age or be Medicare certified to provide services to program participants 65 years of age and older. Distinct part psychiatric units and psychiatric hospitals located in Illinois, or within 100 miles of Illinois, must execute an agreement with an Illinois Department of Human Services (DHS) operated mental health center (State-operated facility) for coordination of services including, but not limited to, crisis screening and discharge planning to ensure linkage to aftercare services with private practitioners or community mental health services, as described in subsection (a)(5).
5) Coordination of Care − Purpose. The Coordination of Care Agreement shall set forth an agreement between the State-operated facility and the hospital for the coordination of services, including but not limited to crisis screening and discharge planning to ensure efficient use of inpatient care. The agreement shall also set forth the manner in which linkage to aftercare services with community mental health agencies or private practitioners shall be carried out.
6) Coordination of Care – General Provisions. The general provisions of the Coordination of Care Agreement described in subsection (a)(5) are as follows:
A) The hospital shall agree, on a continuing basis, to comply with applicable licensing standards as contained in State laws or regulations and shall maintain accreditation by TJC or another Health and Human Services Approved Accreditation Organization.
B) The provider shall comply with Title VI of the Civil Rights Act of 1964 and the Rehabilitation Act of 1973 and regulations promulgated under those Acts prohibit discrimination on the grounds of sex, race, color, national origin or handicap.
C) The provider shall comply with the following applicable federal, State and local statutes pertaining to equal employment opportunity, affirmative action, and other related requirements: 42 USCA 2000e, 29 USCA 203 et seq. and 775 ILCS 25.
D) The Coordination of Care Agreement shall remain in effect until amended by mutual consent or cancelled in writing by either party having given 30 days prior notification.
7) Coordination of Care – Special Requirements. The hospital shall:
A) Provide on its premises, the facilities, staff, and programs for the diagnosis, admission, and treatment of persons who may require inpatient care or assessment of mental status, mental illness, emotional disability, and other psychiatric problems.
B) Notify the community mental health agency that serves the geographic area from which the recipient originated to allow the agency to prescreen the case prior to referring the individual to the designated State-operated facility. The community mental health agency's resources and other appropriate community alternatives shall be considered prior to making a referral to the State-operated facility for admission.
C) Complete any forms necessary and consistent with the Mental Health and Developmental Disabilities Code in the event of a referral for involuntary or judicial admission.
D) Notify the community mental health agency or private practitioner of the date and time of discharge and invite their participation in the discharge planning process.
E) Refer to the State-operated facility only those individuals for whom less restrictive alternatives are documented not to be appropriate at the time based on a clinical determination by the community mental health agency, a private practitioner (if applicable), or the hospital.
F) Notify the State-operated facility prior to planned transfer of an individual and transfer the individual at such time as to assure arrival of the person prior to 11 a.m. Monday through Friday. In unusual situations, transfers may be made at other times after prior discussion between the hospital and the State-operated facility. The individual will only be transported to the State-operated facility when, based on a clinical determination, he or she is medically stable as determined by the transferring physician. A copy of the transfer summary from the hospital must accompany the recipient at the time of admission to the State-operated facility.
8) Coordination of Care – Special Requirements of the State-Operated Facility. The State-operated facility shall:
A) Admit individuals who have been screened as defined in the Coordination of Care Agreement and are appropriate for admission consistent with the provisions of the Mental Health and Developmental Disabilities Code.
B) Evaluate individuals for whom the hospital has executed a Petition and Certificate for involuntary/judicial admission consistent with the Mental Health and Developmental Disabilities Code.
C) Consider for admission voluntary individuals for whom less restrictive alternatives are documented not to be appropriate at the time, based on a clinical determination by the community mental health agency, private practitioner (if applicable), the hospital, or the State-operated facility.
9) Coordination of Care – Special Requirements for the Children's Mental Health Screening, Assessment and Support Services (SASS) Program. For individuals under 21 years of age, all inpatient admissions must be authorized through the SASS Program. The hospital shall:
A) Prior to admission, contact the Crisis and Referral Entry Service (CARES), the Department's Statewide centralized intake and referral point for a mental health screening and assessment of the patient, pursuant to 59 Ill. Adm. Code 131.40;
B) For admissions authorized through a SASS screening, involve the SASS provider in the patient's treatment plan during the inpatient stay and in the development of a discharge plan in order to facilitate linkage to appropriate aftercare resources.
10) A participating hospital not enrolled for inpatient psychiatric services may provide psychiatric care as a general inpatient service only on an emergency basis for a maximum period of 72 hours or in cases in which the psychiatric services are secondary to the services for which the period of hospitalization is approved.
b) Inpatient Rehabilitation Services
1) Payment for inpatient rehabilitation services shall be made only to a general hospital, as defined in Section 148.25(b), with a functional unit of the hospital, as defined in Section 148.25(c)(2), which specializes in, and is enrolled with the Department to provide, physical rehabilitation services or a hospital, as defined in Section 148.25(d)(2), which holds a valid license as, and is enrolled with the Department as, a physical rehabilitation hospital.
2) The primary reason for hospitalization is to provide a structured program of comprehensive rehabilitation services, furnished by specialists, to the patient with a major handicap for the purpose of habilitating or restoring the person to a realistic maximum level of functioning.
3) For payment to be made, a rehabilitation facility, which includes a distinct part unit as described in Section 148.25(c)(2), must be certified for participation under the Medicare Program and must be licensed and/or certified by DPH to provide comprehensive physical rehabilitation services. Out-of-state hospitals that specialize in physical rehabilitation services must be licensed or certified to provide comprehensive physical rehabilitation services by the authorized licensing agency in the state in which the hospital is located.
4) A rehabilitation facility must meet the following criteria:
A) Have a full-time (at least 35 hours per week) director of rehabilitation; a participating general hospital with a functional rehabilitation unit must have a part-time (at least 20 hours per week) director of rehabilitation.
B) Have an organized medical staff.
C) Have available consultants qualified to perform services in appropriate specialties.
D) Have adequate space and equipment to provide comprehensive diagnostic and treatment services.
E) Maintain records of diagnosis, treatment progress (notations must be made at regular intervals) and functional results.
F) Submit reports as required by the Department.
5) A rehabilitation facility must provide, or have a contractual arrangement with an appropriate entity or agency to provide, the following minimal services:
A) Full-time nursing services under the supervision of a registered nurse formally trained in rehabilitation nursing.
B) Full-time physical therapy and occupational therapy services.
C) Social casework services as an integral part of the rehabilitation program.
6) A rehabilitation facility must have available the following minimal services:
A) Psychological evaluation services.
B) Prosthetic and orthotic services.
C) Vocational counseling.
D) Speech therapy.
E) Clinical laboratory and x-ray services.
F) Pharmacy services.
7) The director of rehabilitation must meet the following criteria:
A) Provide services to the hospital and its patients as specified in subsection (b)(4).
B) Be a doctor of medicine or osteopathy.
C) Be licensed under State law to practice medicine or surgery.
D) Must have, after completing a one-year hospital internship, at least two years of training or experience in the medical management of inpatients requiring rehabilitation services.
8) Personnel of the rehabilitation facility must meet the following minimum standards:
A) Physicians shall have unlimited licenses to practice medicine and surgery in the state in which they practice. Consultants shall be Board Qualified or Board Certified in their specialty.
B) Physical therapists shall be licensed by the Illinois Department of Financial and Professional Regulation or comparable licensing agency in the state in which the facility is located.
C) Occupational therapists shall be licensed by the Illinois Department of Financial and Professional Regulation or comparable licensing agency in the state in which the facility is located.
D) Registered nurses and licensed practical nurses shall be currently licensed by the Illinois Department of Financial and Professional Regulation or comparable licensing agency in the state in which the facility is located.
E) Social workers shall have completed two years of graduate training leading to a Master's Degree in social work from an accredited graduate school of social work.
F) Psychologists shall have a Master's Degree in clinical psychology.
G) Vocational counselors shall have a Master's Degree in Rehabilitation Counseling, Psychology or Guidance from a school accredited by the North Central Association or its equivalent.
H) An orthotist or prosthetist, certified by the American Board of Certification in Orthotics and Prosthetics, shall fabricate or supervise the fabrication of all limbs and braces.
c) End-Stage Renal Disease Treatment (ESRDT) Services. The Department provides payment to hospitals, as defined in Section 148.25(b), for ESRDT services only when the hospital is Medicare certified for ESRDT and services are provided as follows:
1) Inpatient hospital care is provided for the evaluation and treatment of acute renal disease.
2) Outpatient chronic renal dialysis treatments are provided in the outpatient renal dialysis department of the hospital, a satellite unit of the hospital that is professionally associated with the center for medical direction and supervision, or a free-standing chronic dialysis center certified by Medicare, pursuant to 42 CFR 405, Subpart U (2013).
3) Home dialysis treatments are provided through the outpatient renal dialysis department of the hospital, a satellite unit of the hospital that is professionally associated with the center for medical direction and supervision, in a patient's home, or through a free-standing chronic dialysis center certified by Medicare, pursuant to 42 CFR 405, Subpart U (2013).
d) Hospital-Based Organized Clinic Services. Hospital-based clinics, as described in Section 148.25(b)(4), must meet the requirements of 89 Ill. Adm. Code 140.461(a). The following two categories of hospital-based organized clinic services are recognized in the Medical Assistance Program:
1) Psychiatric Clinic Services
A) Psychiatric Clinic Services (Type A). Type A psychiatric clinic services are clinic service packages consisting of diagnostic evaluation; individual, group and family therapy; medical control; optional Electroconvulsive Therapy (ECT); and counseling, provided in the hospital clinic setting.
B) Psychiatric Clinic Services (Type B). Type B psychiatric clinic services are active treatment programs in which the individual patient is participating in no less than social, recreational, and task‑oriented activities at least four hours per day at a minimum of three half days of active treatment per week. The duration of an individual patient's participation in this treatment program is limited to six months in any 12 month period.
C) Approval. The Department and DHS are responsible for approval and enrollment of community hospitals providing psychiatric clinic services. In order to participate as a provider of psychiatric clinic services, a hospital must have previously been enrolled with the Department for the provision of inpatient psychiatric services on or after June 1, 2002 or must be currently enrolled for the provision of inpatient psychiatric services and execute a Psychiatric Clinic Services Type A and B Enrollment Assurance with DHS and the Department, which assures that the hospital is enrolled for the provision of inpatient psychiatric services and meets the following requisites:
i) The hospital must be accredited by, and be in good standing with, TJC or another Health and Human Services Approved Accreditation Organization.
ii) The hospital must have executed a Coordination of Care Agreement between the hospital and the designated DHS State-operated facility serving the mentally ill in the appropriate geographic area.
iii) The clinical staff of the psychiatric clinic must collaborate with the mental health service network to provide discharge, linkage and aftercare planning for recipients of outpatient services.
iv) The hospital must be enrolled to participate in Medicaid Program (Title XIX) and must meet all conditions and requirements set forth by the Department.
D) Duration of Approval. The approval described in subsection (d)(1)(D) of this Section shall be in effect for a period of two years from the date HFS approves the psychiatric clinic's enrollment. The approval may be terminated by HFS or DHS with cause upon 30 days written notice to the hospital. Accordingly, the hospital must submit a 30 day written notification to HFS and DHS when terminating delivery of psychiatric clinic services.
2) Physical Rehabilitation Clinic Services
Physical rehabilitation clinic services include the same rehabilitative services provided to inpatients by hospitals enrolled to provide the services described in Section 148.40(b). Clinic services should be utilized when the patient's condition is such that it does not necessitate inpatient care and adequate care and treatment can be obtained on an outpatient basis through the hospital's specialized clinic.
e) Zero Balance Bills. The Department requires a hospital to submit a bill for any inpatient service provided to an individual enrolled in any of the Medical Assistance Programs administered by the Department, including newborns, regardless of payer. A "zero balance bill" is one on which the total "prior payments" are equal to or exceed the Department's liability on the claim. The Department requires that zero balance bills be submitted subsequent to discharge in the same manner as are other bills so that information may be available for the maintenance of accurate patient profiles and diagnosis-related grouping (DRG) data, and information needed for calculation of disproportionate share and other rates. The provisions of this subsection apply to all hospitals regardless of the reimbursement methodology under which they are reimbursed.
(Source: Amended at 39 Ill. Reg. 10824, effective July 27, 2015)
Section 148.50 Covered Hospital Services
Effective for dates of outpatient services on or after July 1, 2014 and inpatient discharges on or after July 1, 2014, unless a later effective date is specified in this Section:
a) The Department shall pay hospitals for the essential provision of inpatient, outpatient, and clinic diagnostic and treatment services not otherwise excluded or limited that are provided by a hospital, as described in Section 148.25(b), or a distinct part unit, as described in Section 148.25(c), and that are provided in compliance with hospital licensing standards. Payment may be made for the following types of care subject to the special requirements described in Section 148.40:
1) General/specialty services.
2) Psychiatric services.
3) Rehabilitation services.
4) End-Stage Renal Disease Treatment (ESRDT) services.
b) Certain services are defined as hospital covered services with certain restrictions. These programs include hospital residing long term care services, subacute alcoholism and substance abuse treatment services, and the transplant program.
c) Hospital Long Term Care Services
1) Effective for dates of service on or after July 1, 2019, Hospital Long Term Care Days shall be covered. Hospital Long Term Care Days are defined as days when:
A) The discharging hospital or the assigned peer review agent determines that continued hospital level of care is no longer necessary; and
B) Discharge of the patient is delayed due to the lack of available placement outside of the hospital at the next level of care provided in a nursing facility, ICF/DD facility, MC/DD facility, rehabilitation hospital, psychiatric hospital, Long-Term Services and Supports Waiver setting, or a residence when home health care services (as defined in Section 140.471) are required.
2) For dates of service on or after July 1, 2019, Hospital Long Term Care Days shall be reimbursed in accordance with this subsection (c). Hospitals are required to notify the Department when post-discharge placement is required. Approval from the Department that the stay meets the requirements of this subsection (c)(2) is required before payment can be made. In order to approve payment for Hospital Long Term Care Days, documentation demonstrating the following shall be provided:
A) The hospital attempted to place the individual in at least five appropriate settings;
B) Following the five placement attempts, the hospital notified the Department or its designated contractor of its inability to place the individual;
C) The individual requires the level of care described in subsection (c)(1)(B).
3) Reimbursement is limited to services provided after the minimum number of contacts have been made and the Department or its contractor has been notified of the need for post-discharge placement. For dates of service on or after July 1, 2019 and prior to November 1, 2020, the Department will not limit reimbursement to days after the Department or its contractor have been notified of the need for post-placement discharge and approved payment; however, the hospital still must provide documentation that the requirements of subsections (c)(2)(A) and (C) are met.
4) Reimbursement Limitations
A) Reimbursement will not be made for services when the underlying inpatient stay was denied as not medically necessary.
B) When the initial hospital stay is reimbursed under the DRG system, only days that exceed the DRG average length of stay can qualify as Hospital Long Term Care Days.
C) When a hospital is reimbursed on a per diem basis, only days beyond the period of time when hospital level of care is needed can qualify as Hospital Long Term Care Days.
D) Services reimbursable under 305 ILCS 5/5-5.07 shall not be reimbursed as Hospital Long Term Care Days.
E) Services reimbursable under the Long Term Acute Care Hospital Quality Improvement Transfer Program Act [210 ILCS 155] and certified as part of a continued stay review by the Department's Quality Improvement Organization shall not be reimbursed as Hospital Long Term Care Days.
5) The reimbursement rate for each eligible Hospital Long Term Care Day is $289.48 per day.
6) Payments for Hospital Long Term Care Days are not eligible for per diem add-on payments under the Medicaid High Volume Adjustment (MHVA) and Medicaid Percentage Adjustment (MPA) programs.
7) If a hospital seeks reimbursement for services provided to any individual enrolled in a Managed Care Organization (MCO), the requirements of Section 14-13(e) of the Public Aid Code [305 ILCS 5] must be followed.
8) Effective January 1, 2024, the rate for each eligible Hospital Long Term Care Day is $318.43.
d) Subacute Alcoholism and Substance Abuse Treatment Services
Rules regarding reimbursement for sub-acute alcoholism and substance abuse treatment services may be found under Sections 148.340 through 148.390.
e) Transplant Program
The Medical Assistance Program provides for payment for organ transplants only when provided by a certified transplantation center as described in Section 148.82. Payment for kidney and cornea transplants does not require enrollment as an approved transplantation center.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.60 Services Not Covered as Hospital Services
Effective for dates of service on or after July 1, 2014, certain services, although included in the Medical Assistance Program and under certain circumstances provided in the hospital setting or by an entity associated with the hospital, are not reimbursed by the Department as hospital services. In addition, certain services currently provided in the hospital outpatient and hospital‑based clinic setting are subject to fee-for-service payment methodologies. This means that for these services, hospitals shall be required to conform to the policies and billing procedures in effect for other non-hospital providers of services. Payment for these services shall be based on the same fee schedule that applies to these services when they are provided in the non-hospital setting. Services not covered or reimbursed as hospital services are as follows:
a) Private Duty Nursing Services. Private duty nursing services for hospitalized program participants are not covered under the Medical Assistance Program. Hospitals are expected to provide all required nursing services.
b) Sitter Services. Sitter services for hospitalized program participants are not covered under the Medical Assistance Program.
c) Dental Services. Hospitals may not enroll to provide dental services. When dental services are provided in the outpatient/clinic setting of a hospital, the dentist shall submit charges to the Department according to the provisions of the Dental Program.
d) Nurse Anesthetist Services. Payment for general anesthesia services not reimbursed under 89 Ill. Adm. Code 140.400 shall be made only to hospitals that qualify for these payments under the Medicare Program and shall be made to such hospitals when provided by a hospital employed non-physician anesthetist (certified registered nurse anesthetist or "CRNA").
e) Pharmacy Services. Policy and reimbursement for pharmacy services are described in 89 Ill. Adm. Code 140.440 through 140.450. A hospital pharmacy may enroll on a fee-for-service basis for services provided to a patient in:
1) A specified bed or special hospital unit which is certified for skilled nursing facility services under the Medicare Program.
2) A special hospital unit or separate facility which is administratively associated with the hospital and is licensed as a long term care facility.
3) The outpatient/clinic setting when the services provided are not unique to the hospital setting.
f) Medical Transportation Services. A hospital that owns and operates medical transportation vehicles as a separate entity (for example, a private corporation) must enroll as a medical transportation provider. A hospital that owns and operates medical transportation vehicles that are included on the hospital's cost report as a cost center of the hospital may not submit a separate claim for transportation services provided to persons admitted as inpatients. Policy and reimbursements for medical transportation services is described in 89 Ill. Adm. Code 140.490 through 140.492.
g) Home Health Services. A home health agency that is administratively associated with a hospital and that is certified for participation as a home health agency by the Medicare Program may apply for participation for the provision of home health services. Policy and reimbursement for home health services is described in 89 Ill. Adm. Code 140.470 through 140.474.
h) Sub-acute Alcoholism and Substance Abuse Treatment Services. Only acute alcoholism and substance abuse treatment services (i.e., detoxification) are covered as hospital services. Rules regarding reimbursement for sub-acute alcoholism and substance abuse treatment services may be found under Sections 148.340 through 148.390.
i) Hospice Services. Hospice is an alternative to traditional Medicaid coverage. The Hospice Program is responsible for all the client's medical needs related to a terminal illness. If a client chooses the Hospice Program, a physician must certify that the client is terminally ill and has a life expectancy of six months or less. Policy and reimbursement for hospice services is described in 89 Ill. Adm. Code 140.469.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.70 Limitation On Hospital Services
Effective for dates of discharge on or after July 1, 2014:
a) Payment for inpatient hospital care in general and specialty hospitals, including psychiatric hospitals, shall be made only when it is recommended by a qualified physician, and the care is essential as determined by the appropriate utilization review authority. For hospitals or distinct part units reimbursed on a per diem basis under Sections 148.105 through 148.115 and 148.160 through 148.170, payment shall not exceed the number of days approved for the recipient's care by the appropriate utilization review authority (see Section 148.240). If Medicare benefits are not paid because of non-approval by the utilization review authority, payment shall not be made on behalf of the Department.
b) For hospitals reimbursed on a per case basis, payment for inpatient hospital services shall be made in accordance with 89 Ill. Adm. Code 149.
c) For hospitals, or distinct part units reimbursed on a per diem basis, under Sections 148.105 through 148.115 and 148.160 through 148.170, payment for inpatient hospital services shall be made based on calendar days. The day of admission shall be counted. The day of discharge shall not be counted. An admission with discharge on the same day shall be counted as one day. If a recipient is admitted, discharged and re-admitted on the same day, only one day shall be counted.
d) Payment for inpatient psychiatric hospital care in a psychiatric hospital, as defined in Section 148.25(d)(1), shall be made only when such services have been provided in accordance with federal regulations at 42 CFR 441, subparts C and D.
e) Payment for transplantation costs (with the exception of kidney and cornea transplants), including organ acquisition costs, shall be made only when provided by an approved transplantation center as described in Section 148.82. Payment for kidney and cornea transplantation costs does not require enrollment as an approved transplantation center.
f) The Department shall reduce the payment for a claim that indicates the occurrence of a provider preventable condition during the admission as specified in this subsection (f).
1) The Department shall reduce each claim by the amount that the payment on the claim is increased directly due to the occurrence of and treatment for a healthcare acquired condition (HAC).
2) The Department shall not pay for services related to Other Provider Preventable Conditions (OPPCs).
3) For HACs, hospitals shall code inpatient claims with a Present on Admission (POA) indicator for principal and secondary diagnosis codes billed. For OPPCs, hospitals shall submit claims to report these incidents and will be instructed to populate the inpatient claims with specific supplementary diagnosis coding.
4) Definitions. As used in this subsection (f), the following terms are defined as follows:
"Provider Preventable Condition" means a health care acquired condition as defined under the federal Medicaid regulation found at 42 CFR 447.26 (2012) or an Other Provider Preventable Condition.
"Other Provider Preventable Condition" means a wrong surgical or other invasive procedure performed on a patient, a surgical or other invasive procedure performed on the wrong body part, or a surgical procedure or other invasive procedure performed on the wrong patient.
h) Payment for caesarean sections shall be at the normal vaginal delivery rate unless a caesarean section is medically necessary.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
SUBPART B: REIMBURSEMENT AND RELATED PROVISIONS
Section 148.80 Organ Transplants Services Covered Under Medicaid (Repealed)
(Source: Repealed at 17 Ill. Reg. 14643, effective August 30, 1993)
Section 148.82 Organ Transplant Services
Effective for dates of outpatient services on or after July 1, 2014 and inpatient discharges on or after July 1, 2014:
a) Introduction
The Department will cover organ transplants as identified under subsection (b) that are provided to United States citizens or aliens who are lawfully admitted for permanent residence in the United States under color of law pursuant to 42 USC 1396a(a) and 1396b(v). These services must be provided by certified organ transplant centers that meet the requirements specified in subsections (c) through (g) of this Section.
b) Covered Services
1) Inpatient heart, heart/lung, lung (single or double), liver, pancreas or kidney/pancreas transplantation. Inpatient bone marrow transplants, inpatient and outpatient stem cell transplants.
2) Inpatient intestinal (small bowel or liver/small bowel) transplantation for children only (see subsection (d)(1)(H) of this Section).
3) Other types of transplant procedures may be covered when a hospital has been certified by the Department as a transplant center eligible to perform such transplants. Centers must complete the certification process established in subsection (c) and provide the necessary documentation of the number of transplant procedures performed and the survival rates.
4) Medically necessary work-up.
c) Certification Process
1) In order to be certified to receive reimbursement for transplants performed on Medical Assistance patients, the hospital must:
A) Request an application from the Bureau of Comprehensive Health Services.
B) Submit a completed application to the Department for the type of transplant for which the center is seeking certification.
C) Meet certification criteria established in subsection (d).D) Submit a detailed status report on each patient for the type of transplant for which the hospital is seeking certification. The reports must include the patient's diagnosis, date of transplant, the length of hospitalization, charges, survival rates, patient-specific transplant outcome, and complications (including cause of death, if applicable) for all transplants performed in the time frames required for the type of transplant indicated in subsections (d)(1)(C), (D), (E), (F), (G), (H), (I) or (J). To protect the privacy of patients included in this report, names of patients who are not covered under Medical Assistance are not required.
2) The Department shall notify the hospital of approval or denial of the hospital as a transplant center for Medical Assistance eligible patients.
3) In the event the Department receives a request for prior approval to provide a service from a hospital not formally certified under this Section, the Department may approve the request if it determines that circumstances are such that the health, safety and welfare of the recipient would best be served by receiving the service at that hospital. In making its determination, the Department shall take into account the ability and qualifications of the hospital and its medical staff to provide the service, the burden on the recipient's family if a certified hospital is a great distance from their home, and the urgent nature of the transplant.
4) A joint application combining the statistical data for the adult and pediatric programs from two affiliated hospitals that share the same surgeons may be submitted for review. The hospitals must meet the criteria under subsections (d)(1)(A), (B), (K), (L), (M), (N), (O), (P) and (Q), the applicable criteria under subsections (d)(1)(C), (D) or (J) and (d)(1)(R), subsections (d)(2), (3) and (4), and subsection (e) for certification and recertification.
d) Certification Criteria
1) Hospitals seeking certification as a transplant center shall submit documentation to verify that:
A) The hospital is capable of providing all necessary medical care required by the transplant patient.
B) The hospital is affiliated with an academic health center.
C) The hospital has had the transplant program for inpatient adult heart and liver transplants in operation for at least three years with 12 transplant procedures per year for the past two years and 12 cases in the three-year period preceding the most current two-year period for adult heart and liver transplants.
D) The hospital has had the transplant program for inpatient adult heart/lung and lung transplants in operation for at least three years with ten transplant procedures per year for the past two years and 10 cases in the three-year period preceding the most current two‑year period for adult heart/lung and lung transplants.
E) A hospital specializing in inpatient pediatric heart/lung and lung transplants has had a program in operation for at least three years and has performed a minimum of six transplant procedures per year for the past two years, and six procedures in the three-year period preceding the most current two-year period.
F) The hospital has had the transplant program for inpatient adult and pediatric bone marrow transplants in operation for at least two years with 12 transplant procedures per year for the past two years.
G) The hospital performing outpatient adult and pediatric stem cell transplants must be part of a certified inpatient program and must have been in operation for at least two years with at least 12 outpatient stem cell transplant procedures per year in the past two years.
H) A hospital specializing in inpatient pediatric heart or liver transplants, or both, has had a program in operation for at least three years and has performed a minimum of six transplant procedures per year for the past two years, and six procedures in the three-year period preceding the most current two-year period.
I) A hospital specializing in inpatient pediatric intestinal (small bowel or liver/small bowel) transplants has had a program in operation for at least three years and has performed a minimum of six transplant procedures per year for the past two years, and six procedures in the three-year period preceding the most current two-year period.
J) A hospital specializing in inpatient kidney/pancreas and/or pancreas transplants has had the transplant program in operation for at least three years with 25 kidney transplant procedures per year for the past two years and 25 cases in the three-year period preceding the most current two-year period, and five pancreas transplant procedures per year for the past two years and five in the three year period preceding the most current two-year period, or 12 kidney/pancreas transplant procedures per year for the past two years and 12 in the three-year period preceding the most current two-year period.
K) The hospital has experts, on staff, in the fields of cardiology, pulmonology, anesthesiology, immunology, infectious disease, nursing, social services, organ procurement, associated surgery and internal medicine to complement the transplant team. In addition, in order to qualify as a transplant center for pediatric patients, the hospital must also have experts in the field of pediatrics.
L) The hospital has an active cardiovascular medical and surgical program as evidenced by the number of cardiac catheterizations, coronary arteriograms and open heart procedures per year for heart and heart/lung transplant candidates.
M) The hospital has pathology resources that are available for studying and reporting the pathological responses for transplantation as supported by appropriate documentation.
N) The hospital complies with applicable State and federal laws and regulations.
O) The hospital participates in a recognized national donor procurement program for organs or bone marrow provided by unrelated donors, abides by its rules, and provides the Department with the name of the national organization of which it is a member.
P) The hospital has an interdisciplinary body to determine the suitability of candidates for transplantation as supported by appropriate documentation.
Q) The hospital has blood bank support necessary to meet the demands of a certified transplant center as supported by appropriate documentation.
R) The hospital meets the applicable transplant survival rates as supported by the Kaplan-Meier method or other method accepted by the Department:
i) A one-year survival rate of 50 percent for inpatient bone marrow and inpatient and outpatient stem cell transplant patients.
ii) A one-year survival rate of 75 percent and a two-year survival rate of 60 percent for heart transplant patients.
iii) A one-year survival rate of 75 percent and a two-year survival rate of 60 percent for liver transplant patients.
iv) A one-year survival rate of 90 percent for kidney transplant and a one-year survival rate of 80 percent for pancreas transplant; or a one-year survival rate of 80 percent for kidney/pancreas transplant.
v) A one-year survival rate of 65 percent and a two-year survival rate of 60 percent for heart/lung and lung (single or double) transplant patient.
vi) A one-year survival rate of 60 percent and a two-year survival rate of 55 percent for intestinal transplants (small bowel or liver/small bowel).
2) The commitment of the hospital to support the transplant center must be at all levels as evidenced by such factors as financial resources, allocation of space and the support of the professional staff for the transplant program and its patients. The hospital must submit appropriate documentation to demonstrate that:
A) Component teams are integrated into a comprehensive transplant team with clearly defined leadership and responsibility.
B) The hospital safeguards the rights and privacy of patients.
C) The hospital has adequate patient management plans and protocols to meet the patient and hospital's needs.
3) The hospital must identify, in writing, the director of the transplant program and the members of the team as well as their qualifications. Physician team members must be identified as board certified, in preparation for board certification, or pending board certification, and the transplant coordinator's name must be submitted.
4) The hospital must provide patient selection criteria including indications and contraindications for the type of transplant procedure for which the facility is seeking certification.
e) Recertification Process/Criteria
1) The Department will conduct an annual review for certification of transplant centers. A certified center must submit documentation established under subsections (c), (d), (f) and (g) for recertification as a transplant center.
2) Survival rates of previous transplant patients must be documented prior to certification. The center must maintain patient volume in the year of certification based on previous transplant statistics.
3) The Department shall notify the hospital of approval or denial of the recertification of the hospital as a transplant center.
4) If the hospital has previously met the requirements for certification or recertification of its program under subsections (d)(1)(K), (L), (M), (N), (O), (P) and (Q) and (d)(2), (3) and (4) and the program has experienced no changes under the above subsections, as evidenced in written documentation on the hospital's application, the hospital will not be required to resubmit the same data.
5) If a center has previously met the requirements for certification or recertification of its program under subsections (d)(1) (K), (L), (M), (N), (O), (P), (Q) and (R)(i) through (R)(vi), but has performed fewer than the required number of transplants pursuant to subsections (d)(1)(C), (D), (E), (F), (G), (H), (I) or (J) as appropriate, the Department may recertify the center if it determines that the best interests of the Medical Assistance client eligible for transplant services would be served by allowing continued certification of the center. Criteria the Department may consider in making such a determination include, but are not limited to:
A) Not recertifying a center would limit the accessibility of available organs.
B) Other centers are not accepting new patients or have extensive waiting lists.
C) The distance to other eligible centers would jeopardize the client's opportunity to receive a viable organ/tissue transplant.
f) Notification of Transplant
1) The hospital must notify the Department prior to performance of the transplant procedure. The notification letter must be from a physician on the transplant team.
2) The notification must include the admission diagnosis and pre-transplant diagnosis.
3) The Department shall notify the hospital regarding receipt of the notification and provide the appropriate outcome summary forms to the hospital.
g) Reporting Requirements of Certified Transplant Center
The following documentation must be submitted within the time limits set forth in this subsection (g).
1) Outcome Summary
A) The discharge summary for each Medical Assistance patient must be received by the Department within 30 days after the patient's discharge.
B) For those Medical Assistance patients who expire, a summary must be received by the Department within 30 days after the patient's death.
2) Notification of Changes
The center must notify the Department within 30 days after any changes in its program including, but not limited to, certification criteria, patient selection criteria, members of the transplant team and the coordinator.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.85 Supplemental Tertiary Care Adjustment Payments (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.90 Medicaid Inpatient Utilization Rate (MIUR) Adjustment Payments (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.95 Medicaid Outpatient Utilization Rate (MOUR) Adjustment Payments (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.100 County Trauma Center Adjustment Payments
Effective for dates of service on or after July 1, 2014:
a) County Trauma Center Adjustment (TCA) Payments. Illinois hospitals that, on the first day of July preceding the TCA rate period, are recognized as Level I or Level II trauma centers by DPH, shall receive an adjustment that shall be calculated as follows:
1) The available funds from the Trauma Center Fund each quarter shall be divided by the number of each eligible hospital's (as defined in subsection (a)(4)) Medicaid trauma admissions in the same quarter of the TCA base period to determine the adjustment for the TCA rate period. The result of this calculation shall be the County TCA adjustment per Medicaid trauma admission for the applicable quarter.
2) The TCA payments shall not be treated as payments for hospital services under Title XIX of the Social Security Act for purposes of the calculation of the intergovernmental transfer provided for in Section 15-3(a) of the Illinois Public Aid Code.
3) The trauma center adjustments shall be paid to eligible hospitals on a quarterly basis.
4) Trauma Center Adjustment Limitations. Hospitals that qualify for trauma center adjustments under this Section shall not be eligible for the total trauma center adjustment if, during the TCA rate period, the hospital is no longer recognized by DPH, or the appropriate licensing agency, as a Level I or Level II trauma center as required for the adjustments described in subsection (a)(1). In these instances, the adjustments calculated under this subsection (a)(4) shall be pro-rated as applicable, based upon the date that recognition ceased.
b) Definitions. The definitions of terms used with reference to calculation of the trauma center adjustments in this Section are as follows:
1) "Available funds" means funds that have been deposited into the Trauma Center Fund, have been distributed to the Department by the State Treasurer, and have been appropriated by the Illinois General Assembly.
2) "Medicaid trauma admission" means, for discharges through June 30, 2014, those services provided to Medicaid-enrolled beneficiaries that were received and processed as hospital inpatient admissions, excluding admissions for normal newborns, that were subsequently adjudicated by the Department through the last day of June preceding the TCA rate period and contained within the Department's paid claims data base, with an ICD-9-CM principal diagnosis code of: 800.0 through 800.99; 801.0 through 801.99; 802.0 through 802.99; 803.0 through 803.99; 804.0 through 804.99; 805.0 through 805.98; 806.0 through 806.99; 807.0 through 807.69; 808.0 through 808.9; 809.0 through 809.1; 828.0 through 828.1; 839.0 through 839.3; 839.7 through 839.9; 850.0 through 850.9; 851.0 through 851.99; 852.0 through 852.59; 853.0 through 853.19; 854.0 through 854.19; 860.0 through 860.5; 861.0 through 861.32; 862.8; 863.0 through 863.99; 864.0 through 864.19; 865.0 through 865.19; 866.0 through 866.13; 867.0 through 867.9; 868.0 through 868.19; 869.0 through 869.1; 887.0 through 887.7; 896.0 through 896.3; 897.0 through 897.7; 900.0 through 900.9; 902.0 through 904.9; 925; 926.8; 929.0 through 929.99; 958.4; 958.5; 990 through 994.99.
For discharges after June 30, 2014, those services provided to Medicaid‑enrolled beneficiaries that were received and processed as hospital inpatient admissions that were subsequently adjudicated by the Department through the last day of June preceding the TCA rate period and contained within the Department's paid claims data base, and have been grouped to one of the following DRGs:
020 Craniotomy for trauma.
055 Head trauma, with coma lasting more than one hour or hemorrhage.
056 Brain contusion/laceration and complicated skull fracture, coma less than one hour or no coma.
057 Concussion, closed skull fracture not otherwise specified, uncomplicated intracranial injury, coma less than one hour or no coma.
135 Major chest and respiratory trauma.
308 Hip and femur procedures for trauma, except joint replacement.
384 Contusion, open wound and other trauma to skin and subcutaneous tissue.
841 Extensive third degree burns with skin graft, as of July 1, 2018.
842 Full thickness burns with graft, as of July 1, 2018.
843 Extensive burns without skin graft, as of July 1, 2018.
844 Partial thickness burns with or without graft, as of July 1, 2018.
910 Craniotomy for multiple significant trauma.
911 Extensive abdominal/thoracic procedures for multiple significant trauma.
912 Musculoskeletal and other procedures for multiple significant trauma.
930 Multiple significant trauma, without operating room procedure.
3) "TCA base period" means the 12-month period ending on the last day of June preceding the TCA rate period.
4) "TCA rate period" means the 12-month period beginning on October 1 of the year and ending September 30 of the following year.
5) "Trauma Center Fund" means the fund created in the State treasury by Section 5.325 of the State Finance Act [30 ILCS 105] and described in Section 3.225 of the Emergency Medical Services (EMS) Systems Act [210 ILCS 50] and Section 5-5.03 of the Public Aid Code.
(Source: Amended at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.103 Outpatient Service Adjustment Payments (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.105 Reimbursement Methodologies for Inpatient Rehabilitation Services
Effective with discharges on or after July 1, 2014:
a) Inpatient rehabilitation services not excluded from the DRG PPS pursuant to 89 Ill. Adm. Code 149.50(b) shall be reimbursed through the DRG PPS.
b) Inpatient rehabilitation services excluded from the DRG PPS shall be reimbursed a hospital-specific rate paid per day of covered inpatient care, determined pursuant to subsection (c) or (d), as applicable. The total payment for an inpatient stay will equal the sum of:
1) the payment determined in this Section; and
2) any applicable adjustments to payment specified in Section 148.290.
c) Rehabilitation Hospital. Effective January 1, 2024, payment for inpatient rehabilitation services provided by a rehabilitation hospital, as defined in Section 148.25(d)(2):
1) That was not enrolled with the Department on December 31, 2023, shall be the product of the following:
A) $1,000.67; and
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
2) That was enrolled with the Department on December 31, 2023, shall be the product of the following:
A) The greater of:
i) the hospital's rehabilitation rate in effect on December 31, 2023 multiplied by 1.1; or
ii) $1,000.67.
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
d) Distinct Part Rehabilitation Unit. Effective January 1, 2024, payment for inpatient rehabilitation services provided by a distinct part rehabilitation unit, as defined in Section 148.25(c)(2):
1) For which was not enrolled with the Department on December 31, 2023, shall be the product of the following:
A) $593.25; and
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
2) For which was enrolled with the Department on December 31, 2023, shall be the product of the following:
A) The greater of:
i) The distinct part rehabilitation rate in place on December 31, 2023 multiplied by 1.1; or
ii) $593.25.
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.110 Reimbursement Methodologies for Inpatient Psychiatric Services
Effective for dates of discharge on or after July 1, 2014:
a) Inpatient psychiatric services not excluded from the DRG PPS pursuant to 89 Ill. Adm. Code 149.50(b) shall be reimbursed through the DRG PPS.
b) Inpatient psychiatric services excluded from the DRG PPS shall be reimbursed a hospital-specific rate paid per day of covered inpatient care, determined pursuant to subsection (c), (d) or (g), as applicable. The total payment for an inpatient stay will equal the sum of:
1) the payment determined in this Section; and
2) any applicable adjustments to the payment specified in Section 148.290.
c) Psychiatric Hospital. Effective January 1, 2024, payment for inpatient psychiatric services provided by a psychiatric hospital, as defined in Section 148.25(d)(1):
1) For psychiatric hospitals not enrolled with the Department on December 31, 2023, shall be the product of:
A) 90% of the minimum rate in subsection (d)(3); and
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
2) For psychiatric hospitals enrolled with the Department on December 31, 2023, shall be the product of:
A) The greater of:
i) The hospital's psychiatric rate in effect on December 31, 2023 multiplied by 1.1; or
ii) 90% of the minimum rate in subsection (d)(3);
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
d) Distinct Part Psychiatric Unit. Effective January 1, 2024, payment for psychiatric services provided by a distinct part psychiatric unit, as defined in Section 148.25(c)(1):
1) Distinct part psychiatric units that were not enrolled with the Department on December 31, 2023 shall be the product of the following:
A) 90 percent of the minimum rate in subsection (d)(3); and
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
2) Distinct part psychiatric units that were enrolled with the Department on December 31, 2023, shall be the product of the following:
A) The greater of:
i) The rate in effect on December 31, 2023 multiplied by 1.1, or;
ii) 90 percent of the minimum rate in subsection (d)(3).
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
3) For Safety Net Hospitals, as defined in 305 ILCS 5/5-5e.1(a), effective January 1, 2024, the per diem rate for psychiatric services is the greater of:
A) the rate in effect on December 31, 2023 multiplied by 1.1; or
B) the minimum rate of $693.
4) For general acute care hospitals that provide more than 9,500 inpatient psychiatric days in a calendar year, effective January 1, 2024, the per diem rate for psychiatric services is as follows:
A) The greater of
i) The hospital's per diem rate for psychiatric services as of December 31, 2021; or
ii) $693.
e) Psychiatric hospital adjustors for dates of service beginning July 1, 2014. For Illinois freestanding psychiatric hospitals, defined in Section 148.25(d)(1), that were not children's hospitals as defined in Section 148.25(d)(3) in FY 2013 and whose Medicaid covered days were 90% or more for individuals under 20 years of age in FY 2013, the Department shall pay a per day add-on of $48.25.
f) Effective January 1, 2022, payment for long-acting injectable antipsychotic drugs and long-acting injectable substance use disorder drugs administered in the inpatient psychiatric setting will be reimbursed at the Department's rate.
1) All rates are published on the Department's website in the Practitioner Fee Schedule.
2) Regarding long-acting injectable antipsychotics, the following criteria shall be adhered to regardless of whether the individual is enrolled with a Medicaid Managed Care Organization or fee-for-service:
A) The prescriber must be a board-certified psychiatrist or a board-eligible psychiatrist. For the purposes of this subsection, a "board-eligible psychiatrist" is a physician who has, within the past 7 years, successfully completed residency training accredited by the Accreditation Council for Graduate Medical Education or approved by the American Board of Psychiatry and Neurology in a psychiatric primary specialty or subspecialty;
B) The injectable atypical antipsychotic agents (AAPI) prior approval will follow the Food and Drug Administration (FDA) approved labeling for the indication for each medication; and
C) The prescriber agrees to coordinate a follow up outpatient appointment for administration of the next recommended dose of the AAPI and provide documentation of the follow up appointment with request for prior authorization.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.112 Medicaid High Volume Adjustment Payments
Effective for dates of service on or after July 1, 2014:
a) The Department shall make Medicaid High Volume Adjustments (MHVA) to hospitals that are eligible to receive the adjustment payments described in Section 148.122.
b) Calculation of Medicaid High Volume Adjustments
1) A children's hospital, as defined in Section 148.25(d)(3), shall receive an MHVA payment adjustment of $120.
2) Any hospital other than a children's hospital meeting the criteria specified in subsection (a) shall receive an MHVA payment adjustment of $60.
3) The amount calculated pursuant to subsections (b)(1) and (b)(2) shall be adjusted as authorized in Section 5-5.02 of the Illinois Public Aid Code.
c) Payment
The adjustments calculated under subsection (b)(3) shall be paid on a per diem basis and, except as provided in paragraph (d), shall be applied to each covered day of care provided so long as the hospital meets the criteria specified in subsection (a) on the covered day. The annual effective dates for the adjustments calculated under subsection (b)(3) shall be consistent with the "Medicaid Percentage determination year" as defined in Section 148.122(g)(1).
d) Covered days associated with claims for normal newborn DRGs 626 or 640 are not eligible for the MHVA adjustment or the MHVA payment under subsection (c).
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.115 Reimbursement Methodologies for Long Term Acute Care Services
Effective with discharges on or after July 1, 2014:
a) Inpatient long term acute care psychiatric services excluded from the DRG PPS pursuant to 89 Ill. Adm. Code 149.50(b) shall be reimbursed under the inpatient psychiatric services methodologies specified in Section 148.110.
b) Inpatient long term acute care services excluded from the DRG PPS shall be reimbursed a hospital-specific rate paid per day of covered inpatient care, determined pursuant to this Section. The total payment for an inpatient stay will equal the sum of:
1) the payment determined in this Section; and
2) any applicable adjustments to payment specified in Section 148.290.
c) Payment for long term acute care services provided by a long term acute care hospital, as defined in Section 148.25(d)(4):
1) That was not enrolled with the Department on December 31, 2023, shall be the product of the following:
A) $800.16; and
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
2) That was enrolled with the Department on December 31, 2023, shall be the product of the following:
A) The rate in effect on December 31, 2023 multiplied by 1.1; and
B) The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.116 Reimbursement Methodologies for Children's Specialty Hospitals
Effective for dates of outpatient services on or after July 1, 2014 and inpatient discharges on or after July 1, 2014:
a) Inpatient general acute care services provided by a children's specialty hospital located in Illinois, as defined in Section 148.25(i) and excluded from the DRG PPS pursuant to 89 Ill. Adm. Code 149.50(b), shall, per day of covered inpatient care, be reimbursed as follows:
1) For a hospital that would not have met the definition of a children's specialty hospital as of July 1, 2013, $1,400.00 per day.
2) For a hospital or a cost reporting hospital located outside of Illinois that would have met the definition of a children's specialty hospital as of July 30, 2023, a rate equal to $2,003.13.
3) The total payment for inpatient stay will equal the sum of:
A) The payment determined in this subsection; and
B) Any applicable adjustments to payment specified in Section 148.290.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.117 Outpatient Assistance Adjustment Payments (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.120 Disproportionate Share Hospital (DSH) Adjustments
Effective for dates of service on or after July 1, 2014:
a) Qualified Disproportionate Share Hospitals (DSH). The Department shall make adjustment payments to hospitals that are deemed as disproportionate share by the Department. A hospital may qualify for a DSH adjustment in one of the following ways:
1) The hospital's Medicaid inpatient utilization rate (MIUR), as defined in subsection (i)(4), is at least one standard deviation above the mean Medicaid utilization rate, as defined in subsection (i)(3).
2) The hospital's low income utilization rate, as defined in subsection (i)(6), exceeds 25 per centum.
b) In addition, to be deemed a DSH hospital, a hospital must provide the Department, in writing, with the names of at least two obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to such services under a State Medicaid plan. In the case of a hospital located in a rural area (that is, an area outside of a Metropolitan Statistical Area, as defined by the Executive Office of Management and Budget), the term "obstetrician" includes any physician with staff privileges to perform nonemergency obstetric procedures at the hospital. This requirement does not apply to a hospital in which the inpatients are predominantly individuals under 18 years of age; or does not offer nonemergency obstetric services as of December 22, 1987. Hospitals that do not offer nonemergency obstetrics to the general public, with the exception of those hospitals described in Section 148.25(d), must submit a statement to that effect.
c) In making the determination described in subsection (a)(1), the Department shall utilize:
1) Hospital Cost Reports
A) The hospital's final audited cost report for the hospital's base fiscal year. Medicaid inpatient utilization rates, as defined in subsection (i)(4), that have been derived from final audited cost reports, are not subject to the Review Procedure described in Section 148.310, with the exception of errors in calculation.
B) In the absence of a final audited cost report for the hospital's base fiscal year, the Department shall utilize the hospital's unaudited cost report for the hospital's base fiscal year. Due to the unaudited nature of this information, hospitals shall have the opportunity to submit a corrected cost report for the determination described in subsection (a)(1). Submittal of a corrected cost report in support of subsection (a)(1) must be received or post marked no later than the first day of July preceding the DSH determination year for which the hospital is requesting consideration of such corrected cost report for the determination of DSH qualification. Corrected cost reports which are not received in compliance with these time limitations will not be considered for the determination of the hospital's MIUR as described in subsection (i)(4).
C) Hospitals' Medicaid inpatient utilization rates, as defined in subsection (i)(4), that have been derived from unaudited cost reports are not subject to the Review Procedure described in Section 148.310, with the exception of errors in calculation. Pursuant to subsection (c)(1)(B), hospitals shall have the opportunity to submit corrected information prior to the Department's final DSH determination.
D) In the event a subsequent final audited cost report reflects an MIUR, as described in subsection (i)(4), that is lower than the Medicaid inpatient utilization rate derived from the unaudited cost report or the HDSC form utilized for the DSH determination, the Department shall recalculate the MIUR based upon the final audited cost report, and recoup any overpayments made if the percentage change in the DSH payment rate is greater than five percent.
2) Days Not Available from Cost Report
Certain types of inpatient days of care provided to Title XIX recipients are not available from the cost report, i.e., Medicare/Medicaid crossover claims, out-of-state Title XIX Medicaid utilization levels, Medicaid managed care entity (MCE) days, hospital residing long term care days, and Medicaid days for alcohol and substance abuse sub-acute care under category of service 035. To obtain Medicaid utilization levels in these instances, the Department shall utilize:
A) Medicare/Medicaid Crossover Claims. The Department will utilize the Department's paid claims data adjudicated through the last day of June preceding the DSH determination year for each hospital's base fiscal year.
B) Out-of-state Title XIX Utilization Levels. Hospital statements and verification reports from other states will be required to verify out-of-state Medicaid recipient utilization levels. The information submitted must include only those days of care provided to out-of-state Medicaid recipients during the hospital's base fiscal year.
C) MCE days. The Department will utilize the Department's MCE claims data available to the Department as of the last day of June preceding the DSH determination year, or specific claim information from each MCE, for each hospital's base fiscal year to determine the number of inpatient days provided to recipients enrolled in an MCE.
D) Hospital Residing Long Term Care Days. The Department will utilize the Department's paid claims data adjudicated through the last day of June preceding the DSH determination year for each hospital's base fiscal year to determine the number of hospital residing long term care days provided to recipients.
E) Alcohol and Substance Abuse Days. The Department will utilize its paid claims data under category of service 35 available to the Department as of the last day of June preceding the DSH determination year for each hospital's base fiscal year to determine the number of inpatient days provided for alcohol and substance abuse rehabilitative care.
d) Hospitals may apply for DSH status under subsection (a)(2) by submitting an audited certified financial statement, for the hospital's base fiscal year, to the Department. The statements must contain the following breakdown of information prior to submittal to the Department for consideration:
1) Total hospital net revenue for all patient services, both inpatient and outpatient, for the hospital's base fiscal year.
2) Total payments received directly from State and local governments for all patient services, both inpatient and outpatient, for the hospital's base fiscal year.
3) Total gross inpatient hospital charges for charity care (this must not include contractual allowances, bad debt or discount), for the hospital's base fiscal year.
4) Total amount of the hospital's gross charges for inpatient hospital services for the hospital's base fiscal year.
e) With the exception of cost-reporting children's hospitals in contiguous states that provide 100 or more inpatient days of care to Illinois program participants, only those cost-reporting hospitals located in states contiguous to Illinois that qualify for DSH in the state in which they are located based upon the federal definition of a DSH hospital (42 USC 1396-4(b)(1)) may qualify for DSH hospital adjustments under this Section. For purposes of determining the MIUR, as described in subsection (i)(4) and as required in the federal definition (42 USC 1396r-4(b)(1)), out-of-state hospitals will be measured in relationship to one standard deviation above the mean Medicaid inpatient utilization rate in their state. Out-of-state hospitals that do not qualify by the MIUR from their state may submit an audited certified financial statement as described in subsection (d). Payments to out-of-state hospitals will be allocated using the same method as described in subsection (g).
f) Time Limitation Requirements for Additional Information.
1) The information required in subsections (a), (c), (d) and (e) must be received or post marked no later than the first day of July preceding the DSH determination year for which the hospital is requesting consideration of the information for the determination of DSH qualification. Information required in subsections (a), (c), (d) and (e) that is not received or post marked in compliance with these limitations will not be considered for the determination of those hospitals qualified for DSH adjustments.
2) The information required in subsection (b) must be submitted after receipt of notification from the Department. Information required in this Section that is not received in compliance with these limitations will not be considered for the determination of those hospitals qualified for DSH adjustments.
g) Inpatient Payment Adjustments to DSH Hospitals. The adjustment payments required by subsection (a) shall be calculated annually as follows:
1) Five Million Dollar Fund Adjustment for hospitals defined in Section 148.25(b)(1), with the exception of any Illinois hospital that is owned or operated by the State or a unit of local government.
A) Hospitals qualifying as DSH hospitals under subsection (a)(1) or (a)(2) will receive an add-on payment to their inpatient rate.
B) The distribution method for the add-on payment described in subsection (g)(1) is based upon a fund of $5 million. All hospitals qualifying under subsection (g)(1)(A) will receive a $5 per day add-on to their current rate. The total cost of this adjustment is calculated by multiplying each hospital's most recent completed fiscal year Medicaid inpatient utilization data (adjusted based upon historical utilization and projected increases in utilization) by $5. The total dollar amount of this calculation is then subtracted from the $5 million fund.
C) The remaining fund balance is then distributed to the hospitals that qualify under subsection (a)(1) in proportion to the percentage by which the hospital's MIUR exceeds one standard deviation above the State's mean Medicaid inpatient utilization rate, as described in subsection (i)(3). This is done by finding the ratio of each hospital's percent Medicaid utilization to the State's mean plus one standard deviation percent Medicaid value. These ratios are then summed and each hospital's proportion of the total is calculated. These proportional values are then multiplied by each hospital's most recent completed fiscal year Medicaid inpatient utilization data (adjusted based upon historical utilization and projected increases in utilization). These weighted values are summed and each hospital's proportion of the summed weighted value is calculated. Each individual hospital's proportional value is then multiplied against the $5 million pool of money available after the $5 per day base add-on has been subtracted.
D) The total dollar amount calculated for each qualifying hospital under subsection (g)(1)(C), plus the initial $5 per day add-on amount calculated for each qualifying hospital under subsection (g)(1)(B), is then divided by the Medicaid inpatient utilization data (adjusted based upon historical utilization and projected increases in utilization) to arrive at a per day add-on value. Hospitals qualifying under subsection (a)(2) will receive the minimum adjustment of $5 per inpatient day. The adjustments calculated under this subsection (g)(1) are subject to the limitations described in subsection (h). The adjustments calculated under subsection (g) shall be paid on a per diem basis and shall be applied to each covered day of care provided.
2) Department of Human Services (DHS) State-Operated Facility Adjustment for Hospitals Defined in Section 148.25(a)(3). DHS State-operated facilities qualifying under subsection (a)(2) shall receive an adjustment calculated as follows:
A) The amount of the adjustment is based on a State DSH Pool. The State DSH Pool amount shall be the federal DSH allotment for mental health facilities as determined in section 1923(h) of the Social Security Act, minus the estimated DSH payments to such facilities that are not operated by the State.
B) The State DSH Pool amount is then allocated to hospitals defined in Section 148.25(a)(3) that qualify for DSH adjustments by multiplying the State DSH Pool amount by each hospital's ratio of uncompensated care costs, from the most recent final cost report, to the sum of all qualifying hospitals' uncompensated care costs.
C) The adjustment calculated in subsection (g)(2)(B) shall meet the limitation described in subsection (h)(4).
D) The adjustment calculated pursuant to subsection (g)(2)(B), for each hospital defined in Section 148.25(a)(3) that qualifies for DSH adjustments, is then divided by four to arrive at a quarterly adjustment. This amount is subject to the limitations described in subsection (h). The adjustment described in this subsection (g)(2)(D) shall be paid on a quarterly basis.
3) Assistance for Certain Public Hospitals
A) The Department may make an annual payment adjustment to qualifying hospitals in the DSH determination year. A qualifying hospital is a public hospital as defined in section 701(d) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Public Law 106-554).
B) Hospitals qualifying shall receive an annual payment adjustment that is equal to:
i) A rate amount equal to the amount specified in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, section 701(d)(3)(B) for the DSH determination year;
ii) Divided first by Illinois' Federal Medical Assistance Percentage;
iii) Divided secondly by the sum of the qualified hospitals' total Medicaid inpatient days, as defined in subsection (i)(4); and
iv) Multiplied by each qualified hospital's Medicaid inpatient days as defined in subsection (i)(4).
C) The annual payment adjustment calculated under this subsection (g)(3), for each qualified hospital, will be divided by four and paid on a quarterly basis.
D) Payment adjustments under this subsection (g)(3) shall be made without regard to subsections (h)(3) and (4) of this Section, 42 CFR 447.272, or any standards promulgated by the Department of Health and Human Services pursuant to section 701(e) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.
E) In order to qualify for assistance payments under this subsection (g)(3), with regard to this payment adjustment, there must be in force an executed intergovernmental agreement between the authorized governmental body of the qualifying hospital and the Department.
4) Disproportionate Share Payments for Certain Government-Owned
or -Operated Hospitals
A) The following classes of government-owned or -operated Illinois hospitals shall, subject to the limitations set forth in subsection (h), be eligible for the Disproportionate Share Hospital Adjustment payment:
i) Hospitals defined in Section 148.25(a).
ii) Hospitals owned or operated by a unit of local government that is located within Illinois and is not a hospital defined in subsection (i).
B) The annual amount of the payment shall be the amount computed for the hospital pursuant to federal limitations.
C) The annual amount shall be paid to the hospital in monthly installments.
h) DSH Adjustment Limitations
1) Hospitals that qualify for DSH adjustments under this Section shall not be eligible for the total DSH adjustment if, during the DSH determination year, the hospital discontinues provision of nonemergency obstetrical care. The provisions of this subsection (h)(1) shall not apply to those hospitals described in Section 148.25(d) or those hospitals that have not offered nonemergency obstetric services as of December 22, 1987. In this instance, the adjustments calculated under subsection (g)(1) shall cease to be effective on the date that the hospital discontinued the provision of such nonemergency obstetrical care.
2) Inpatient Payment Adjustments based upon DSH Determination Reviews. Appeals based upon a hospital's ineligibility for DSH payment adjustments, or their payment adjustment amounts, in accordance with Section 148.310(b), which result in a change in a hospital's eligibility for DSH payment adjustments or a change in a hospital's payment adjustment amounts, shall not affect the DSH status of any other hospital or the payment adjustment amount of any other hospital that has received notification from the Department of its eligibility for DSH payment adjustments based upon the requirements of this Section.
3) DSH Payment Adjustment. If the aggregate DSH payment adjustments calculated under this Section do not meet the State's final DSH Allotment as determined by the federal Centers for Medicare and Medicaid Services, DSH payment adjustments calculated under this Section shall be adjusted to meet the State DSH Allotment. Subject to any limitation, disproportionate share payments will be made to qualifying hospitals in the following order:
A) Hospitals defined in Section 148.25(a)(3) – the annual amount shall be credited quarterly via certification of public expenditure.
B) Hospitals defined in Section 148.25(a)(2).
C) Hospitals defined in subsection (g)(4)(A)(ii) of this Section.
D) Hospitals that are not owned or operated by a unit of government – the annual amount shall be paid on each inpatient claim.
E) Hospitals defined in Section 148.25(a)(1).
4) Omnibus Budget Reconciliation Act of 1993 (OBRA'93) Adjustments. In accordance with Public Law 103-66, adjustments to individual hospitals' disproportionate share payments shall be made if the sum of estimated Medicaid payments (inpatient, outpatient, and disproportionate share) to a hospital exceed the costs of providing services to Medicaid clients and persons without insurance. Federal upper payment limit requirements (42 CFR 447.272) shall be considered when calculating the OBRA'93 adjustments. The adjustments shall reduce disproportionate share spending until the costs and spending (described in this subsection (h)(4)) are equal or until the disproportionate share payments are reduced to zero. In this calculation, persons without insurance costs do not include contractual allowances. Hospitals qualifying for DSH payment adjustments must submit the information required in Section 148.150.
5) Medicaid Inpatient Utilization Rate Limit. Hospitals that qualify for DSH payment adjustments under this Section shall not be eligible for DSH payment adjustments if the hospital's MIUR, as defined in subsection (i)(4) of this Section, is less than one percent.
i) Inpatient Payment Adjustment Definitions. The definitions of terms used with reference to calculation of the inpatient payment adjustments are as follows:
1) "Base fiscal year" means the hospital's fiscal year ending in the calendar year 22 months before the beginning of the DSH determination year.
2) "DSH determination year" means the 12-month period beginning on October 1 of the year and ending September 30 of the following year.
3) "Mean Medicaid inpatient utilization rate" means a fraction, the numerator of which is the total number of inpatient days provided in a given 12-month period by all Medicaid-participating Illinois hospitals to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act (42 USC 1396a et seq.), and the denominator of which is the total number of inpatient days provided by those same hospitals. In this subsection (i)(3), the term "inpatient day" includes each day in which an individual (including a newborn) is an inpatient in the hospital whether or not the individual is in a specialized ward and whether or not the individual remains in the hospital for lack of suitable placement elsewhere.
4) "Medicaid inpatient utilization rate" means a fraction, the numerator of which is the number of a hospital's inpatient days provided in a given 12 month period to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act (42 USC 1396a et seq.) and the denominator of which is the total number of the hospital's inpatient days in that same period. In this subsection (i)(4), the term "inpatient day" includes each day in which an individual (including a newborn) is an inpatient in the hospital whether or not the individual is in a specialized ward and whether or not the individual remains in the hospital for lack of suitable placement elsewhere.
5) "Obstetric services" shall at a minimum include non-emergency inpatient deliveries in the hospital.
6) "Low income utilization rate" means a fraction, expressed as a percentage that is the sum of the amount resulting from the calculations in subsection (i)(6)(A) plus (i)(6)(B):
A) The fraction (expressed as a percentage) −
i) the numerator of which is the sum of the total revenues paid the hospital for patient services under Medicaid State plan (regardless of whether the services were furnished on a fee-for-service basis or through a managed care entity) and the amount of the cash subsidies for patient services received directly from State and local governments, and
ii) the denominator of which is the total amount of revenues of the hospital for patient services (including the amount of such cash subsidies) in the period; and
B) The fraction (expressed as a percentage) −
i) the numerator of which is the total amount of the hospital's charges for inpatient hospital services which are attributable to charity care in a period, less the portion of any cash subsidies described in subsection (6)(A)(i); and
ii) the denominator of which is the total amount of the hospital's charges for inpatient hospital services in the hospital in the period.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.122 Medicaid Percentage Adjustments
Effective for dates of service on or after July 1, 2014, unless another date is specified, the Department shall make an annual determination of those hospitals qualified for adjustments under this Section effective October 1 of each year unless otherwise noted.
a) Qualified Medicaid Percentage Hospitals. The Department shall make adjustment payments to hospitals that are deemed as a Medicaid percentage hospital by the Department. A hospital, except those that are owned or operated by a unit of government, may qualify for a Medicaid Percentage Adjustment (MPA) in one of the following ways:
1) The hospital's Medicaid inpatient utilization rate (MIUR), as defined in Section 148.120(i)(4), is at least one-half standard deviation above the mean Medicaid utilization rate, as defined in Section 148.120(i)(3).
2) The hospital's low income utilization rate, as defined in Section 148.120(i)(6), exceeds 25 per centum.
3) Illinois hospitals that, on July 1, 1991, had an MIUR, as defined in Section 148.120(i)(4), that was at least the mean Medicaid inpatient utilization rate, as defined in Section 148.120(i)(3), and that were located in a planning area with one-third or fewer excess beds as determined by the Illinois Health Facilities Planning Board (see 77 Ill. Adm. Code 1100), and that, as of June 30, 1992, were located in a federally designated Health Manpower Shortage Area (see 42 CFR 5 (1989)).
4) Illinois hospitals that meet the following criteria:
A) Have an MIUR, as defined in Section 148.120(i)(4), that is at least the mean Medicaid inpatient utilization rate, as defined in Section 148.120(i)(3).
B) Have a Medicaid obstetrical inpatient utilization rate, as defined in subsection (g)(3), that is at least one standard deviation above the mean Medicaid obstetrical inpatient utilization rate, as defined in subsection (g)(2).
5) Any children's hospital, as defined in Section 148.25(d)(3).
6) Out of state hospitals meeting the criteria in Section 148.120(e).
7) A hospital that reopened a previously closed hospital facility, which includes hospitals that have been terminated from participation in the medical assistance program in accordance with 305 ILCS 5/12-4.25, within 4 calendar years of the hospital facility's closure.
b) In making the determination described in subsections (a)(1) and (a)(4)(A), the Department shall utilize the data described in Section 148.120(c) and received in compliance with Section 148.120(f). Effective for Medicaid Percentage rate year 2024 and thereafter, the Medicaid Inpatient utilization rate, as defined in Section 148.120(i)(4) and used in the determination of eligibility for payments under subsection (d), shall be modified to exclude from both the numerator and denominator, all days of care provided to military recruits or trainees for the United States Navy and covered by TRICARE or its successor.
c) Hospitals that qualified as an MPA hospital under subsection (a)(2) for the Medicaid percentage determination year beginning October 1, 2013 may apply annually to become qualified under subsection (a)(2) by submitting audited certified financial statements as described in Section 148.120(d) and received in compliance with Section 148.120(f).
d) Medicaid Percentage Adjustments. The adjustment payments required by subsection (a) for qualified hospitals shall be calculated annually as follows for hospitals defined in Section 148.25(b)(1), excluding hospitals defined in Section 148.25(a).
1) The payment adjustment shall be calculated based upon the hospital's MIUR, as defined in Section 148.120(i)(4), and subject to subsection (e), as follows:
A) Hospitals with an MIUR below the mean Medicaid inpatient utilization rate shall receive a payment adjustment of $25;
B) Hospitals with an MIUR that is equal to or greater than the mean Medicaid inpatient utilization rate but less than one standard deviation above the mean Medicaid inpatient utilization rate shall receive a payment adjustment of $25 plus $1 for each one percent that the hospital's MIUR exceeds the mean Medicaid inpatient utilization rate;
C) Hospitals with an MIUR that is equal to or greater than one standard deviation above the mean Medicaid inpatient utilization rate but less than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a payment adjustment of $40 plus $7 for each one percent that the hospital's MIUR exceeds one standard deviation above the mean Medicaid inpatient utilization rate; and
D) Hospitals with an MIUR that is equal to or greater than 1.5 standard deviations above the mean Medicaid inpatient utilization rate shall receive a payment adjustment of $90 plus $2 for each one percent that the hospital's MIUR exceeds 1.5 standard deviations above the mean Medicaid inpatient utilization rate.
E) Hospitals that reopen a previously closed hospital facility within 4 calendar years of the hospital facility's closure, if the previously closed hospital facility qualified for payments under subsection (d) at the time of closure, shall receive the rate in place at the time of the closure until utilization data for the new facility is available for the Medicaid inpatient utilization rate calculation.
2) The MPA payment, calculated in accordance with this subsection (d), to a hospital shall not exceed $155 per day for a children's hospital, as defined in Section 148.25(d)(3), and shall not exceed $215 per day for all other hospitals.
3) The amount calculated pursuant to subsections (d)(1) through (d)(2) shall be adjusted by the aggregate annual increase in the national hospital market basket price proxies (DRI) hospital cost index from DSH determination year 1993, as defined in Section 148.120(i)(2), through DSH determination year 2003 and annually thereafter, by a percentage equal to the lesser of:
A) The increase in the national hospital market basket price proxies (DRI) hospital cost index for the most recent 12 month period for which data are available; or
B) The percentage increase in the Statewide average hospital payment rate, over the previous year's Statewide average hospital payment rate.
4) The amount calculated pursuant to subsections (d)(1) through (d)(3) shall be the inpatient payment adjustment in dollars for the applicable Medicaid percentage determination year. The adjustments calculated under subsections (d)(1) through (d)(3) shall be paid on a per diem basis and, except as provided in subsection (d)(5), shall be applied to each covered day of care provided.
5) Covered days associated with claims for normal newborn DRGs 626 or 640 are not eligible for the MPA adjustment or the per diem payments on adjustments calculated under subsections (d)(1) through (d)(3).
e) Inpatient Adjustor for Children's Hospitals. For a children's hospital, as defined in Section 148.25(d)(3), the payment adjustment calculated under subsection (d)(1) shall be multiplied by 2.0.
f) Medicaid Percentage Adjustment Limitations
1) In addition, to be deemed an MPA hospital, a hospital must provide to the Department, in writing, the names of at least two obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to such services under a State Medicaid plan. In the case of a hospital located in a rural area (that is, an area outside of a Metropolitan Statistical Area, as defined by the federal Executive Office of Management and Budget), the term "obstetrician" includes any physician with staff privileges to perform obstetric services at the hospital. This requirement for obstetric services does not apply to a hospital:
A) In which the inpatients are predominantly individuals under 18 years of age;
B) That does not offer non-emergency obstetric services as of December 22, 1987; or
C) That was providing obstetric services prior to February 1, 2019 and discontinues obstetric services after February 1, 2019 and is located within 15 miles of a hospital that continues to provide obstetric services at the time of discontinuation. Hospitals that do not offer obstetric services to the general public, with the exception of those hospitals described in Section 148.25(d), must submit a statement to that effect that includes the date obstetric services were discontinued.
2) Hospitals that qualify for MPAs under this Section shall not be eligible for the total MPA if, during the MPA determination year, the hospital discontinues provision of obstetric services. The provisions of this subsection (f)(2) shall not apply to those hospitals described in Section 148.25(d) or those hospitals that have not offered obstetric services as of December 22, 1987, or those hospitals that discontinue obstetric services after February 1, 2019 and are located within 15 miles of a hospital that continues to provide obstetric services at the time of discontinuation. In this instance, the adjustments calculated under subsection (d) shall cease to be effective on the date that the hospital discontinued the provision of obstetric services.
3) Appeals based upon a hospital's ineligibility for Medicaid Percentage payment adjustments, or their payment adjustment amounts, in accordance with Section 148.310(b), that result in a change in a hospital's eligibility for Medicaid Percentage payment adjustments or a change in a hospital's payment adjustment amounts, shall not affect the Medicaid Percentage status of any other hospital or the payment adjustment amount of any other hospital that has received notification from the Department of its eligibility for Medicaid Percentage payment adjustments based upon the requirements of this Section.
4) Medicaid Inpatient Utilization Rate Limit. Hospitals that qualify for Medicaid percentage payment adjustments under this Section shall not be eligible for Medicaid percentage payment adjustments if the hospital's MIUR, as defined in Section 148.120(i)(4), is less than one percent.
g) Inpatient Payment Adjustment Definitions. The definitions of terms used with reference to calculation of Inpatient Payment Adjustments are as follows:
1) "Medicaid Percentage determination year" has the same meaning as the DSH determination year defined in Section 148.120(i)(2), except that:
A) The Medicaid Percentage determination year that begins on October 1, 2022 will end on December 31, 2023; and
B) Effective January 1, 2024, Medicaid Percentage determination years will begin on January 1 and end on December 31.
2) "Mean Medicaid obstetrical inpatient utilization rate" means a fraction, the numerator of which is the total Medicaid (Title XIX) obstetrical inpatient days, as defined in subsection (g)(4), provided by all Medicaid-participating Illinois hospitals providing obstetrical services to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act (42 U.S.C. 1396a), and the denominator of which is the total Medicaid inpatient days, as defined in subsection (g), for all such hospitals. That information shall be derived from claims for applicable services provided in the Medicaid obstetrical inpatient utilization rate base year that were subsequently adjudicated by the Department through the last day of June preceding the Medicaid percentage determination year and contained within the Department's paid claims data base.
3) "Medicaid obstetrical inpatient utilization rate" means a fraction, the numerator of which is the Medicaid (Title XIX) obstetrical inpatient days, as defined in subsection (g)(4), provided by a Medicaid-participating Illinois hospital providing obstetrical services to patients who, for such days, were eligible for Medicaid under Title XIX of the federal Social Security Act (42 U.S.C. 1396a), and the denominator of which is the total Medicaid (Title XIX) inpatient days, as defined in subsection (g), provided by such hospital. This information shall be derived from claims for applicable services provided in the Medicaid obstetrical inpatient utilization rate base year that were subsequently adjudicated by the Department through the last day of June preceding the Medicaid Percentage determination year and contained within the Department's paid claims data base.
4) "Medicaid (Title XIX) obstetrical inpatient days" means hospital inpatient days that were subsequently adjudicated by the Department through the last day of June preceding the MPA determination year and contained within the Department's paid claims data base, for recipients of medical assistance under Title XIX of the Social Security Act (specifically excluding Medicare/Medicaid crossover claims), with a Diagnosis Related Grouping (DRG) of:
A) 370 through 375 for claims adjudicated before July 1, 2014; or
B) 540, 541, 542 or 560 for claims adjudicated on or after July 1, 2014.
5) "Total Medicaid (Title XIX) inpatient days", as referred to in subsections (g)(2) and (g)(3), means hospital inpatient days, excluding days for normal newborns, that were subsequently adjudicated by the Department through the last day of June preceding the Medicaid Percentage determination year and contained within the Department's paid claims data base, for recipients of medical assistance under Title XIX of the Social Security Act, and specifically excludes Medicare/Medicaid crossover claims.
6) "Medicaid obstetrical inpatient utilization rate base year" means, for example, fiscal year 2002 for the October 1, 2003 MPA determination year; fiscal year 2003 for the October 1, 2004 MPA determination year; etc.
7) "Obstetric services" shall at a minimum include non-emergency inpatient deliveries in the hospital.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.126 Safety Net Adjustment Payments (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.130 Outlier Adjustments for Exceptionally Costly Stays
a) Outlier Adjustments. Outlier adjustments are provided for exceptionally costly stays provided by hospitals or distinct part units reimbursed on a per diem basis or hospitals reimbursed in accordance with Section 148.82(g) for discharges before July 1, 2014. For discharges on or after July 1, 2014, this Section shall not be utilized for the basis of any hospital payments.
b) The determination of those services qualified for an outlier adjustment shall be made as follows for services provided on and after October 1, 1992, and for each subsequent rate period, as defined in Section 148.25(g)(2)(B), for hospitals or distinct part units reimbursed on a per diem basis or hospitals reimbursed in accordance with Section 148.82(g):
1) The services must have been provided on or after October 1, 1992; and
2) The services must have been provided to:
A) Children who have not attained the age of six years by hospitals defined by the Department as DSH hospitals under Section 148.120(a); or
B) Infants who have not attained the age of one year by hospitals that do not meet the definition of a DSH hospital under Section 148.120(a); or
C) Children who have not attained the age of 19 on the date of admission for services provided on or after January 1, 2008 by a hospital devoted exclusively to the care of children as defined in 89 Ill. Adm. Code 149.50(c)(3)(A); or
D) Children who have not attained the age of 19 on the date of admission for services provided on or after July 1, 2009 by a Children's Hospital as defined in 89 Ill. Adm. Code 149.50(c)(3)(B).
3) Claims with total covered charges equal to or above the mean total covered charges plus one standard deviation shall be considered for outlier adjustments once the following calculations have been performed:
A) Total covered charges (less charges attributable to medical education) equal to or exceeding one standard deviation above the mean shall be multiplied by the hospital's cost to charge ratio.
B) The hospital's rate for services provided on the claim shall be multiplied by the number of covered days on the claim.
C) The product of subsection (b)(3)(B) shall be subtracted from the product of subsection (b)(3)(A).
D) The difference of subsection (b)(3)(C) shall be multiplied by .25, the product of which shall be the outlier adjustment for the claim.
E) Third party payments (credits) shall be applied to the final payment made on the claim.
c) The determination of those services qualified for an outlier adjustment shall be made in accordance with 89 Ill. Adm. Code 149.105 for hospitals reimbursed on a per case basis.
d) Definition of terms relating to outlier adjustments are as follows:
1) "Base fiscal year" means the hospital's fiscal year cost report most recently audited by the Department.
2) "Cost to Charge Ratio" means the hospital's Medicaid total allowable cost for all care divided by the Medicaid total covered charges for all care. The Cost to Charge Ratio is derived by utilizing cost report data from the hospital's base fiscal year.
3) "Mean total covered charges" means the mean total covered charges (as described in subsection (d)(5)), for services provided in the most recent state fiscal year for which complete information is available and which have been adjudicated by the Department, as follows:
A) For hospitals that do not meet the definition of a DSH hospital under Section 148.120(a) in the DSH determination year, the mean total covered charges for all claims for inpatient services provided to individuals under the age of one year; and
B) For hospitals defined by the Department as DSH hospitals under Section 148.120(a) in the DSH determination year, the mean total covered charges for all claims for inpatient services provided to individuals under the age of six years.
4) "Rate for services provided" means the inpatient rate in effect for the type of services provided.
5) "Total covered charges" means the amount entered on the UB-82 or UB-92 Uniform Billing Form for revenue code 001 in column 53 (Total Charges).
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.140 Hospital Outpatient and Clinic Services
Effective for dates of service on or after July 1, 2014, unless another date is specified:
a) Fee-For-Service Professional Services Reimbursement. Effective for dates of service on or after July 1, 2020, all fee-for-service hospital outpatient professional services will be reimbursed in accordance with subsection (b)(1) except for end stage renal disease treatment (ESRDT) services, as described in subsection (g).
b) EAPG PPS Reimbursement. Reimbursement under EAPG PPS, described in subsection (c), shall be all-inclusive for all services provided by the hospital, without regard to the amount charged by a hospital. Except as provided in subsection (b)(3), no separate reimbursement will be made for ancillary services or the services of hospital personnel.
1) Outpatient hospital services reimbursed through the EAPG PPS shall include:
A) Surgical services.
B) Diagnostic and therapeutic services.
C) Emergency department services.
D) Observation services.
E) Psychiatric treatment services.
2) Excluded from reimbursement under the EAPG PPS are outpatient hospital services reimbursed pursuant to 59 Ill. Adm. Code 131 and 132, 77 Ill. Adm. Code 2090, and Section 148.330 of this Part.
3) As an exception to the all-inclusive EAPG PPS rate, a separate professional claim may be submitted under a physician's name and NPI for a physician who provided direct patient care. For purposes of this subsection (b)(3), a physician means:
A) A physician salaried by the hospital. Physicians salaried by the hospital do not include radiologists, pathologists, nurse practitioners, or certified registered nurse anesthetists; no separate reimbursement will be allowed for those providers.
B) A physician who is reimbursed by the hospital through a contractual arrangement to provide direct patient care.
C) A group of physicians with a financial contract to provide emergency department care.
4) Effective for dates of service on or after January 1, 2023, a general acute care hospital that provides more than 500 outpatient psychiatric Medicaid services to persons under 19 years of age in any calendar year prior to the rate year shall be paid a $113 add-on payment. "Rate Year" means the calendar year beginning January 1st, with the first rate year being calendar year 2023.
c) EAPG PPS Payment. The reimbursement to hospitals for outpatient services provided on the same day shall be the product, rounded to the nearest hundredth, of the following:
1) The EAPG weighting factor of the EAPG to which the service was assigned by the EAPG grouper.
2) The EAPG conversion factor, based on the sum of:
A) The product, rounded to the nearest hundredth, of:
i) the labor-related share;
ii) the Medicare IPPS wage index; and
iii) the applicable EAPG standardized amount.
B) The product, rounded to the nearest hundredth, of:
i) non-labor share; and
ii) the applicable EAPG standardized amount.
3) The applicable consolidation factor.
4) The applicable packaging factor.
5) The applicable discounting factor.
6) The applicable policy adjustment factors, as defined in subsection (f), for which the service qualifies.
d) EAPG Standardized Amount. The standardized amount established by the Department as the basis for EAPG conversion factor differs based on the provider type:
1) County-operated Large Public Hospital EAPG Standardized Amount. For a large public hospital, as defined in Section 148.25(a)(1), the EAPG standardized amount is determined in Section 148.160.
2) University-operated Large Public Hospital EAPG Standardized Amount. For a large public hospital, as defined in Section 148.25(a)(2), the EAPG standardized amount is determined in Section 148.170.
3) Critical Access Hospital EAPG Standardized Amount.
A) For critical access hospitals, as defined in Section 148.25(g), the EAPG standardized amounts are determined separately for each critical access hospital such that simulated EAPG payments using outpatient base period paid claim data plus payments as defined in Section 148.423 net of tax costs are equal to the estimated costs of outpatient base period claims data with a rate year cost inflation factor applied.
B) Effective January 1, 2024, simulated EAPG payments using outpatient base period paid claim data are calculated to be budget neutral to simulated payments using the rates in effect as of December 31, 2023. The budget neutral hospital specific EAPG rates are then increased by 10%, except as limited by the federally required upper payment limit (UPL).
4) Acute EAPG Standardized Amount
A) Qualifying Criteria. General acute hospitals and freestanding emergency centers as defined in 148.25(e) excluding providers in subsections (d)(1) through (d)(3), freestanding psychiatric hospitals, psychiatric distinct part units, freestanding rehabilitation hospitals, and rehabilitation distinct part units.
B) Effective January 1, 2024, the acute EAPG standardized amount is based on a single statewide amount determined such that simulated EAPG allowed amount using general acute hospital outpatient base period paid claims data, is equal to the sum of general acute hospital base period paid claims data allowed amount increased by 10%. For subsequent years, acute EAPG standardized amount is based on a single statewide amount determined such that simulated EAPG allowed amount using general acute hospital outpatient base period paid claims data is equal to the sum of general acute hospital base period paid claims data allowed amount.
5) Psychiatric EAPG Standardized Amount
A) Qualifying Criteria. Freestanding psychiatric hospitals and psychiatric distinct part units.
B) Effective January 1, 2024, the psychiatric EAPG standardized amount is based on a single statewide amount, determined such that simulated EAPG allowed amount, using freestanding psychiatric hospitals and psychiatric distinct part units outpatient base period paid claims data, is approximately equal to the sum of the freestanding psychiatric hospitals and psychiatric distinct part units outpatient base period paid claims data allowed amount increased by 10%. For subsequent years, psychiatric EAPG standardized amount is based on a single statewide amount determined such that simulated EAPG allowed amount using freestanding psychiatric hospitals and psychiatric distinct part units outpatient base period paid claims data, is approximately equal to the sum of the freestanding psychiatric hospitals and psychiatric distinct part units outpatient base period paid claims data allowed amount.
6) Rehabilitation EAPG Standardized Amount
A) Qualifying Criteria. Freestanding rehabilitation hospitals and rehabilitation distinct part units.
B) The rehabilitation EAPG standardized amount is based on a single statewide amount, determined such that simulated EAPG payments using freestanding rehabilitation hospitals and rehabilitation distinct part units outpatient base period paid claims data, results in allowed amount approximately equal to freestanding rehabilitation hospitals and rehabilitation distinct part units outpatient base period paid claims data allowed amount increased by 10%. For subsequent years, simulated EAPG payments using freestanding rehabilitation hospitals and rehabilitation distinct part units outpatient base period paid claims data, results in allowed amount approximately equal to freestanding rehabilitation hospitals and rehabilitation distinct part units outpatient base period paid claims data allowed amount.
7) Ambulatory Surgical Treatment Center (ASTC) EAPG Standardized Amount. For ASTC's, as defined in 89 Ill. Adm. Code 146.105, the EAPG standardized amount is determined such that simulated EAPG payments using outpatient base period paid claims data are equal to reported payments of outpatient base period paid claims data as contained in the Department's claims data warehouse.
8) Out-of-State Non-Cost Reporting Hospital EAPG Standardized Amount. For non-cost reporting hospitals, the EAPG standardized amount is $362.32, and is not wage adjusted.
e) Discounting Factor. The applicable discounting factor is based on the discounting flags designated by the EAPG grouper under default EAPG settings:
1) The discounting factor will be 1.0000, if the following criteria are met:
A) The service has not been designated with a Bilateral Procedure Discounting flag, Multiple Procedure Discounting flag, Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by the EAPG grouper under default EAPG settings; or
B) The service has not been designated with a Bilateral Procedure Discounting flag and has been designated with a Multiple Procedure Discounting flag by the EAPG grouper under default EAPG settings and the service has the highest EAPG weighting factor among other services with a Multiple Procedure Discounting flag provided on the same day.
2) The discounting factor will be 0.5000 if the following criteria are met:
A) The service has been designated with a Multiple Procedure Discounting flag, Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by the EAPG grouper under default EAPG settings; and if the Multiple Procedure Discounting flag is present, the service does not have the highest EAPG weighting factor among other services with a Multiple Procedure Discounting flag provided on the same day; and
B) The service has not been designated with a Bilateral Procedure Discounting flag by the EAPG grouper under default EAPG settings.
3) The discounting factor will be 0.7500 if the following criteria are met:
A) The service has been designated with a Bilateral Procedure Discounting flag by the EAPG grouper under default EAPG settings; and
B) The service has been designated with a Multiple Procedure Discounting flag, the Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by the EAPG grouper under default EAPG settings; and if the Multiple Procedure Discounting flag is present, the service does not have the highest EAPG weighting factor among other services with a Multiple Procedure Discounting flag provided on the same day.
4) The discounting factor will be 1.5000 if the following criteria are met:
A) The service has been designated with a Bilateral Procedure Discounting flag by the EAPG grouper under default EAPG settings; and
B) The service has not been designated with a Multiple Procedure Discounting flag, the Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by the EAPG grouper under default EAPG settings; or if the Multiple Procedure Discounting flag is present, the service has the highest EAPG weighting factor among other services with a Multiple Procedure Discounting flag provided on the same day.
f) Policy Adjustments. Claims for services by providers that meet certain criteria shall qualify for further adjustments to payment. If a claim qualifies for more than one policy adjustment, then the EAPG PPS payment will be multiplied by both factors.
1) Crossover Adjustment Factor
A) Acute EAPG standardized amounts, as defined in subsection (d)(4), shall be reduced by a Crossover Adjustment factor such that:
i) The absolute value of the total simulated payment reduction that occurs when applying the Crossover Adjustment Factor to simulated EAPG payments, including Policy Adjustments, using general acute hospital outpatient base period paid claims data, is equal to the amount derived in subsection (f)(1)(A)(ii):
ii) The difference of total simulated EAPG payments using general acute hospital outpatient crossover paid claims data, and general acute hospital outpatient crossover paid claims data total reported Medicaid net liability.
B) Crossover Adjustment Factor effective SFY 2015 and 2016 is 0.98912. Effective July 1, 2018, the Crossover Adjustment Factor is defined in (f)(1)(A)(i).
2) If a claim does not qualify for a Policy Adjustment described in subsection (f)(3) or (f)(4), the policy adjustment factor is 1.0.
3) High Outpatient Volume Hospital Effective July 1, 2018
A) High Outpatient Volume Hospital is defined as:
i) an Illinois hospital for which the high outpatient volume is at least one and one-half standard deviations above the mean regional high outpatient volume;
ii) an Illinois hospital for which the high outpatient volume is at least one and one-half standard deviations above the mean statewide high outpatient volume;
iii) an Illinois Safety-Net Hospital as defined in Section 149.100; or
iv) an Illinois Small Public Hospital, which is defined as any publicly owned hospital that is not a large public hospital as defined in Section 148.25.
B) Policy adjustment factor is set:
i) For acute care claims such that total expenditures on qualifying claims less the rate reductions defined in P.A. 97-0689 is increased by $79.2 million more than base period qualifying claims allowed amount.
ii) For non-acute care claims to equal the factor in place prior to July 1, 2018.
4) For High Outpatient Volume Hospitals effective on or after January 1, 2023:
A) The hospital is a High Outpatient Volume hospital, defined as:
i) an Illinois hospital for which the high outpatient volume is at least two times above the mean regional high outpatient volume;
ii) an Illinois hospital for which the high outpatient volume is at least one and one-half standard deviations above the mean statewide high outpatient volume;
iii) an Illinois Safety-Net Hospital as defined in 89 Ill. Adm. Code 149.100(f)(4); or
iv) an Illinois Small Public Hospital, which is defined as any publicly owned hospital that is not a large public hospital as defined in 89 Ill. Adm. Code 148.25.
B) Upon any update of EAPG groupers, the policy adjustment factor shall be set so that expenditures attributed to the adjustment factor on claims in the base period is equal to the expenditures attributed to the adjustment factor on the same claims under the new grouper.
g) Payment for outpatient end-stage renal disease treatment (ESRDT) services provided pursuant to Section 148.40(b) shall be made at the Department's payment rates, as follows:
1) For outpatient services or home dialysis treatments provided pursuant to Section 148.40(c)(2) or (c)(3), the Department will reimburse hospitals and clinics for ESRDT services at a rate that will reimburse the provider for the dialysis treatment and all related supplies and equipment, as defined in 42 CFR 405.2124 and 413.170 (2010). This rate will be the rate established by Medicare pursuant to 42 CFR 405.2124 and 413.170 (2010).
2) Payment for Non-routine Services. For services that are provided during outpatient or home dialysis treatment pursuant to Section 148.40(c)(2) or (c)(3), but are not defined as a routine service under 42 CFR 405.2163 (1994), separate payment will be made to independent laboratories, pharmacies, and medical supply providers pursuant to 89 Ill. Adm. Code 140.430 through 140.434, 140.440 through 140.50, and 140.75 through 140.481, respectively.
3) Payment for physician services relating to ESRDT will be made separately to physicians, pursuant to 89 Ill. Adm. Code 140.400.
4) Effective with dates of service July 1, 2013, hospital and freestanding chronic dialysis centers will receive an add-on payment of $60 per treatment day to the rate described in subsection (g)(1) for outpatient renal dialysis treatments or home dialysis treatments provided to Medicaid recipients under Title XIX of the Social Security Act, excluding services for individuals eligible for Medicare under Title XVIII of that Act (Medicaid/Medicare crossovers) and excluding services provided under Subpart D: State Chronic Renal Disease Program, as defined in Sections 148.600 through 148.640.
h) Updates to EAPG PPS Reimbursement. The Department may annually review the components listed in subsection (c) and make adjustments as needed. Grouper shall be updated at least triennially and no more frequently than annually.
i) Definitions, as used in this Section:
"Aggregate ancillary cost-to-charge ratio" means the ratio of each hospital's total ancillary costs and charges reported in the Medicare cost report, excluding special purpose cost centers and the ambulance cost center, for the cost reporting period matching the outpatient base period claims data. Aggregate ancillary cost-to-charge ratios applied to SFY 2011 outpatient base period claims data will be based on fiscal year ending 2011 Medicare cost report data.
"Allowed amounts" means the calculated fee schedule amount prior to any adjustment for secondary payer amounts for outpatient base period claims data. If volume in base period data is estimated to differ from rate year volume, then completion factors are applied.
"Consolidation factor" means a factor of 0 percent applicable for services designated with a Same Procedure Consolidation flag or Clinical Procedure Consolidation flag by the EAPG grouper under default EAPG settings.
"Default EAPG settings" means the default EAPG grouper options in 3M's Core Grouping Software for each EAPG grouper version, except where the Department made adjustments.
"Detailed ancillary cost-to-charge ratios" means for each standardized ancillary Medicare cost-center cost-to-charge ratios for each hospital calculated by dividing total costs in Worksheet C, Part 1, Column 5 and Worksheet B, Part 1, Columns 21 and 22 by total charges for each standardized ancillary Medicare cost center in Worksheet C, Part 1, Columns 6 and 7. For all hospitals missing Worksheet C, Part 1, Column 5 data, use Worksheet C, Part 1, Column 3 data. Use aggregate ancillary cost-to-charge ratios as a default when a cost-center specific cost-to-charge ratio is not available or the claim revenue code is all-inclusive ancillary.
"EAPG" means Enhanced Ambulatory Patient Groups, as defined in the EAPG grouper, which is a patient classification system designed to explain the amount and type of resources used in an ambulatory visit. Services provided in each EAPG have similar clinical characteristics and similar resource use and cost.
"EAPG grouper" means the version of the EAPG software, distributed by 3M Health Information Systems, being used by the Department for pricing hospital outpatient services in accordance with 305 ILCS 5/14-12(a), (b) and (e).
"EAPG PPS" means the EAPG prospective payment system as described in this Section.
"EAPG weighting factor" means, for each EAPG, the product, rounded to the nearest ten-thousandth, of:
the national weighting factor, as published by 3M Health Information Systems for the EAPG grouper; and
the Illinois experience adjustment.
"Estimated cost of outpatient base period claims data" means:
Prior to July 1, 2018, the product of:
outpatient base period paid claims data total covered charges;
the critical access hospital's aggregate ancillary cost-to-charge ratio; and
a rate year cost inflation factor.
Effective July 1, 2018, the product of:
Outpatient base period claims data total covered charges;
The critical access hospital's detailed ancillary cost-to-charge ratios; and
A rate year cost inflation factor.
"High outpatient volume" means the number paid outpatient claims described in subsection (b)(1) provided during the high volume outpatient base period paid claims data.
"High volume outpatient base period paid claims data" means:
Prior to July 1, 2018, SFY 2011 outpatient Medicaid fee-for-service paid claims data, excluding Medicare dual eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS payment for services provided in SFY 2015 and 2016. For subsequent dates of service, the term means the SFY ending 30 months prior to the beginning of the calendar year during which the service is provided.
Effective July 1, 2018, SFY 2015 outpatient Medicaid fee-for-service paid claims data and completed MCO encounter claims data, excluding Medicare dual eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS payment for services provided in SFY 2019 and 2020; for subsequent dates of service, the most recently available adjudicated 12 months of outpatient paid claims data to be identified by the Department.
"Illinois experience adjustment" means, for the calendar year beginning January 1, 2014, a factor of 1.0; for subsequent calendar years, means the factor applied to 3M EAPG national weighting factors when updating EAPG grouper versions determined such that the arithmetic mean EAPG weighting factor under the new EAPG grouper version is equal to the arithmetic mean EAPG weighting factor under the prior EAPG grouper version using outpatient base period claims data.
"In-state" means all:
Illinois hospitals; and
out-of-state hospitals that are designated a level I pediatric trauma center or a level I trauma center by the Illinois Department of Public Health as of December 1, 2017.
"Labor-related share" means that portion of the statewide standardized amount that is allocated in the EAPG PPS methodology to reimburse the costs associated with personnel. The labor-related share for a hospital is 0.60.
"Mean regional high outpatient volume" means the quotient, rounded to the nearest tenth, resulting from the number of paid outpatient services described in subsections (b)(1)(A) through (D), provided by hospitals within a region, based on outpatient base period paid claims data.
"Mean statewide high outpatient volume" means the quotient, rounded to the nearest tenth, resulting from the number of paid outpatient services described in subsections (b)(1)(A) through (D), provided by hospitals within the state, based on outpatient base period paid claims data.
"Medicare IPPS wage index" means for in-state providers and out-of-state Illinois Medicaid cost reporting providers, the wage index used for inpatient reimbursement as described in 89 Ill. Adm. Code 149.100. For out-of-state non‑cost reporting providers, the wage index used to adjust the EAPG standardized amount shall be a factor of 1.0.
"Non-labor share" means the difference resulting from the labor-related share being subtracted from 1.0.
"Outpatient base period paid claims data" means:
Prior to July 1, 2018, SFY 2011 outpatient Medicaid fee-for-service paid claims data, excluding Medicare dual eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS payment for services provided in SFY 2015, 2016 and 2017;
Effective July 1, 2018 through June 30, 2020, for in-state SFY 2015 outpatient Medicaid fee-for-service paid claims data and completed MCO encounter claims data, excluding Medicare dual eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS payment for services provided in SFY 2019 and 2020.
Effective July 1, 2020:
SFY 2017, or the most recent 12 months of available data as identified by the Department, outpatient Medicaid claims data, for in-state hospitals that are not large public hospitals; and
SFY 2017 and 2018, or the most recent 12 months of available data as identified by the Department, outpatient Medicaid claims data for out-of-state hospitals.
"Outpatient crossover paid claims data" means:
Outpatient Medicaid/Medicare dual eligible fee-for-service and managed care paid claims data, excluding renal dialysis claims and therapy claims, with dates of service from the same time period as outpatient base period claims data.
"Packaging factor" means a factor of 0 percent applicable for services designated with a Packaging flag by the EAPG grouper under default EAPG settings plus EAPG 430 (Class I Chemotherapy Drugs), EAPG 435 (Class I Pharmacotherapy), EAPG 495 (Minor Chemotherapy Drugs), EAPG 496 (Minor Pharmacotherapy), and EAPGs 1001-1020 (Durable Medical Equipment Level 1-20), and non-covered revenue codes defined in the Handbook for Hospital Services.
"Rate year cost inflation factor" means the cost inflation from the midpoint of the outpatient base period paid claims data to the midpoint of the rate year based on changes in Centers for Medicare and Medicaid Services (CMMS) input price index levels. For critical access hospital rates effective SFY 2015, the rate year cost inflation factor will be based on changes in CMMS input price index levels from the midpoint of SFY 2011 to SFY 2015.
"Region" means, for a given hospital, the rate region, as defined in 89 Ill. Adm. Code 140.Table J, within which the hospital is located.
"SFY" means State fiscal year.
"Total covered charges" means the amount entered for revenue code 001 in column 53 (Total Charges) on the Uniform Billing Form (form CMMS 1450), or one of its electronic transaction equivalents.
j) Supplemental Payment. A one-time supplemental payment will be made to a critical access hospital (which is an Illinois hospital designated by the Illinois Department of Public Health in accordance with 42 CFR 485 Subpart F) for outpatient discharges occurring in SFY 2019 for which the outpatient claims were priced and paid under the methodology in subsection (d)(3)(A). The amount of the supplemental payment will be equal to the difference of:
1) The payment amount of each claim calculated using the critical access hospital EAPG standardized amount set to equal a 23% increase in simulated EAPG payments using base period paid claims data set forth in subsection (d)(3)(B); and
2) The payment amount of each claim calculated using the critical access hospital EAPG standardized amount in effect on July 1, 2018.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.150 Public Law 103-66 Requirements
a) All cost reporting hospitals are required to submit annually, on or before August 15 of the rate year in a form or format specified by the Department, at least the following information separated by inpatient and outpatient (including hospital-based clinic services) to the Department:
1) The dollar amount of Illinois Medicaid charges rendered in the base year.
2) The dollar amount of hospital charity care charges rendered in the base year for uninsured patients.
3) The dollar amount of hospital bad debt, less any recoveries, rendered in the base year for uninsured patients.
4) The dollar amount of Illinois total hospital charges for care rendered in the base year.
b) Definitions
1) "Medicaid charges" means hospital charges for inpatient, outpatient and hospital-based clinic services provided to recipients of medical assistance under Title XIX of the Social Security Act.
2) "Total charges" means the total amount of a hospital's charges for inpatient, outpatient and hospital-based clinic services it has provided.
3) "Base year" means the hospital's cost reporting period, utilized in the current rate year disproportionate share determination, and as described in Section 148.120(i)(1).
4) "Hospital charity care charges" and "hospital bad debt" mean inpatient, outpatient and hospital clinic services provided to individuals without health insurance or other sources of third party coverage. For purposes of the previous statement in this subsection (b)(4), State or unit of local government payments made to a hospital on behalf of indigent patients is not considered to be a form of insurance or a source of third-party coverage. Therefore, unreimbursed charges for persons covered under these programs may be included. Charity care charges and bad debt cannot include unpaid co-pays or third party obligations of insured patients, contractual allowances, or the hospital's charges or reduced charges attributable to services provided under its obligation pursuant to the federal Hill-Burton Act (42 USC 291).
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.160 Payment Methodology for County-Owned Large Public Hospitals
a) Effective for dates of outpatient services on or after July 1, 2014 and inpatient discharges on July 1, 2014 through December 31, 2015:
1) Inpatient Reimbursement Methodology
In accordance with 89 Ill. Adm. Code 149.50(b)(5), county-owned hospitals, as defined in Section 148.25(a)(1), are excluded from the DRG PPS for reimbursement for inpatient hospital services and are reimbursed on a per diem basis.
A) Inpatient Per Diem Rate Calculation
County-owned hospital inpatient per diem rates are calculated as follows:
i) Each county-owned hospital's inpatient base year costs, including operating capital and direct medical education costs, shall be calculated using inpatient base period claims data and Medicare cost report data with reporting periods matching the inpatient base period. Effective July 1, 2018, direct and indirect medical education costs shall be reduced from the inpatient base year cost.
ii) The inpatient base year costs shall be inflated from the midpoint of the inpatient base period claims data to the midpoint of the time period for which rates are being set (rate period) based on an inflation methodology determined by the Department and approved by Centers for Medicare and Medicaid Services (CMMS).
iii) Calculate the sum of:
· The total hospital inflated base year costs, excluding non-Medicare crossover claims, in the inpatient base period claims data; and
· Total uncovered Medicare crossover claim cost in the inpatient base period claims data.
iv) The inpatient per diem rate shall be the quotient of:
· Combined inflated base year cost and uncovered Medicare crossover claims cost, per subsection (a)(1)(C); and
· Total hospital base year covered days, excluding non-Medicare crossover claims, in the inpatient base period claims data.
v) The inpatient per diem rates shall be reduced if resulting payments exceed available Department funding or the CMMS Upper Payment Limit.
B) Rate Updates
County-owned hospital per diem rates shall be updated on an annual basis using more recent inpatient base period claims data, Medicare cost report data and cost inflation data.
C) New hospitals, for which inpatient base period claims data or Medicare cost reports are not on file, will be reimbursed the per diem rate calculated in subsection (a)(1)(A).
D) Review Procedure
The review procedure shall be in accordance with Section 148.310.
2) Outpatient Reimbursement Methodology
Large public hospitals, as defined in Section 148.25(a), are included in the EAPG PPS for reimbursement for outpatient hospital services as described in Section 148.140, and are to receive provider-specific EAPG standardized amounts.
A) Outpatient EAPG Standardized Amount Calculation
County-owned hospital outpatient EAPG standardized amounts are calculated as follows:
i) Each county-owned hospital's outpatient base year costs, including operating, capital and direct medical education costs, shall be calculated using outpatient base period claims data and Medicare cost report data with reporting periods matching the outpatient base period.
ii) The outpatient base year costs shall be inflated from the midpoint of the outpatient base period claims data to the midpoint of the rate period based on an inflation methodology determined by the Department and approved by CMMS.
iii) Prior to July 1, 2018, EAPG standardized amounts shall be determined for each county-owned hospital such that simulated EAPG payments are equal to outpatient base period costs inflated to the rate period, based on outpatient based period paid claims data. Effective July 1, 2018, EAPG standardized amounts shall be determined for each county-owned hospital such that simulated EAPG payments are equal to outpatient base period costs inflated to the rate period, based on outpatient based period claims data, less an amount calculated in Section 148.406(f).
iv) EAPG standardized amounts shall be reduced if resulting payments exceed available HFS funding or the CMMS Upper Payment Limit.
B) Rate Updates and Adjustments
i) County-owned hospital EAPG standardized amounts shall be updated on an annual basis using more recent outpatient base period claims data, Medicare cost report data, and costs inflation data.
ii) Restructuring Adjustments
Adjustments to outpatient base year costs, as described in subsection (a)(2)(A), will be made to reflect restructuring since filing the base year costs reports. The restructuring must have been mandated to meet State, federal or local health and safety standards. The allowable Medicare/Medicaid costs (see 42 CFR 405, Subpart D, (1982)) must be incurred as a result of mandated restructuring and identified from the most recent audited cost reports available before or during the rate year. The restructuring cost must be significant, i.e., on a per unit basis; they must constitute one percent or more of the total allowable Medicare/Medicaid unit costs for the same time period. The Department will use the most recent available cost reports to determine restructuring costs.
C) New hospitals, for which outpatient base period claims data or Medicare cost reports are not on file, will be reimbursed the EAPG standardized amount calculated in subsection (a)(2)(A).
D) Review Procedure
The review procedure shall be in accordance with Section 148.320.
3) Definitions, as used in this Section:
"Inpatient base period paid claims data" means:
Prior to July 1, 2018, Medicaid fee-for-service inpatient paid claims data from the State fiscal year ending 36 months prior to the beginning of the rate period.
Effective July 1, 2018, Medicaid fee-for-service and MCO encounter inpatient claims data from the State fiscal year ending 12 months prior to the beginning of the rate period.
"Outpatient base period paid claims data" means:
Prior to July 1, 2018, Medicaid fee-for-service outpatient paid claims data from the State fiscal year ending 36 months prior to the beginning of the rate period, excluding crossover claims.
Effective July 1, 2018, Medicaid fee-for-service and MCO encounter outpatient claims data from the State fiscal year ending 12 months prior to the beginning of the rate period, excluding crossover claims.
"Rate period" means the State fiscal year for which the county-owned hospital inpatient and outpatient rates are effective.
b) Effective for inpatient acute care discharges on or after January 1, 2016, county-owned hospitals, as defined in Section 148.25(a)(1), shall be reimbursed at allowable cost on a DRG basis. The DRG base payment shall be the product, rounded to the nearest hundredth, of:
1) The DRG weighting factor of the DRG and SOI (severity of illness), to which the inpatient stay was assigned by the grouper.
2) The DRG base rate determined:
A) Prior to July 1, 2018, such that simulated base period as defined in subsection (a)(3) DRG payments are equal to adjusted base period costs, as determined in subsection (a)(1)(A)(ii); and
B) Effective July 1, 2018, such that simulated DRG payments are equal to inpatient base period costs inflated to the rate period, based on inpatient based period claims data, less an amount calculated in Section 148.406(c).
(Source: Amended at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.170 Payment Methodology for University-Owned Large Public Hospitals
a) Effective for dates of outpatient services on or after July 1, 2014 and inpatient discharges on July 1, 2014 through December 31, 2015:
1) Inpatient Reimbursement Methodology
In accordance with 89 Ill. Adm. Code 149.50(b)(5), a large public hospital, as defined in Section 148.25(a)(2), is excluded from the DRG PPS for reimbursement for inpatient hospital services and shall be reimbursed on a per diem basis.
A) Inpatient Per Diem Rate Calculation
University-owned hospital inpatient per diem rates are calculated as follows:
i) Each University-owned hospital's inpatient base year costs, including operating, capital and direct medical education costs, shall be calculated using inpatient base period claims data and Medicare cost report data with reporting periods matching the inpatient base period. Effective July 1, 2018, direct and indirect medical education costs shall be reduced from the inpatient base year cost.
ii) The inpatient base year costs shall be inflated from the midpoint of the inpatient base period claims data to the midpoint of the time period, for which rates are being set (rate period) based on an inflation methodology determined by the Department and approved by the Center for Medicare and Medicaid Services (CMMS).
iii) Calculate the sum of:
· The total hospital inflated base year costs, excluding non-Medicare crossover claims, in the inpatient base period claims data; and
· Total uncovered Medicare crossover claim cost in the inpatient base period claims data.
iv) The inpatient per diem rate shall be the quotient of:
· Combined inflated base year cost and uncovered Medicare crossover claims cost, per subsection (a)(1)(A)(iii); and
· Total hospital base year covered days, excluding non-Medicare crossover claims, in the inpatient base period claims data.
v) The inpatient per diem rates shall be reduced if resulting payments exceed available Department funding or the CMMS Upper Payment Limit.
B) Rate Updates and Adjustments
University-owned hospital per diem rates shall be updated on an annual basis using more recent inpatient base period claims data, Medicare cost report data and cost inflation data.
C) New hospitals, for which inpatient base period claims data or Medicare cost reports are not on file, will be reimbursed the per diem rate calculated in subsection (a)(1)(A).
D) Review Procedure
The review procedure shall be in accordance with Section 148.310.
E) Applicable Adjustment for DSH Hospitals
The criteria and methodology for making applicable adjustments to DSH hospitals shall be in accordance with Section 148.120.
2) Outpatient Reimbursement Methodology
Large public hospitals, as defined in Section 148.25(a)(2), are included in the EAPG PPS for reimbursement for outpatient hospital services as described in Section 148.140 and are to receive a provider-specific EAPG standardized amount.
A) Outpatient EAPG Standardized Amount Calculation
University-owned hospital outpatient EAPG standardized amount is calculated as follows:
i) Each University-owned hospital's outpatient base year costs, including operating, capital and direct medical education costs, shall be calculated using outpatient base period claims data and Medicare cost report data with reporting periods matching the outpatient base period.
ii) The outpatient base year costs shall be inflated from the midpoint of the outpatient base period claims data to the midpoint of the rate period based on an inflation methodology determined by the Department and approved by CMMS.
iii) Prior to July 1, 2018, EAPG standardized amounts shall be determined for each State-owned hospital such that simulated EAPG payments are equal to outpatient base period costs inflated to the rate period, based on outpatient based period paid claims data. Effective July 1, 2018, EAPG standardized amounts shall be determined for each county-owned hospital such that simulated EAPG payments are equal to outpatient base period costs inflated to the rate period, based on outpatient based period claims data, less an amount calculated in 148.406(f).
iv) EAPG standardized amounts shall be reduced if resulting payments exceed available Department funding or the Centers for Medicare and Medicaid Services Upper Payment Limit.
B) Rate Updates and Adjustments
State-owned hospital EAPG standardized amounts shall be updated on an annual basis using more recent outpatient base period claims data, Medicare cost report data and cost inflation data.
C) Review Procedure
The review procedure shall be in accordance with Section 148.310.
3) Definitions, as used in this Section:
"Inpatient base period paid claims data" means:
Prior to July 1, 2018, Medicaid fee-for-service inpatient paid claims data from the State fiscal year ending 36 months prior to the beginning of the rate period.
Effective July 1, 2018, Medicaid fee-for-service and MCO encounter inpatient claims data from the State fiscal year ending 12 months prior to the beginning of the rate period.
"Outpatient base period paid claims data" means:
Prior to July 1, 2018, Medicaid fee-for-service outpatient paid claims data from the State fiscal year ending 36 months prior to the beginning of the rate period, excluding crossover claims.
Effective July 1, 2018, Medicaid fee-for-service and MCO encounter outpatient claims data from the State fiscal year ending 12 months prior to the beginning of the rate period, excluding crossover claims.
"Rate period" means the State fiscal year for which the University-owned hospital inpatient and outpatient rates are effective.
b) Effective for inpatient acute care discharges on or after January 1, 2016, University-owned hospitals, as defined in Section 148.25(a)(2), shall be reimbursed at allowable cost on a DRG basis. The DRG base payment shall be the product, rounded to the nearest hundredth, of:
1) The DRG weighting factor of the DRG and SOI, to which the inpatient stay was assigned by the grouper.
2) Prior to July 1, 2018, the DRG base rate determined such that simulated base period as defined in subsection (a)(3) DRG payments are equal to adjusted base period costs, as determined in subsection (a)(1)(A)(ii). Effective July 1, 2018, the DRG base rate shall be determined such that simulated DRG payments are equal to inpatient base period costs inflated to the rate period, based on inpatient based period claims data, less an amount calculated in Section 148.406(c).
(Source: Amended at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.175 Supplemental Disproportionate Share Payment Methodology for Hospitals Organized Under the Town Hospital Act (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.180 Payment for Pre-operative Days and Patient Specific Orders
Effective for dates of discharge on or after July 1, 2014:
a) Pre-operative Days. For hospitals and distinct part units reimbursed on a per diem basis under Sections 148.105, 148.110, 148.116, 148.160 or 148.170, payment for pre-operative days shall be limited to the day immediately preceding surgery unless the attending physician has documented the medical necessity of an additional day or days. The documentation must be kept in the patient's medical record and must consist of a written notation made by the physician which documents that more than one pre-operative day is medically necessary.
b) Ancillary Services and Tests
1) Ancillary services and routine tests (those services other than routine room and board and nursing which are required because of the patient's medical condition, including lab tests and x-rays) shall not be covered unless there is a patient specific written order for the test from the attending or operating physician responsible for the care and treatment of the patient. The attending or operating physician responsible for the care and treatment of the patient is required to sign all applicable sections for each test ordered in the appropriate place in the medical record. The order must be legible and explain completely all services or tests to be performed. Standing orders are not acceptable.
2) Upon completion of the service or test, a fully documented description of results with findings, or the administration of medication, must be maintained in the patient medical records. Radiological services must have the actual x-rays and the interpretation report; laboratory/pathological tests must have the specific findings for each test; and drugs and pharmaceutical supplies must indicate strength, dosages and durations.
3) Charges for any and all such services or tests cannot exceed those charged to the general public. The failure to maintain and provide records as described in this Section shall result in the disallowance of the applicable charges upon audit.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.190 Copayments
The following implements cost sharing in compliance with 42 USC 1396o (section 1916 of the Social Security Act):
a) With the exception of those classes of individuals identified in 89 Ill. Adm. Code 140.402(d) and those services identified in 89 Ill. Adm. Code 140.402(e), copayments will be assessed on inpatient services provided under all Medical Assistance Programs administered by the Department, as provided in the Illinois Public Aid Code [305 ILCS 5]. Effective July 1, 2012 through August 31, 2019, copayments will be in the following amounts:
1) Inpatient hospital services: a daily copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013 through August 31, 2019, the nominal copayment amount is $3.90.
2) Non-emergency services defined as Non-emergency/Screening Level in Section 148.140(b) rendered in an emergency room: a nominal copayment amount as defined in federal regulations at 42 CFR 447.50 et seq., which, for dates of service beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1, 2013 through August 31, 2019, the nominal copayment amount is $3.90.
b) In each instance where a copayment is payable, the Department will reduce the amount payable to the affected provider by the amount of the required copayment.
c) No provider may deny care or services on account of an individual's inability to pay a copayment; this requirement, however, shall not extinguish the liability for payment of the copayment by the individual to whom the care or services were furnished.
(Source: Amended at 44 Ill. Reg. 18579, effective November 9, 2020)
Section 148.200 Alternate Reimbursement Systems (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.210 Filing Cost Reports
a) Excepting those operated by an agency of the United States government, all hospitals in Illinois and hospitals in contiguous states providing 100 or more paid acute inpatient days of care to the Illinois Medicaid Program shall be required to file Medicaid and Medicare cost reports within 150 days after the close of that provider's fiscal year. Any hospital accredited by TJC or another Health and Human Services Approved Accreditation Organization not eligible for or subject to Medicare certification shall be required to file financial statements, a statement of revenues and expenses by program and census logs by program and financial class. The Bureau of Health Finance may request an audit of the financial statements by an independent Certified Public Accountant (CPA) firm if the financial statements are to be used as the base year for rate analysis.
b) No extension of the Medicaid cost report due date will be granted by the Department unless the Centers for Medicare and Medicaid Services (CMMS) grants an extension of the due date for the related Medicare cost report. Should CMMS extend the Medicare cost report due date, the Department will extend the Medicaid and Medicare cost reports due date by an equivalent period of time.
c) If the hospital has not filed the required Medicaid cost reports within 150 days after the close of the hospital's fiscal year, the Department shall suspend payment for covered medical services until the Department receives the required information.
e) Cost Report Reviews
The Bureau of Health Finance shall audit the information shown on the cost reports. The audit shall be made in accordance with generally accepted auditing standards and shall include tests of the accounting and statistical records and applicable auditing procedures. Hospitals shall be notified of the results of the final audited cost report, which may contain adjustments and revisions that may have resulted from the audited Medicare Cost Report. Hospitals shall have the opportunity to request a review of the final audited cost report. The request must be received in writing by the Department within 45 days after the date of the Department's notice to the hospital of the results of the finalized audit. The request shall include all items of documentation and analysis that support the request for review. No additional data shall be accepted after the 45 day period.
f) Hospitals described in Section 148.25(a)(1) and (a)(2) shall be required to submit outpatient cost reports to the Department within 150 days after the close of the facility's fiscal year.
(Source: Amended at 39 Ill. Reg. 10824, effective July 27, 2015)
Section 148.220 Pre September 1, 1991, Admissions (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.230 Admissions Occurring on or after September 1, 1991 (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.240 Utilization Review and Furnishing of Inpatient Hospital Services Directly or Under Arrangements
Effective for dates of discharge on or after July 1, 2014:
a) Utilization Review
The Department, or its designated peer review organization, shall conduct utilization review in compliance with Section 1152 of the Social Security (42 U.S.C. 1320c-1) and 42 (Chapter IV, Subchapter F (October 1, 2013). A peer review shall be conducted by a Physician Peer Reviewer who is licensed to practice medicine in all its branches, engaged in the active practice of medicine, board certified or board eligible in the physician's specialty and has admitting privileges in one or more Illinois hospitals. Payment will only be made for those admissions and days approved by the Department or its designated peer review organization. Utilization review may consist of, but not be limited to, preadmission, concurrent, pre-payment, and post-payment reviews to determine, pursuant to 42 CFR 476, Subpart C (October 1, 2013), the following:
1) Whether the services are or were reasonable and medically necessary for the diagnosis and treatment of illness or injury;
2) The medical necessity, reasonableness and appropriateness of hospital admissions and discharges, including, but not limited to, the coordination of care requirements defined in Section 148.40(a)(9) for the Children's Mental Health Screening, Assessment and Support Services (SASS) Program;
3) Through DRG validation, the validity of diagnostic and procedural information supplied by the hospital;
4) The completeness, adequacy and quality of hospital care provided;
5) Whether the quality of the services meets professionally
recognized standards of health care; or
6) Whether those services furnished or proposed to be furnished on an inpatient basis could, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient health care facility of a different type.
b) Notice
of Utilization Review
The Department shall provide hospitals with notice 30 days before a service is subject to utilization review, as described in subsections (c), (d), (e) and (f) of this Section, that the service is subject to such review. In determining whether a particular service is subject to utilization review, the Department may consider factors that include:
1) Assessment of appropriate level of care;
2) The service could be furnished more economically on an outpatient basis;
3) The inpatient hospital stays for the service deviate from the norm for inpatient stays using accepted length of stay criteria;
4) The cost of care for the service;
5) Denial rates; and
6) Trends or patterns that indicate potential for abuse.
c) Preadmission Review
Preadmission review may be conducted prior to admission to a hospital to determine if the services are appropriate for an inpatient setting. The Department shall provide hospitals with notice of the criteria used to determine medical necessity in preadmission reviews 30 days before a service is subject to preadmission review.
d) Concurrent Review
Concurrent review consists of a certification of admission and, if applicable, a continued stay review.
1) The certification of admission is performed to determine the medical necessity of the admission and to assign an initial length of stay based on the criteria for the admission.
2) The continued stay review is conducted to determine the medical necessity and appropriateness of continuing the inpatient hospitalization. More than one continued stay review can be performed in an inpatient stay.
e) Pre-payment Review
The Department may require hospitals to submit claims to the Department for pre-payment review and approval prior to rendering payment for services provided.
f) Post-payment Review
Post-payment review shall be conducted on a random sample of hospital stays following reimbursement to the hospital for the care provided. The Department may also conduct post-payment review on specific types of care.
g) Hospital Utilization Control
Hospitals and distinct part units that participate in Medicare (Title XVIII) must use the same utilization review standards and procedures and review committee for Medicaid as they use for Medicare. Hospitals and distinct part units that do not participate in Medicare must meet the utilization review plan requirements in 42 CFR 456 (October 1, 2013). Utilization control requirements for inpatient psychiatric hospital care in a psychiatric hospital, as defined in 89 Ill. Adm. Code 148.25(d)(1) shall be in accordance with the federal regulations.
h) Denial
of Payment as a Result of Utilization Review
1) If the Department determines, as a result of utilization review, that a hospital has misrepresented admissions, length of stay, discharges, or billing information, or has taken an action that results in the unnecessary admission or inappropriate discharge of a program participant, unnecessary multiple admissions of a program participant, unnecessary transfer of a program participant, or other inappropriate medical or other practices with respect to program participants or billing for services furnished to program participants, the Department may, as appropriate:
A) Deny payment (in whole or in part) with respect to inpatient hospital services provided with respect to such an unnecessary admission, inappropriate length of stay or discharge, subsequent readmission, transfer of an individual or failure to comply with the coordination of care requirements of Section 148.40.
B) Require the hospital to take action necessary to prevent or correct the inappropriate practice.
2) When payment with respect to the discharge of an individual patient is denied by the Department or its designated peer review organization, under subsection (h)(1)(A) as a result of prepayment review, a reconsideration will be provided within 30 days upon the request of a hospital or physician if such request is the result of a medical necessity or appropriateness of care denial determination and is received within 60 days after receipt of the notice of denial. The date of the notice of denial is counted as day one.
3) When payment with respect to the discharge of an individual patient is denied by the Department or its designated peer review organization under subsection (h)(1)(A) as a result of a preadmission or concurrent review, the hospital or physician may request an expedited reconsideration. The request for expedited reconsideration must include all the information, including the medical record, needed for the Department or its designated peer review organization to make its determination. A determination on an expedited reconsideration request shall be completed within one business day after the Department's or its designated peer review organization's receipt of the request. Failure of the hospital or physician to submit all needed information shall toll the time in which the reconsideration shall be completed. The results of the expedited reconsideration shall be communicated to the hospital by telephone within one business day and in writing within three business days after the determination.
4) A determination under subsection (h)(1), if it is related to a pattern of inappropriate admissions, length of stay and billing practices that has the effect of circumventing the prospective payment system, may result in:
A) Withholding payment (in full or in part) to the hospital until the hospital provides adequate assurances of compliance; or
B) Termination of the hospital's Provider Agreement.
i) Furnishing of Inpatient Hospital Services Directly or Under Other Arrangements
1) The applicable payments made under this Part and 89 Ill. Adm. Code 149 are payment in full for all inpatient hospital services other than for the services of nonhospital-based physicians to individual program participants and the services of certain hospital-based physicians as described in subsections (i)(1)(B)(i) through (i)(1)(B)(v).
A) Hospital-based physicians who may not bill separately on a fee-for-service basis:
i) A physician whose salary is included in the hospital's cost report for direct patient care.
ii) A teaching physician who provides direct patient care, if the salary paid to the teaching physician by the hospital or other institution includes a component for treatment services.
B) Hospital-based physicians who may bill separately on a fee-for-service basis:
i) A physician whose salary is not included in the hospital's cost report for direct patient care.
ii) A teaching physician who provides direct patient care, if the salary paid to the teaching physician by the hospital or other institution does not include a component for treatment services.
iii) A resident, when, by the terms of his or her contract with the hospital, he or she is permitted to and does bill private patients and collect and retain the payments received for those services.
iv) A hospital-based specialist who is salaried, with the cost of his or her services included in the hospital reimbursement costs, when, by the terms of his or her contract with the hospital, he or she may charge for professional services and does, in fact, bill private patients and collect and retain the payments received.
v) A physician holding a nonteaching administrative or staff position in a hospital or medical school, to the extent that he or she maintains a private practice and bills private patients and collects and retains payments made.
2) Charges are to be submitted on a fee-for-service basis only when the physician seeking reimbursement has been personally involved in the services being provided. In the case of surgery, it means presence in the operating room, performing or supervising the major phases of the operation, with full and immediate responsibility for all actions performed as a part of the surgical treatment.
j) "Designated peer review organization" means an organization designated by the Department that is experienced in utilization review and quality assurance, which meets the guidelines in 42 U.S.C. 1320c-1 and 42 CFR 475 (2013).
(Source: Amended at 47 Ill. Reg. 13121, effective August 25, 2023)
Section 148.250 Determination of Alternate Payment Rates to Certain Exempt Hospitals (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.260 Calculation and Definitions of Inpatient Per Diem Rates (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.270 Determination of Alternate Cost Per Diem Rates For All Hospitals; Payment Rates for Certain Exempt Hospital Units; and Payment Rates for Certain Other Hospitals (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.280 Reimbursement Methodologies for Children's Hospitals and Hospitals Reimbursed Under Special Arrangements (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.285 Excellence in Academic Medicine Payments (Repealed)
(Source: Repealed at 37 Ill. Reg. 10432, effective June 27, 2013)
Section 148.290 Adjustments and Reductions to Total Payments
Effective for dates of outpatient services on or after July 1, 2014 and inpatient discharges on or after July 1, 2014:
a) The adjustments described in this Section, as applicable, shall be made to reimbursement amounts calculated pursuant to Sections 148.105, 148.110, 148.115, 148.140, 148.160, 148.170, 148.330 and 89 Ill. Adm. Code 149.100 prior to payment. The adjustments are to be applied in the order in which they are listed in this Section.
b) Adjustments to base rates made pursuant to 89 Ill. Adm. Code 152.150.
c) Increases in Payments. Supplemental payments pursuant to the Long Term Acute Care Hospital Quality Improvement Transfer Program Act [210 ILCS 155] in accordance with Section 148.115(f).
d) Reductions in Payments. The Department's payment obligation shall be reduced by:
1) Charges. Except for reimbursement calculated under Sections 148.140, 148.160 and 148.170, payment shall not exceed the lesser of:
A) The reimbursement amount determined pursuant to subsections (a) and (b).
B) The allowable charges billed to the Department on the claim.
2) Hospital Rate Reductions. Payment shall be reduced pursuant to the provisions of 89 Ill. Adm. Code 152.100.
3) Third-party Liability. Hospitals shall determine whether services are covered, in whole or in part, under any program or under any other private group indemnification or insurance program or managed care entity. To the extent that coverage is available, the Department's payment obligation shall be reduced.
4) Copayments. Copayments are assessed in accordance with Section 148.190.
e) Increases in Payments. The Department's payments obligations shall be increased, if applicable, by:
1) Medicaid high volume adjustment payments pursuant to Section 148.112.
2) Medicaid percentage adjustment payments pursuant to Section 148.122.
3) DSH adjustment payments pursuant to Section 148.120.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.295 Critical Hospital Adjustment Payments (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.296 Transitional Supplemental Payments (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.297 Physician Development Incentive Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.298 Pediatric Inpatient Adjustment Payments (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.299 Medicaid Facilitation and Utilization Payments (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.300 Payment
Effective for dates of service on or after July 1, 2014:
a) The Department will adjust rate methodologies used to reimburse hospitals to assure compliance with applicable aggregate and hospital-specific federal payment limitations.
b) Effect of Change of Ownership on Payments. When a hospital's ownership changes, payment for hospital services for each patient, including payment adjustments, will be made to the entity that is the legal owner on the date of discharge. Payment will not be prorated between the buyer and seller.
1) The owner on the date of discharge is entitled to submit a bill for all inpatient hospital services furnished regardless of when the client's coverage began or ended during a stay, or how long the stay lasted.
2) Each bill submitted must include all information necessary for the Department to compute the payment amount, whether some of the information is attributable to a period during which a different party legally owned the hospital.
c) Notwithstanding any other provisions of 89 Ill. Adm. Code 148, 149 or 152, a hospital that is located in a county of the State in which the Department mandates some or all of the beneficiaries of the Medical Assistance Program residing in the county to enroll in a Care Coordination Program, as defined in Section 5-30 of the Illinois Public Aid Code, shall not be eligible for any non-claims based payments not mandated by Article V-A of the Illinois Public Aid Code that it would otherwise be qualified to receive, unless the hospital is a Coordinated Care Participating Hospital, as defined in Section 148.25(f), no later than August 14, 2012, or 60 days after the first mandatory enrollment of a beneficiary in a Coordinated Care Program.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.310 Review Procedure
Effective for dates of service on or after July 1, 2014:
a) Rate Reviews
Hospitals shall be notified of their rates for the rate year and shall have an opportunity to request a review, pursuant to subsection (f), of any rate for errors in calculation made by the Department.
b) Disproportionate Share Hospital (DSH) and Medicaid Percentage Adjustment (MPA) Determination Reviews
1) Hospitals shall be notified of their qualification for DSH or MPApayment adjustments and shall have an opportunity to request a review pursuant to subsection (f) of the DSH or MPA add-on for errors in calculation made by the Department.
2) DSH or MPA determination reviews shall be limited to the following:
A) DSH or MPA Determination Criteria. The criteria for DSH determination shall be in accordance with Section 148.120. The criteria for MPA determination shall be in accordance with Section 148.122. Review shall be limited to verification that the Department utilized criteria in accordance with State regulations.
B) Medicaid Inpatient Utilization Rates.
i) Medicaid inpatient utilization rates shall be calculated pursuant to Section 1923 of the Social Security Act and as defined in Section 148.120(i)(4). Review shall be limited to verification that Medicaid inpatient utilization rates were calculated in accordance with federal and State regulations.
ii) Hospitals' Medicaid inpatient utilization rates, as defined in Section 148.120(i)(4), which have been derived from unaudited cost reports, are not subject to the Review Procedure with the exception of errors in calculation by the Department. Pursuant to Section 148.120(c)(1)(B), hospitals shall have the opportunity to submit corrected information prior to the Department's final DSH or MPA determination.
C) Low Income Utilization Rates. Low Income utilization rates shall be calculated in accordance with Section 1923 of the Social Security Act, as defined in Section 148.120(a)(2). Review shall be limited to verification that low income utilization rates were calculated in accordance with federal and State regulations.
D) Federally Designated Health Manpower Shortage Areas (HMSAs). Illinois hospitals located in federally designated HMSAs shall be identified in accordance with 42 CFR 5 (1989) and Section 148.122(a)(3) based upon the methodologies utilized by, and the most current information available to, the Department from the federal Department of Health and Human Services. Review shall be limited to hospitals in locations that have failed to obtain designation as federally designated HMSAs only when such a request for review is accompanied by documentation from the Department of Health and Human Services substantiating that the hospital was located in a federally designated HMSA.
E) Excess Beds. Excess bed information shall be determined in accordance with Public Act 86-268 (Section 148.122(a)(3) and 77 Ill. Adm. Code 1100) based upon the methodologies utilized by, and the most current information available to, the Illinois Health Facilities Planning Board as of July 1, 1991. Reviews shall be limited to requests accompanied by documentation from the Illinois Health Facilities Planning Board substantiating that the information supplied to and utilized by the Department was incorrect.
F) Medicaid Obstetrical Inpatient Utilization Rates. Medicaid obstetrical inpatient utilization rates shall be calculated in accordance with Section 148.122(g)(3). Review shall be limited to verification that Medicaid obstetrical inpatient utilization rates were calculated in accordance with State regulations.
c) Outlier Adjustment Reviews
The Department shall make outlier adjustments to payment amounts in accordance with 89 Ill. Adm. Code 149.105. Hospitals shall be notified of the specific information that shall be utilized in the determination of those services qualified for an outlier adjustment and shall have an opportunity to request a review, pursuant to subsection (f), of specific information for errors in calculation made by the Department.
d) Cost Report Reviews
Cost report reviews are described in Section 148.210(e).
e) Medicaid High Volume Adjustment Reviews
The Department shall make Medicaid high volume adjustments in accordance with Section 148.112. Hospitals shall be notified of the Department's determination and have an opportunity to request a review, pursuant to subsection (f). That review shall be limited to verification that the Medicaid inpatient days were calculated in accordance with Section 148.120.
f) Rate Review Requirements
1) Requests for Review
A) All requests for review must be submitted in writing and must either be received by the Department, or post marked within 30 days after the date of the Department's notice to the hospital. The request shall include:
i) a clear explanation of any suspected error;
ii) any additional documentation to be considered; and
iii) the desired corrective action.
B) The Department shall notify the hospital of the results of the review within 30 days after receipt of the hospital's request for review.
2) The review procedures provided for in this Section may not be used to submit any new or corrected information that was required to be submitted by a specific date in order to qualify for a payment or payment adjustment. In addition, only information that was submitted expressly for the purpose of qualifying for the payment or payment adjustment under review shall be considered by the Department. Information that has been submitted to the Department for other purposes will not be considered during the review process.
3) For purposes of this subsection (f), the term "post marked" means the date of processing by the United States Post Office or any independent carrier service.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.320 Alternatives (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.330 Exemptions
Effective for dates of service on or after July 1, 2014, nothing in this Part is intended to prevent a hospital from individually negotiating with the Department to set up an alternate methodology for reimbursement that results in an expenditure that does not exceed the expenditure that would otherwise be made under this Part.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.340 Subacute Alcoholism and Substance Abuse Treatment Services
a) Payment may be made for subacute alcoholism and other substance abuse treatment services provided by:
1) A provider licensed by the Illinois Department of Human Services under the provisions of 77 Ill. Adm. Code 2060.
2) A provider licensed by the Illinois Department of Public Health under the provisions of 77 Ill. Adm. Code 250.2830(b) and (c).
3) Psychiatrists for ancillary diagnostic services.
b) Providers must be certified for participation by the Department of Human Services in accordance with 77 Ill. Adm. Code 2090.
c) Certified providers shall comply with, and provide all services in accordance with, all provisions of 77 Ill. Adm. Code 2090.
d) Providers shall enroll for participation in the Medical Assistance Program as provided in 89 Ill. Adm. Code 140.11.
(Source: Amended at 24 Ill. Reg. 11846, effective August 1, 2000)
Section 148.350 Definitions (Repealed)
(Source: Repealed at 24 Ill. Reg. 11846, effective August 1, 2000)
Section 148.360 Types of Subacute Alcoholism and Substance Abuse Treatment Services (Repealed)
(Source: Repealed at 24 Ill. Reg. 11846, effective August 1, 2000)
Section 148.370 Payment for Sub-acute Alcoholism and Substance Abuse Treatment Services
Effective for dates of service on or after July 1, 2014:
a) The amount approved for payment for sub-acute alcoholism and substance abuse treatment is based on the type and amount of services required by and actually delivered to a recipient. The amount is determined in accordance with prospective rates developed by the Department of Human Services and approved and adopted by the Department (see 77 Ill. Adm. Code 2090.70). The adopted rate shall not exceed the charges to the general public.
b) Rates are generated through the application of formal methodologies specific to each category in accordance with the specifications in 77 Ill. Adm. Code 2090.35, 2090.40 and 2090.70. Rate appeals are allowable pursuant to the specifications in 77 Ill. Adm. Code 2090.80.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.380 Rate Appeals for Subacute Alcoholism and Substance Abuse Treatment Services (Repealed)
(Source: Repealed at 24 Ill. Reg. 11846, effective August 1, 2000)
Section 148.390 Hearings
Effective for dates of service on or after July 1, 2014:
a) The Department may initiate administrative proceedings pursuant to 89 Ill. Adm. Code 104.Subpart C to suspend or terminate certification and eligibility to participate in the Illinois Medical Assistance Program where the provider:
1) Has failed to comply with 77 Ill. Adm. Code 2090.40;
2) Does not have a valid license for an enrolled treatment service category;
3) Any of the grounds for payment recovery or termination set forth in 89 Ill. Adm. Code 140.15 or 140.16 or 89 Ill. Adm. Code 104.Subpart C are present.
b) When a proceeding is initiated against providers of alcoholism or substance abuse services, the Department shall notify the provider of the intended actions. Notice, service and proof of service shall be in accordance with the "Rules of Practice For Medical Vendor Administrative Proceedings" (89 Ill. Adm. Code 104.Subpart C).
c) All hearings held pursuant to these rules shall be conducted by an attorney designated by the Director of the Department as a hearing officer and said hearing shall be conducted under and governed by the applicable "Rules of Practice For Medical Vendor Administrative Proceedings" promulgated by the Department (89 Ill. Adm. Code 104.Subpart C).
d) The hearing officer shall prepare a written report of the case which shall contain findings of fact and recommended decisions with regard to the issues of recoupment, certification and continued participation in the Medicaid Program. The Director of the Division of Alcoholism and Substance Abuse (Department of Human Services) may also make a recommendation in writing and forward to the Director of the Department. The Director of the Department shall then make a final decision based on the findings of fact and all recommendations. A final administrative decision shall be issued in writing and contain findings of fact and the final determinations concerning recoupment, certification and continued participation in the Medicaid Program. A copy of the decision shall be served on each party.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.400 Special Hospital Reporting Requirements
Corrective Action Plans. Effective for dates of service on or after July 1, 2014, hospitals are responsible for assuring that services provided to Medical Assistance Program participants meet or exceed the appropriate standards for care. Any provider that is under any corrective action plans, while enrolled with the Department, by any licensing, certification and/or accreditation authority, including, but not limited to, the Illinois Department of Public Health, the federal Department of Health and Human Services, a peer review organization, or TJC or another Health and Human Services Approved Accreditation Organization, must report the request for the corrective action plans to the Department. Information submitted will remain confidential.
(Source: Amended at 39 Ill. Reg. 10824, effective July 27, 2015)
Section 148.401 Alzheimer's Treatment Access Payment
Effective for dates of service starting July 1, 2020, except when specifically designated otherwise in this Section:
a) Qualifying Criteria. An Illinois academic medical center or teaching hospital as defined in Section 148.25(h) that is identified as the primary hospital affiliate of one of the regional Alzheimer's Disease Assistance Centers as designated by the Alzheimer's Disease Assistance Act [410 ILCS 405] and identified in the Illinois Department of Public Health Alzheimer's Disease State Plan dated December 2016.
b) Payment. A qualifying hospital shall receive a payment that is the product of the following factors:
1) The hospital's calendar year 2019 inpatient days; and
2) The hospital's Alzheimer's Treatment Rate:
A) For qualifying hospitals located in Cook County: $244.36; and
B) For qualifying hospitals located outside of Cook County: $312.03.
c) "Inpatient days" means, for a given hospital, the sum of inpatient fee-for-service hospital days provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding days for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for total days occurring during SFY 2018 as of July 10, 2019.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.402 Expensive Drugs and Devices Add-On Payment
a) Qualifying Criteria: Beginning July 1, 2018, in addition to the statewide standardized amounts for in-state hospitals as defined in 89 Ill. Adm Code 149.100(i), the Department shall make an add-on payment for outpatient expensive devices and drugs. This add-on payment shall apply to claim lines that:
1) Are:
A) assigned with one of the following EAPGs: 490 or 1001 through 1020; and
B) coded with one of the following revenue codes: 0274 through 0276, 0278;
2) Are assigned with one of the following EAPGs: 430 through 441, 443, 444, 460 to 465, 495, 496, 1090; or
3) Are assigned to EAPGs that clinically represent drugs and devices outside of those listed in subsections (a)(1) and (a)(2), upon installation of grouping software updates, as determined by the Department.
b) The add-on payment shall be the sum of the following calculations:
1) The product of:
A) The claim line's covered charges; and
B) The hospital's total acute cost to charge ratio as defined in subsection (b)(3).
2) The sum of:
A) The claim line's EAPG payment; and
B) $1,000.
3) The product of:
A) The difference between subsections (b)(2)(A) and (2)(B); and
B) 0.8.
c) For purposes of this Section, estimated claim cost is based on the product of the claim total covered charges and the hospital's Medicare IPPS outlier cost-to-charge ratio. The Medicare IPPS outlier cost-to-charge ratio is determined based on:
1) For Medicare IPPS hospitals, the outlier cost-to-charge ratio is based on the sum of the Medicare inpatient prospective payment system hospital-specific operating and capital outlier cost-to-charge ratios effective at the beginning of the federal fiscal year starting three months prior to the calendar year during which the discharge occurred.
2) For non-Medicare IPPS, the outlier cost-to-charge ratio is based on the sum of the Medicare inpatient prospective payment system statewide average operating and capital outlier cost-to-charge ratios for urban hospitals for the state in which the hospital is located, effective at the beginning of the federal fiscal year starting three months prior to the calendar year during which the discharge occurred.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.403 General Provisions – Inpatient
Effective for dates of service starting July 1, 2018, except when specifically designated otherwise in this Section:
a) General Provisions. Unless otherwise indicated, the following apply to these Sections: 148.401 and 148.421.
1) Payments
A) Effective July 1, 2018, payments shall be paid in 12 installments on or before the 7th State business day of the month.
B) The Department may adjust payments made under these Sections to comply with federal law or regulations regarding disproportionate share, hospital-specific payment limitations on government-owned or government-operated hospitals.
C) If the State or federal Centers for Medicare and Medicaid Services finds that any federal upper payment limit applicable to the payments under these Sections is exceeded, then the payments under these Sections that exceed the applicable federal upper payment limit shall be reduced uniformly to the extent necessary to comply with the federal limit.
b) Definitions. As used in this Section, unless the context requires otherwise:
1) "General acute care admissions" means, for a given hospital, the sum of inpatient hospital admissions provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, excluding admissions for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover admissions), as tabulated from the Department's paid claims data for general acute care admissions occurring during SFY 2015 as of October 28, 2016.
2) "Occupancy ratio" is determined utilizing the Illinois Department of Public Health Hospital Profile CY15 – Facility Utilization Data – Source 2015 Annual Hospital Questionnaire. Utilizes all beds and days including observation days but excludes Long Term Care and Swing bed and their associated beds and days.
3) "Outpatient services" means, for a given hospital, the sum of the number of outpatient encounters identified as unique services provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding outpatient services for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover services), as tabulated from the Department's paid claims data for outpatient services occurring during SFY 2015 as of October 28, 2016.
4) "Total days" means, for a given hospital, the sum of inpatient hospital days provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding days for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for total days occurring during SFY 2015 as of October 28, 2016.
5) "Total admissions" means, for a given hospital, the sum of inpatient hospital admissions provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding admissions for individuals eligible for Medicare under Title XVIII of that Act (Medicaid/Medicare crossover admissions), as tabulated from the Department's paid claims data for admissions occurring during SFY 2015 as of October 28, 2016. [305 ILCS 5/5A-12.6(p)]
6) "Academic medical centers and major teaching hospital" means the academic medical centers and major teaching hospital definition found in Section 148.25.
7) "MIUR" means Medicaid inpatient utilization rate for rate year 2017.
8) "Publicly owned hospital" means any hospital owned by a political subdivision.
9) As used in this subsection, "service credit factor" is determined based on a hospital's rate year 2017 Medicaid inpatient utilization rate ("MIUR") rounded to the nearest whole percentage.
c) Rate reviews
1) A hospital shall be notified in writing of the results of the payment determination pursuant to the applicable Section.
2) Hospitals shall have a right to appeal the calculation of, or their ineligibility for, payment if the hospital believes that the Department has made a technical error. The appeal must be submitted in writing to the Department and must be received or postmarked within 30 days after the date of the Department's notice to the hospital of its qualification for the payment amounts, or a letter of notification that the hospital does not qualify for payments. Such a request must include a clear explanation of the reason for the appeal and documentation that supports the desired correction. The Department shall notify the hospital of the results of the review within 30 days after receipt of the hospital's request for review.
(Source: Amended at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.404 General Provisions – Outpatient
Effective for dates of service starting July 1, 2018, except when specifically designated otherwise in this Section:
a) General Provisions. Unless otherwise indicated, the following apply to Sections 148.412, 148.413, 148.419, 148.420, and 148.423:
1) Payments
A) Effective July 1, 2018, payments shall be paid in 12 installments on or before the 7th State business day of the month.
B) The Department may adjust payments made under these Sections to comply with federal law or regulations regarding disproportionate share, hospital-specific payment limitations on government-owned or government-operated hospitals.
C) If the State or federal Centers for Medicare and Medicaid Services finds that any federal upper payment limit applicable to the payments under these Sections is exceeded, then the payments under these Sections that exceed the applicable federal upper payment limit shall be reduced uniformly to the extent necessary to comply with the federal limit.
b) Rate reviews
1) A hospital shall be notified in writing of the results of the payment determination pursuant to these Sections.
2) Hospitals shall have a right to appeal the calculation of, or their ineligibility for, payment if the hospital believes that the Department has made a technical error. The appeal must be submitted in writing to the Department and must be received or postmarked within 30 days after the date of the Department's notice to the hospital of its qualification for the payment amounts, or a letter of notification that the hospital does not qualify for payments. Such a request must include a clear explanation of the reason for the appeal and documentation that supports the desired correction. The Department shall notify the hospital of the results of the review within 30 days after receipt of the hospital's request for review.
(Source: Amended at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.405 Graduate Medical Education (GME) Payment
Effective for payments starting July 1, 2020, except when specifically designated otherwise in this Section:
a) Definitions. As used in this Section, unless the context requires otherwise:
1) Medicare cost report ending in 2018, as reported in Medicare cost reports released on October 19, 2019, with data through September 30, 2019.
2) "Hospital's annualized Medicaid Intern Resident Cost" is the product of the following factors:
A) Annualized intern and resident costs obtained from Worksheet B Part I, Column 21 and 22 the sum of lines 30 through 43, 50 through 76, 90 through 93,96 through 98, and 105 through 112;
B) A quotient of:
i) The numerator of which is the hospital's Medicaid days (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through 18, and 32); and
ii) The denominator of which is the hospital's total days (Worksheet S3 Part I, Column 8, Lines 14, 16 through 18, and 32); and
3) "Hospital Annualized Medicaid Indirect Medical Education (IME) payment" is the product of the following factors:
A) Hospital IME payments (Worksheet E Part A, Line 29, Col 1); and
B) A quotient of:
i) The numerator of which is the hospital Medicaid days (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through 18, and 32); and
ii) The denominator of which is the hospital Medicare days (Worksheet S3 Part I, Column 6, Lines 2 through 4, 14, and 16 through 18).
4) "Statewide average cost per intern and resident" is the quotient of subsection (a)(4)(A) divided by subsection (a)(4)(B).
A) The sum of:
i) All qualifying hospitals annualized Medicaid Intern Resident Cost; and
ii) All qualifying hospitals annualized Medicaid IME payment.
B) The sum of all qualifying hospitals interns and residents as reported on Worksheet S3, Part 1, Col 9, Line 14.
b) Qualifying Criteria: An Illinois hospital, excluding large public hospitals defined in Section 148.25, reporting intern and resident cost on its Medicare cost report ending in 2018 shall be eligible for a Graduate Medical Education (GME) payment.
c) Payment. A qualifying hospital shall receive a payment that is the product of the following factors:
1) The lesser of:
A) The sum of the hospital's annualized Medicaid Intern Resident Cost and annualized Medicaid IME payment; or
B) The product of:
i) The number of interns and residents as reported on Worksheet S3, Part 1, Col 9, Line 14; and
ii) 120% of the statewide average cost per intern and resident for all eligible hospitals.
2) For payment on or after January 1, 2023:
A) 35% for safety net hospitals or hospitals with 100 or more full-time equivalent residents and interns, as reported on the hospital's Medicare cost report ending in calendar year 2018; or
B) 30%.
C) For payment on or after April 1, 2024, for a children's hospital, as defined in Section 148.25(d)(3)(A), 100%.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.406 Graduate Medical Education (GME) Payment for Large Public Hospitals
Effective for dates of service starting July 1, 2018, except when specifically designated otherwise in this Section:
a) Inpatient Graduate Medical Education (GME) Payment
1) Definitions. As used in this Section, unless the context requires otherwise:
A) "Medicare cost report" means the Medicare cost report ending in 2015, as reported in Medicare cost reports released on October 19, 2016, with data through September 30, 2016.
B) "Hospital's Annualized Medicaid Inpatient Intern Resident Cost" is the product of the following factors:
i) Annualized intern and resident costs obtained from Worksheet B Part I, Column 21 and 22 the sum of Lines 30 through 43, 50 through 76, 90 through 93, 96 through 98, and 105 through112;
ii) A quotient of:
● The numerator of which is the hospital's Medicaid days (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through 18, and 32); and
● The denominator of which is the hospital's total days (Worksheet S3 Part I, Column 8, Lines 14 and 16 through18); and.
iii) The quotient of:
● The numerator of which is the hospital's total inpatient charges; and
● The denominator of which is the hospital's total charges.
C) "Hospital Annualized Medicaid Indirect Medical Education (IME) Payment" is the product of the following factors:
i) Hospital IME payments (Worksheet E Part A, Line 29, Col 1); and
ii) The quotient of:
● The numerator of which is the hospital Medicaid days (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through 18, and 32), and
● The denominator of which is the hospital Medicare days (Worksheet S3 Part I, Column 6, Lines 2 through 4, 14, and 16 through 18).
2) Qualifying Criteria: An Illinois large public hospital reporting intern and resident cost on its Medicare cost report ending in 2015 shall be eligible for an inpatient GME payment.
3) Payment. A qualifying large public hospital shall receive a payment that is the sum of each large public hospital's annualized Medicaid Intern Resident Cost and annualized Medicaid IME payment.
4) Effective July 1, 2020, payment amounts in this subsection (a) may be calculated annually, or at least every 3 years, using updated Medicare Cost Report information. Updated Medicare Cost Report information shall be the most recent Medicare Cost Report available as of October of the calendar year preceding the SFY.
b) Outpatient (GME) Payment
1) Definitions. As used in this Section, unless the context requires otherwise:
A) "Medicare Cost Report" means the Medicare cost report ending in 2015, as reported in Medicare cost reports released on October 19, 2016, with data through September 30, 2016.
B) "Hospital's Annualized Medicaid Outpatient Intern Resident Cost" is the product of the following factors:
i) Annualized intern and resident costs obtained from Worksheet B Part I, Column 21 and 22 the sum of Lines 30 through 43, 50 through 76, 90 through 93, 96 through 98, and 105 through 112; and
ii) A quotient of:
● the numerator of which is the hospital's Medicaid days (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through 18, and 32); and
● the denominator of which is the hospital's total days (Worksheet S3 Part I, Column 8, Lines 14 and 16 through 18); and
C) The quotient of:
i) The numerator of which is the hospital's total outpatient charges; and
ii) The denominator of which is the hospital's total charges.
2) Qualifying Criteria: A large public hospital reporting intern and resident cost on its Medicare cost report ending in 2015 shall be eligible for a outpatient graduate medical education payment.
3) Payment. A qualifying large public hospital shall receive an outpatient GME payment that is equal to subsection (d)(2).
4) Effective July 1, 2020, payment amounts in this subsection may be calculated annually, or at least every 3 years, using updated Medicare Cost Report information. Updated Medicare Cost Report information shall be the most recent Medicare Cost Report available as of October of the calendar year preceding the SFY.
(Source: Amended at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.407 Medicaid High Volume Hospital Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.408 Inpatient Simulated Base Rate Adjustment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.409 Inpatient Small Public Hospital Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.410 Long-Term Acute Care Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.411 Medicaid Dependent Hospital Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.412 Outpatient Simulated Base Rate Adjustment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.413 Outpatient Small Public Hospital Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.414 Perinatal and Rural Care Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.415 Perinatal and Trauma Center Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.416 Perinatal Care Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.417 Psychiatric Care Access Payment for Distinct Part Units (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.418 Psychiatric Care Access Payment for Freestanding Psychiatric Hospitals (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.419 Safety-Net Hospital, Private Critical Access Hospital, and Outpatient High Volume Access Payments (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.420 Trauma Care Access Payment (Repealed)
(Source: Repealed at 44 Ill. Reg. 19767, effective December 11, 2020)
Section 148.421 Hospital Inpatient Adjustment
a) Qualifying Criteria. Effective January 1, 2023, the following categories of non-large public hospitals located in Illinois shall qualify for a Hospital Inpatient Adjustment Payment:
1) High Medicaid General Acute Care Hospitals, as defined in subsection (c)(1);
2) Other General Acute Care Hospitals, as defined in subsection (c)(4);
3) Safety-Net Hospitals, as defined in subsection (c)(5);
4) Long Term Acute Care (LTAC) Hospitals, as defined in Section 148.25;
5) Psychiatric Hospitals, as defined in Section 148.25(d)(1);
6) Rehabilitation Hospitals, as defined in Section 148.255(d)(2);
7) Critical Access Hospitals, as defined in 42 CFR 485, Subpart F that are not Small Public Hospitals; and
8) Small Public Hospitals, as defined in subsection (c)(6).
b) Payment. Each qualifying hospital shall receive an annual payment equal to the product of:
1) The hospital's calendar year 2019 inpatient days; and
2) The rate assigned to the group to which the hospital qualifies:
A) General Acute Care Hospitals: $750;
B) Other General Acute Care Hospitals: $550;
C) Safety-Net Hospitals: $1300;
D) LTAC Hospitals: $1410;
E) Psychiatric Hospitals: $810;
F) Rehabilitation Hospitals: $550;
G) Critical Access Hospitals: $750; and
H) Small Public Hospitals: $275.
c) Definitions. For purposes of this Section:
1) "High Medicaid General Acute Care Hospital" means a hospital that is not a public hospital, safety-net hospital, or critical access hospital and that qualifies as a regional high-volume hospital or is a hospital that has a Medicaid Inpatient Utilization Rate (MIUR) above 30%.
2) "Inpatient days" means, for a given hospital, the sum of fee-for-service inpatient hospital days provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding days for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/ Medicare crossover days), as tabulated from the Department's paid claims data for total days occurring during calendar year 2019 as of May 11, 2020.
3) "MIUR" means Medicaid inpatient utilization rate for rate year ending 3 months prior to the calendar year.
4) "Other General Acute Care Hospitals" means an acute care hospital that is not a public hospital, safety net hospital, critical access hospital, or high Medicaid general acute care hospital.
5) "Safety-Net Hospital" means a hospital, as defined in 89 Ill. Adm. Code 149.100(f)(4), except that stand-alone children's hospitals that are not specialty children's hospitals will not be included.
6) "Small Public Hospitals" means any Illinois publicly owned hospital which is not a "large public hospital" as defined in Section 148.25(a).
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.422 Safety Net Obstetrical Payment
a) To qualify for the Safety Net Obstetrical Payment, a hospital must meet all of the following criteria:
1) The hospital is located in Illinois;
2) The hospital meets the definition of a Safety Net Hospital under Section 5-5e.1 of the Illinois Public Aid Code [305 ILCS 5] in the payment period;
3) The hospital is designated as a perinatal hospital with the Illinois Department of Public Health in the payment period; and
4) The hospital is not a children's hospital as defined in 89 Ill. Adm. Code 148.25(d)(3)(A).
b) Safety Net Obstetrical Payments shall be paid as State Directed Payments and determined as follows:
1) On a quarterly basis, each hospital qualifying under subsection (a) shall be paid a safety-net obstetrical payment equal to the product of:
A) $12,500,000; and
B) A quotient of:
i) the numerator of which is the hospital's total delivery admissions in the safety-net obstetrical data period; and
ii) the denominator of which is the total of all qualifying hospitals delivery admissions in the safety-net obstetrical data period.
2) Payments to individual hospitals shall be no more than the following amounts:
A) For the payment period ending March 31, 2025: $1,250,000
B) For the payment period ending June 30, 2025: $1,500,000
C) For the payment period ending September 30, 2025: $1,750,000
D) For the payment period ending December 31, 2025: $2,000,000
E) No limitation for payment periods following calendar year 2025.
F) Any remaining funds in the payment period will be distributed to qualifying hospitals that have not reached the limitations in subsections (b)(2)(A) through (b)(2)(D). These payments will be equal to the product of:
i) All remaining funds; and
ii) A quotient of:
• the numerator of which is the hospital's total delivery admissions in the safety-net obstetrical data period; and
• the denominator of which is the total of all qualifying hospitals delivery admissions in the safety-net obstetrical data period, for those hospitals that have not reached the limitations in subsections (b)(2)(A) through (b)(2)(D).
c) Definitions
1) "Data period" means the quarter of the calendar that begins six months and ends three months prior to the payment period.
2) "Delivery admissions" means all inpatient claims received by the Department as encounters with DRG Group codes equal to 539, 540, 541, 542, and 560 within the data period.
3) "Payment period" means each quarter of the calendar year, beginning January 1, 2025.
4) "State Directed Payments" means payments issued to Medicaid managed care organizations for payment to hospitals as directed by the Department, in accordance with federal requirements as defined by 42 CFR 438, that are based on MCO encounter data received by the Department within the data period.
(Source: Old Section 148.422 repealed at 33 Ill. Reg. 501, effective December 30, 2008; New section added at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.423 Hospital Outpatient Adjustment
a) Qualifying Criteria. Effective January 1, 2023, the following categories of non-large public hospitals located in Illinois shall qualify for a Hospital Outpatient Adjustment Payment:
1) High Medicaid General Acute Care Hospitals, as defined in subsection (c)(1);
2) Other General Acute Care Hospitals, as defined in subsection (c)(3);
3) Safety-Net Hospitals, as defined in subsection (c)(5);
4) Psychiatric Hospitals, as defined in Section 148.25(d)(1);
5) Critical Access Hospitals, as defined 42 CFR 485, Subpart F that are not Small Public Hospitals;
6) Rehabilitation Hospitals, as defined in Section 148.25(d)(2); and
7) Small Public Hospitals, as defined in subsection (c)(6).
b) Payment. Each qualifying hospital shall receive an annual payment equal to the product of:
1) The hospital's calendar year 2019 outpatient claims; and
2) The rate assigned to the group to which the hospital qualifies:
A) High Medicaid General Acute Care Hospitals: $375;
B) Other General Acute Care Hospitals: $325;
C) Safety-Net Hospitals: $500;
D) Psychiatric Hospitals: $700;
E) Critical Access Hospitals that are not Small Public Hospitals: $750;
F) Rehabilitation Hospitals: $125; and
G) Small Public Hospitals: $275, until December 31, 2023. Effective on and after January 1, 2024, the rate shall lower to $0.00.
c) Definitions. For purposes of this Section:
1) "High Medicaid General Acute Care Hospital" means a hospital that is not a public hospital, safety-net hospital, or critical access hospital and that qualifies as a regional high volume hospital or is a hospital that has a Medicaid Inpatient Utilization Rate (MIUR) above 30%.
2) "MIUR" means Medicaid inpatient utilization rate for the rate year ending 3 months prior to the calendar year.
3) "Other General Acute Care Hospital" means an acute care hospital that is not a public hospital, safety net hospital, critical access hospital, or high Medicaid general acute care hospital.
4) "Outpatient claims" means, for a given hospital, the sum of fee-for-service outpatient hospital claims accepted by the Department for outpatient services provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding days for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover claims), as tabulated from the Department's paid claims data for services occurring during calendar year 2019 as of May 11, 2020.
5) "Safety-Net Hospital" means a hospital, as defined in 89 Ill. Adm. Code 149.100(f)(4), except that stand-alone children's hospitals that are not specialty children's hospitals will not be included.
6) "Small Public Hospital" means any Illinois publicly owned hospital which is not a "large public hospital" as defined in Section 148.25(a).
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.424 Outpatient Utilization Payments (Repealed)
(Source: Repealed at 33 Ill. Reg. 501, effective December 30, 2008)
Section 148.425 Directed Payment Classifications
a) For purposes of calculating quarterly directed payment amounts as described in Section 5A-12.7(g) and (h) of the Public Aid Code, effective July 1, 2020 and January 1 of each following calendar year, the Department shall classify Illinois Hospitals into the following classes:
1) Critical Access Hospitals as defined in Section 148.25(g). Beginning January 1, 2023, Critical Access Hospitals means those hospitals as defined in Section 148.25(g), excluding any hospitals meeting the definition of a public hospital in subsection (b)(3);
2) Safety-Net Hospitals as defined in 89 Ill. Adm. Code 149.100(f)(4), except that stand-alone children's hospitals as defined in Section 148.25(d)(3)(A) that are not children's specialty hospitals as defined in Section 148.25(i) will not be included and for calendar years 2025 and 2026 only, hospitals with over 9,000 Medicaid acute care inpatient admissions per calendar year, excluding admissions for Medicare-Medicaid dual eligible patients, will not be included. For the calendar year beginning January 1, 2023 and each calendar year thereafter assignment to the safety net class is based on the annual safety net rate year beginning 15 months before the beginning of the first payout quarter of the calendar year;
3) Long Term Acute Care Hospitals as defined in Section 148.25(d)(4);
4) Freestanding Psychiatric Hospitals as defined in Section 148.25(d)(1);
5) Freestanding Rehabilitation Hospitals as defined in Section 148.25(d)(2);
6) High Medicaid Hospitals;
7) Beginning January 1, 2023, Public Hospitals; and
8) Other General Acute Care Hospitals.
b) Definitions. For purposes of this Section:
1) "Applicable Period" means, for the period July 1, 2020 through December 31, 2020, rate year 2020 MIUR and inpatient days with dates of service in SFY 2018. For each calendar year thereafter, the MIUR calculated for the rate year beginning October 1 preceding the calendar year and inpatient days with dates of service within the SFY ending 18 months prior to the calendar year.
2) "High Medicaid Hospital" means, beginning calendar year 2023, a general acute care hospital that is not a safety-net hospital, public, or critical access hospital and for the applicable period has either:
A) A Medicaid Inpatient Utilization Rate (MIUR) as defined in Section 148.120(i)(4) above 30% for the rate year ending September 30 of the year preceding the beginning of the calendar year; or
B) Qualified as a regional high volume hospital.
3) "Other General Acute Care Hospital" means a hospital that is not a hospital defined in subsection (a)(1) through (7).
4) "Public Hospital" means a hospital that is owned or operated by an Illinois Government body or municipality, excluding a hospital provider that is a State agency, a state university, or a county with a population of 3,000,000 or more.
5) "Regional High Volume Hospital" means a hospital which ranks in the top 2 quartiles based on total hospital services volume, of all eligible general acute care hospitals, when ranked in descending order based on total hospital services volume, within the same Medicaid managed care region, as defined in 89 Ill. Adm. Code 140.Table J.
6) "Total hospital services volume" means the total of all Medical Assistance hospital inpatient admissions plus all Medical Assistance hospital outpatient visits. For purposes of determining regional high volume hospital inpatient admissions and outpatient visits, the Department shall use dates of service from the State fiscal year ending 18 months before the beginning of the first payout quarter of the subsequent annual determination period.
c) For purposes of calculating MIUR under this Section, children's hospitals and affiliated general acute care hospitals shall be considered a single hospital.
d) Hospitals can be reclassified by the Department every calendar year. The Department will notify hospitals, by December 1 of each year, what class a hospital is assigned to for the next calendar year.
(Source: Amended at 49 Ill. Reg. 2024, effective February 10, 2025)
Section 148.426 Outpatient Complexity of Care Adjustment Payments (Repealed)
(Source: Repealed at 33 Ill. Reg. 501, effective December 30, 2008)
Section 148.428 Rehabilitation Hospital Adjustment Payments (Repealed)
(Source: Repealed at 33 Ill. Reg. 501, effective December 30, 2008)
Section 148.430 Perinatal Outpatient Adjustment Payments (Repealed)
(Source: Repealed at 33 Ill. Reg. 501, effective December 30, 2008)
Section 148.432 Supplemental Psychiatric Adjustment Payments (Repealed)
(Source: Repealed at 33 Ill. Reg. 501, effective December 30, 2008)
Section 148.434 Outpatient Community Access Adjustment Payments (Repealed)
(Source: Repealed at 33 Ill. Reg. 501, effective December 30, 2008)
Section 148.436 Long Term Stay Hospital Per Diem Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.440 High Volume Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.442 Inpatient Services Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.444 Capital Needs Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.446 Obstetrical Care Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.448 Trauma Care Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.450 Supplemental Tertiary Care Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.452 Crossover Care Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.454 Magnet Hospital Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.456 Ambulatory Procedure Listing Increase Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.458 General Provisions (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.460 Catastrophic Relief Payments (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.462 Hospital Medicaid Stimulus Payments (Repealed)
(Source: Repealed at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.464 General Provisions (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.466 Magnet and Perinatal Hospital Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.468 Trauma Level II Hospital Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.470 Dual Eligible Hospital Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.472 Medicaid Volume Hospital Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.474 Outpatient Service Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.476 Ambulatory Service Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.478 Specialty Hospital Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.480 ER Safety Net Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.482 Physician Supplemental Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.484 Freestanding Children's Hospital Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
Section 148.486 Freestanding Children's Hospital Outpatient Adjustment Payments (Repealed)
(Source: Repealed at 42 Ill. Reg. 22401, effective November 29, 2018)
SUBPART C: SEXUAL ASSAULT EMERGENCY TREATMENT PROGRAM
Section 148.500 Definitions
"Act" means the Sexual Assault Survivors Emergency Treatment Act [410 ILCS 70].
"Ambulance Provider" means an individual or entity that owns and operates a business or service using ambulances or emergency medical services vehicles to transport emergency patients.
"Area-wide Sexual Assault Treatment Plan" means a plan, developed by the hospitals in the community or area to be served, that provides for hospital emergency services to sexual assault survivors that shall be made available by each of the participating hospitals.
"Department" means the Illinois Department of Healthcare and Family Services.
"Emergency Contraception" means medication as approved by the federal Food and Drug Administration (FDA) that can significantly reduce the risk of pregnancy if taken within 72 hours after sexual assault.
"Follow-up Healthcare" means healthcare services related to a sexual assault, including laboratory services and pharmacy services, rendered within 90 days after the initial visit for hospital emergency services.
"Forensic Services" means the collection of evidence pursuant to a statewide sexual assault evidence collection program administered by the Department of State Police, using the Illinois State Police Sexual Assault Evidence Collection Kit.
"Health Care Professional" means a physician, a physician assistant, or an advanced practice nurse.
"Hospital" means a facility located in Illinois licensed as a hospital by the Department of Public Health pursuant to the Hospital Licensing Act [210 ILCS 85] or that meets both the definition of a hospital and the licensure exemption provisions of the Hospital Licensing Act.
"Hospital Emergency Services" means health care delivered to outpatients within or under the care and supervision of personnel working in a designated emergency department of a hospital, including, but not limited to, care ordered by such personnel for a sexual assault survivor in the emergency department.
"Illinois State Police Sexual Assault Evidence Collection Kit" means a prepackaged set of materials and forms to be used for the collection of evidence relating to sexual assault. The standardized evidence collection kit for the State of Illinois shall be the Illinois State Police Sexual Assault Evidence Collection Kit.
"Nurse" means a nurse licensed under the Nurse Practice Act [225 ILCS 65].
"Physician" means a person licensed to practice medicine in all its branches.
"Sexual Assault" means an act of nonconsensual sexual conduct or sexual penetration, as defined in Section 12-12 of the Criminal Code of 1961 [720 ILCS 5], including, without limitation, acts prohibited under Sections 12-13 through 12-16 of the Criminal Code of 1961.
"Sexual Assault Survivor" means a person who presents for hospital emergency services in relation to injuries or trauma resulting from a sexual assault.
"Sexual Assault Transfer Plan" means a written plan developed by a hospital and approved by the Department of Public Health that describes the hospital's procedures for transferring sexual assault survivors to another hospital in order to receive emergency treatment.
"Sexual Assault Treatment Plan" means a written plan developed by a hospital that describes the hospital's procedures and protocols for providing hospital emergency services and forensic services to sexual assault survivors who present themselves for such services, either directly or through transfer from another hospital.
"Transfer Facility" means a hospital that provides only transfer services to sexual assault survivors, pursuant to 77 Ill. Adm. Code 545.
"Transfer Services" means the appropriate medical screening examination and necessary stabilizing treatment prior to the transfer of a sexual assault survivor to a hospital that provides hospital emergency services and forensic services to sexual assault survivors pursuant to a sexual assault treatment plan or area wide sexual assault treatment plan.
"Treatment Facility" means a hospital that renders emergency treatment to sexual assault survivors, pursuant to 77 Ill. Adm. Code 545.
(Source: Amended at 32 Ill. Reg. 9945, effective June 26, 2008)
Section 148.510 Reimbursement
When a hospital or ambulance provider furnishes emergency services, a hospital or health care professional or laboratory provides follow-up healthcare, or a pharmacy dispenses prescribed medications to any sexual assault survivor who is neither eligible to receive those services under the Illinois Public Aid Code [305 ILCS 5/5] nor covered for those services by a policy of insurance, the hospital, ambulance provider, health care professional, laboratory or pharmacy shall furnish the services without charge to that person, and shall be entitled to be reimbursed in providing the services, under the following conditions:
a) An Illinois hospital shall be eligible for reimbursement only after receiving Department of Public Health approval for participation as a Sexual Assault Treatment Facility or as a Sexual Assault Transfer Facility.
b) Charges for outpatient emergency care, physician, and ambulance transportation, and other related charges, shall be reimbursed as described in this subsection (b):
1) Physicians, ambulance providers, and other miscellaneous medical providers rendering services in the hospital emergency department shall be directly reimbursed by the Department of Healthcare and Family Services.
2) Charges for inpatient care shall not be reimbursed.
3) Charges must be directly related to care rendered for examinations, injuries, or trauma resulting from a sexual assault and/or the completion of sexual assault evidence collection through the use and application of the Illinois State Police Sexual Assault Evidence Collection Kit.
4) Emergency services must have been provided within the hospital emergency department or under the direction of an attending emergency room physician at the facility who supervised or provided the hospital emergency care of the sexual assault survivor, or during the ambulance transport of the sexual assault survivor.
5) Charges may include, but are not limited to, outpatient emergency care, physician, laboratory, x-ray, pharmacy and ambulance services, including charges for follow-up visits to the emergency department that are related to the sexual assault and occur within 90 days after the initial visit.
6) Services provided to sexual assault survivors shall be reimbursed at the Department's reimbursement rates.
7) Claims must be received by the Department within 180 days from the date of service to be eligible for payment pursuant to 89 Ill. Adm. Code 140.20.
c) The hospital shall maintain sufficient records to document its charges for services to each sexual assault survivor. The records shall be available for the Department's review upon its request and shall contain at least the following:
1) Sexual assault survivor's name, address, date of birth, Social Security Number, marital status, sex, employer and name of parent or guardian (if minor patient);
2) Date of service;
3) Hospital patient number and name of attending physician;
4) List of services provided;
5) Charges for each service;
6) Any documentation concerning the sexual assault survivor's insurance coverage; and
7) A report outlining each service provided and paid for by the Department and the services available to sexual assault survivors.
d) The hospital outpatient-billing department shall submit the following documentation in order to be considered for reimbursement:
1) Documentation of any insurance payment that has been received, or a copy of the denial from the insurance carrier; and
2) A properly completed Universal Billing (UB) Form.
e) The health care professional who provides follow-up healthcare, the laboratory that furnishes follow-up services, and the pharmacy that dispenses related prescribed medications to a sexual assault survivor are responsible for submitting the request for reimbursement for follow-up healthcare, laboratory services or pharmacy services to the Illinois Sexual Assault Emergency Treatment Program under the Department of Healthcare and Family Services. Health care professionals, laboratories and pharmacies are to be reimbursed at the Department's reimbursement rates.
f) Under no circumstances shall a sexual assault survivor be billed for outpatient hospital care, emergency room care, follow-up health care or transportation services when the services are directly related to the sexual assault.
g) A request for reimbursement that is rejected by the Department shall be returned to the requestor and accompanied by an explanation that specifies the basis for rejection. Corrected or amended requests may be resubmitted to the Department within 180 days from the date of service pursuant to 89 Ill. Adm. Code 140.20.
(Source: Amended at 37 Ill. Reg. 10432, effective June 27, 2013)
SUBPART D: STATE CHRONIC RENAL DISEASE PROGRAM
Section 148.600 Definitions
"Department" means the Illinois Department of Healthcare and Family Services.
"Dialysis Facility" means a facility that provides dialysis treatments, such as in-facility and home dialysis, and is certified by the federal Centers for Medicare and Medicaid Services as a Medicare-approved dialysis facility.
"Dialysis Treatment" means the filtering of blood in order to remove liquid and unwanted material so that fluid, electrolyte and acid-base balance in the blood can be maintained.
"End Stage Renal Disease" means the level of renal impairment that is irreversible and permanent, results in the kidneys losing their ability to filter blood and excrete urine, and requires a regular course of dialysis or kidney transplantation to maintain life.
"Patient" means an eligible person whose kidneys are non-functioning or absent and who requires dialysis treatment to maintain life.
"Program" means the Illinois Department of Healthcare and Family Services State Chronic Renal Disease Program.
(Source: Amended at 38 Ill. Reg. 13263, effective June 11, 2014)
Section 148.610 Scope of the Program
General Description
The Illinois Department of Healthcare and Family Services State Chronic Renal Disease Program assists patients with End Stage Renal Disease who have not qualified for benefits under Medical Assistance or All Kids. The Program assists eligible patients suffering from chronic renal diseases who require lifesaving care and treatment for such renal diseases, but who are unable to pay for the necessary services on a continuing basis. The Program is supplementary to all other resources, including Medicare, private insurance and private income. Services under the State Chronic Renal Disease Program are not available as emergency medical services to ineligible non-citizens. The Program will assist in connecting individuals with health coverage through Medicaid or the Illinois Health Insurance Marketplace under the Affordable Care Act (42 USC 18001 et seq.).
(Source: Amended at 38 Ill. Reg. 13263, effective June 11, 2014)
Section 148.620 Assistance Level and Reimbursement
a) Only approved dialysis facilities that are enrolled with the Department shall be reimbursed for dialysis treatments received by eligible patients.
b) The Department shall reimburse dialysis facilities for a portion of the costs of dialysis treatments provided to eligible patients. The Department will determine annually the rate of reimbursement to be used for the fiscal year, based on Medicare's Composite Payment Rates.
c) Assistance for chronic outpatient dialysis patients who are Medicare eligible, but who also qualify for the Program for both in-facility dialysis and home dialysis, will not exceed 15 percent of the Medicare rate.
d) New patients who qualify for chronic outpatient dialysis assistance during the waiting period for Medicare eligibility (60 to 90 days from the date of first dialysis) will be assisted at a maximum of 95 percent or less of the rate established under subsection (b) of this Section.
e) Patients who will never be eligible or qualify for Medicare will be assisted at a maximum of 95 percent or a minimum of 80 percent of the rate established under subsection (b).
(Source: Added at 26 Ill. Reg. 4825, effective March 15, 2002)
Section 148.630 Criteria and Information Required to Establish Eligibility
a) An eligible person shall:
1) Be a resident of the State of Illinois as provided in 305 ILCS 5/2-10;
2) Meet requirements of citizenship as provided in 305 ILCS 5/1-11; and
3) Meet the requirements of the Patient Protection and Affordable Care Act (ACA) (26 USC 5000A) by obtaining health coverage. Payment of a tax penalty for not obtaining insurance does not meet the requirement.
b) The following information shall be verified by the dialysis facility and maintained in the patient's record:
1) Citizenship or immigration status;
2) Address;
3) Social Security Number; and
4) Documentation of health coverage.
c) Eligibility of patients shall be determined by the Department based on the information required in this Section. To maintain eligibility for participation in the Program, a patient shall meet the following criteria on an ongoing basis:
1) A physician's diagnosis of End Stage Renal Disease for the patient must be on file at the dialysis facility;
2) The designated Department of Human Services office has determined the patient is not eligible for medical assistance; and
3) The patient shall provide documentation to the dialysis facility of his or her ineligibility for non-spenddown Medicaid or QMB (Qualified Medicare Beneficiary) status.
d) Participation Fees
1) Participants in the Program shall be responsible for paying a monthly participation fee to the dialysis facility from which they receive dialysis treatment. The amount of the Department's payment, as determined under Section 148.620, shall be reduced by the amount of the participation fee. The fee shall be determined by the Department based on income and information contained in the Bureau of Labor Statistics (BLS) standards, as described in Table B, and calculated pursuant to the Direct Care Program Renal Participation Worksheet (Table A).
2) The following shall be obtained and verified by the dialysis facility and submitted with the patient's application to the Department for determination of the amount of a patient's participation fee.
A) Pay stubs for the 90 days preceding the date of signature on the application if not employed for the past year; or
B) Previous year's federal and State Income Tax Returns if employed during the previous year.
3) The following are allowed as deductions from income:
A) Federal, State and local taxes;
B) Special care for children;
C) Support (child, relative or alimony);
D) Retirement or Social Security benefits;
E) Employment expenses (union dues, special tools and clothing);
F) Transportation to and from the site of dialysis; and
G) Medical expenses, both paid and outstanding.
4) If a substantial change in the financial status of any patient occurs after the patient has been found eligible for the Program, the patient shall report the change to the dialysis center. Based on the extent of the change, a new participation fee may be determined and imposed by the Department.
e) The following shall be verified by the dialysis facility and submitted with the patient's application to the Department for determination of nonfinancial eligibility by the Department:
1) Third Party Liability
A) Proof of insurance coverage; and
B) Proof of Medicare coverage.
2) Consent form required under subsection (f), signed by the patient or his or her representative.
f) The applicant or the applicant's parent or guardian must sign a consent form authorizing the release of all medical and financial records to the Department and to an approved chronic renal disease treatment facility.
(Source: Amended at 38 Ill. Reg. 13263, effective June 11, 2014)
Section 148.640 Covered Services
Assistance may be provided for eligible patients for costs associated with:
a) Prescribed medication related to chronic renal disease treatment;
b) Transportation to and from the site of dialysis or the site of out-patient post transplantation care when such needs are defined as emergency situations by the physician and social worker in the approved facility; and
c) Laboratory tests, not otherwise covered, that are related to the patient's status after a transplantation procedure. The laboratory tests are covered for three years after the date of transplantation.
(Source: Added at 26 Ill. Reg. 4825, effective March 15, 2002)
SUBPART E: INSTITUTION FOR MENTAL DISEASES PROVISIONS FOR HOSPITALS
Section 148.700 General Provisions
Section 1905(a)(16) and (a)(28)(B) of the Social Security Act provides that federal financial participation (FFP) is not available for any medical assistance under Title XIX for services provided to any individual who is older than 21 years of age and under 65 years of age and who is a patient in an IMD. The purpose of this Subpart E is to set forth the process by which the Department shall collect information necessary to assure federal compliance.
a) The Department shall request certain data elements from participating hospitals that include but are not limited to daily census information as described in provider notices to hospitals.
b) Participating hospitals shall be notified no less than 90 days before the effective reporting period.
c) If a hospital does not provide the required information within the required deadline as defined through a provider notice, the Department may suspend payments for covered services until the required information is received.
(Source: Added at 35 Ill. Reg. 10033, effective June 15, 2011)
SUBPART F: EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM
Section 148.800 General Provisions
This Subpart F is promulgated to establish an emergency psychiatric demonstration project (hereinafter referred to as the Program) to serve adults 21 through 64 years of age with specified mental illnesses. The State of Illinois was selected by the federal Centers for Medicare and Medicaid Services (CMMS) to establish the Program pursuant to the provisions of section 2707 of the federal Patient Protection and Affordable Care Act (PL 111-148) and subject to the terms of federal demonstration. The program, entitled Community Connect, shall be in effect from December 1, 2012 through June 30, 2015 or for the duration of federal funding should it end earlier. During that time period, participating non-governmental Community Connect IMD hospitals may receive Medicaid payment for providing EMTALA (Emergency Medical Treatment and Active Labor Act) related emergency services to Medicaid recipients 21 through 64 years of age who have expressed suicidal or homicidal thoughts or gestures or who are determined to be dangerous to themselves or others. The Program will promote an integrated approach to evidence-based community resources and emergency room and inpatient hospital care. The Program goals are to improve access to quality inpatient care, reduce unnecessary admissions and readmissions, reduce psychiatric boarding, and enhance coordination of services with community mental health centers. The Department will assess the results of the Program during and at the end of the demonstration. The assessment will be the basis to guide changes for the larger adult population with mental illness, such as potential restructuring of mental health targeted case management; potential adult screening of persons with mental illness presenting for psychiatric hospitalization; potential payment and incentive policies; and potential broad implementation of improved interventions by the hospital and community.
(Source: Added at 37 Ill. Reg. 402, effective December 27, 2012)
Section 148.810 Definitions
For the purposes of this Part, the following terms shall be defined as follows:
"Community Connect Targeted Case Management Agency" or "Community Connect TCM Agency" means the community mental health center that will act as the crisis team, determination of appropriate level of care agent, linkage agent and care coordination entity for participants in the Emergency Psychiatric Demonstration Program.
"Department" means the Illinois Department of Healthcare and Family Services.
"Emergency Psychiatric Demonstration Program" or "Program" means the program under which psychiatric hospitals, general hospitals, and community mental health providers will work to develop new service models to increase the overall quality of service delivery to participants with a psychiatric emergency medical condition.
"EMTALA" means the federal Emergency Medical Treatment and Active Labor Act (42 USC 1395dd) that requires any hospital that accepts payments from Medicare to provide care to any patient who arrives in its emergency department for treatment, regardless of the patient's citizenship, legal status in the United States or ability to pay for the services. EMTALA applies to ambulance and hospital care.
"IMD" means an institution for mental disease and is defined as a hospital, nursing facility, or other institution of 17 or more beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. As used in this Subpart, IMD refers to a hospital.
"IMR" means Illness Management and Recovery and is an evidence-based psychiatric rehabilitation practice. The primary aim of the IMR is to empower consumers to manage their illnesses, find their own goals for recovery, and make informed decisions about their treatment through the necessary knowledge and skills.
"Psychiatric Emergency Medical Condition" means a condition in which an individual is expressing suicidal or homicidal thoughts or gestures or is dangerous to self or others.
(Source: Added at 37 Ill. Reg. 402, effective December 27, 2012)
Section 148.820 Individual Eligibility for the Program
a) For the purposes of this Subpart, only Medicaid eligible individuals 21 through 64 years of age, with a serious mental illness, who present at a participating or partnering hospital with suicidal or homicidal thoughts or gestures, or who are a danger to self or others, will be eligible to participate. Individuals enrolled in a care coordination program [305 ILCS 5/5-30], as well as those individuals who have Medicare coverage, are excluded from participation.
b) Participation shall also be limited to the maximum number of IMD admissions funded by CMMS and the number of deflections to community services before reaching the maximum IMD number funded as provided in the supplemental provider agreement.
(Source: Added at 37 Ill. Reg. 402, effective December 27, 2012)
Section 148.830 Providers Participating in the Program
a) Hospitals that may participate in the Program are limited to those included in the funded demonstration application. A hospital participating in the Program will be designated a Community Connect IMD hospital.
b) In order to participate in the Program, the Community Connect IMD hospital must comply with all of the Department rules, policies and licensure requirements and, additionally, must meet each of the following criteria:
1) Establish a Network Guidance Group consisting of a representative from each of the following: Illinois Department of Healthcare and Family Services; Illinois Department of Human Services-Division of Mental Health; the Community Connect IMD hospital; the Community Connect TCM agency; and representatives from participating emergency departments, local law enforcement, consumers, and other individuals as determined by the Community Connect IMD hospital. The Network Guidance Group shall meet at least quarterly to review the Program operations.
2) Accept Community Connect eligible participants on a priority basis.
3) Include the Community Connect TCM agency in staffing and discharge planning.
4) Not discharge Community Connect participants unless a discharge plan ensures the patient has a place to go and appropriate services will be implemented.
5) Establish a collaborative working relationship with a dedicated community mental health center to function as the Community Connect TCM agency.
6) Contact the Community Connect TCM agency to perform a level of care assessment prior to admission.
7) Update the collaborating Community Connect TCM agency on bed census every day.
8) Enter into a supplemental provider agreement with the Department.
c) In selecting hospitals for the Program, the Department may consider other factors beyond the criteria in subsection (b), including, but not limited to, the facility's history of compliance with all applicable State and federal standards.
d) Each Community Connect IMD hospital will partner with a general acute care hospital. The general acute care hospital will identify individuals who present in a psychiatric emergency medical condition. The number of individuals to be admitted to a Community Connect IMD hospital under the Program will be the number in the supplemental provider agreement. The maximum number allowed for all Community Connect IMD hospitals shall not exceed the number of individuals funded by CMMS for the Program.
e) A Community Connect TCM agency shall be chosen for each Community Connect IMD hospital. A Community Connect TCM agency will be chosen from the pool of qualified community mental health centers in the vicinity of the Community Connect IMD hospital and required to enter into supplemental provider agreements with the Department. The agencies are responsible for providing crisis intervention services for Medicaid eligible individuals presenting at a participating Community Connect IMD hospital or partner hospital. Crisis intervention shall include determination of appropriate level of care and potential stabilization of the individual. For those individuals who are determined to be appropriate for community stabilization, the Community Connect TCM agency shall be responsible for ensuring that the participant has priority access to community services within 24 hours after stabilization. For those participants found to be appropriate for inpatient treatment and admitted to the Community Connect IMD hospital, the Community Connect TCM agency is responsible for a seamless transition for the individual from the Community Connect IMD hospital IMR treatment setting to the community mental health center IMR treatment setting. Prior to discharge, at the point of discharge, and for up to 60 days following the level of care assessment, the Community Connect TCM agency shall act as the linkage agent, assisting the individual to connect to all available needed resources.
f) Certified community mental health center providers who have agreed to provisions of the Program, as defined in a linkage agreement with the Community Connect TCM agency, will be a choice for community-based treatment to the individual after inpatient discharge, or after the individual is deflected from the emergency department to community services.
(Source: Added at 37 Ill. Reg. 402, effective December 27, 2012)
Section 148.840 Stabilization and Discharge Practices
The admitting hospital must establish a stabilization plan for the individual within 48 hours after admission. To ensure continuity of treatment services, a participating Community Connect IMD hospital will not discharge an individual unless the discharge plan ensures the individual has a place to go and appropriate services will be implemented.
(Source: Added at 37 Ill. Reg. 402, effective December 27, 2012)
Section 148.850 Medication Management
On the day of discharge from an inpatient admission, the Community Connect TCM agency will ensure the individual accesses a 30-day supply of medically necessary medication to ensure continuity of this aspect of treatment and medication adherence.
(Source: Added at 37 Ill. Reg. 402, effective December 27, 2012)
Section 148.860 Community Connect IMD Hospital Payment
Effective for dates of service on or after July 1, 2014:
a) The Community Connect IMD hospital in the demonstration program will be reimbursed on an incentive-driven basis. The Department will reimburse the initial claim for the psychiatric admission at 80% of the psychiatric hospital rate. The remainder of the full 100% of the psychiatric hospital rate will be paid if the individual remains stable in the community with no further psychiatric hospitalization for 45 days after the level of care assessment.
b) Payment for any individual who cannot be discharged because the individual does not have a place to go and appropriate services cannot be implemented, but who is not an inpatient based on medical necessity, will be 50% of the alternate cost per diem rate as defined in Section 148.270 and 89 Ill. Adm. Code 152.200 on July 1, 2012.
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)
Section 148.870 Community Connect TCM Agency Payment
a) The Community Connect TCM agency monthly reimbursement rate for each individual will be established in the supplemental provider agreement.
b) The Community Connect TCM agency will be reimbursed on an incentive driven basis for each individual each month. The Department will reimburse the initial claim at 80% of the individual per month rate. The remainder of the full 100% of the individual per month rate will be paid if the individual deflected to community services or hospitalized at the Community Connect IMD remains stable in the community without further psychiatric hospitalization for 45 days after the level of care assessment.
(Source: Added at 37 Ill. Reg. 402, effective December 27, 2012)
Section 148.880 Program Reporting
Each Community Connect IMD and each Community Connect TCM agency will submit periodic reports to the Department in the form and format specified by the Department.
(Source: Added at 37 Ill. Reg. 402, effective December 27, 2012)
Section 148.TABLE A Renal Participation Fee Worksheet
|
Date |
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Initialed |
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Patient Identification Number |
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
PATIENT’S NAME |
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
Last |
First |
Middle Initial |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
In questions 1 through 4 below, please circle one number or group of numbers: |
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
1. |
NUMBER OF PERSONS IN FAMILY |
1 |
2 |
3 |
4 |
5 |
6 or more |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||
|
2. |
NUMBER OF CHILDREN |
|
1 |
2 |
3 |
4 |
5 or more |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||
|
3. |
AGE OF OLDEST CHILD IN YEARS |
|
|
0-5 |
6-15 |
16-17 |
18 and over |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||
|
4. |
AGE OF HEAD OF HOUSEHOLD |
|
|
Under 35 |
35-54 |
55-64 |
65 and over |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
BUREAU OF LABOR STATISTICS (BLS) EQUIVALENCE FACTOR= |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
(see Table B) |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
A. |
LOCATION |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
(See Table C, List of Metropolitan Counties by SMSA Definition) |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
BLS METRO |
= |
$12,815 |
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
BLS NON-METRO |
= |
$11,604 |
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
B. |
STANDARD BUDGET |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
BLS EQUIVALENCE |
BLS STANDARD |
FAMILY STANDARD |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
FACTOR |
BUDGET |
BUDGET |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
$ |
X |
$ |
= |
$ |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
(metro or non-metro) |
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
C. |
PARTICIPATION DETERMINATION |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
ADJUSTED GROSS |
FAMILY STANDARD |
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
INCOME |
BUDGET |
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
$ |
- |
$ |
= |
$ |
X |
.333 |
= |
$ |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
D. |
ADJUSTED GROSS INCOME |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
$ |
X |
.125 |
= |
$ |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
LESSER OF C or D |
= |
$ |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
E. |
ADJUSTED GROSS INCOME |
= |
$ |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
FAMILY STANDARD BUDGET |
= |
$ |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
(B. above) |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
F. |
FEDERAL INCOME TAX |
STATE INCOME TAX |
TOTAL TAX |
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
$ |
+ |
$ |
= |
$ |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
TOTAL TAX |
|
BLS STANDARD TAX |
|
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
$ |
- |
$ |
= |
$ |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
(metro $1,435) |
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
(non-metro $1,260) |
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
G. |
SPECIAL CARE FOR CHILDREN |
$ |
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
H. |
SCHOOL TUITION |
$ |
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
I. |
FAMILY SUPPORT PAID |
$ |
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
J. |
OTHER PAYMENTS |
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
1. |
Transportation to and from dialysis |
$ |
|||||||||||||||||||
|
|
2. |
Employment Expense (dues, uniforms, small tools) |
$ |
|||||||||||||||||||
|
|
SOCIAL SECURITY |
BSL STANDARDS |
||||||||||||||||||||
|
|
$ |
- |
$ |
= |
$ |
|
||||||||||||||||
|
|
|
(metro $702) |
||||||||||||||||||||
|
|
|
(non-metro $676) |
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
|
K. |
MEDICAL EXPENSES |
BLS STANDARD |
MEDICAL EXPENSES |
|||||||||||||||||||
|
|
|
|
ALLOWED |
|||||||||||||||||||
|
|
$ |
- |
$ |
= |
$ |
|
||||||||||||||||
|
|
(includes medical |
(metro $876) |
||||||||||||||||||||
|
|
insurance premiums) |
(non-metro $671) |
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
|
|
MEDICAL EXPENSES |
TOTAL EXPENSES |
INCOME IN EXCESS |
|||||||||||||||||||
|
|
ALLOWED |
|
||||||||||||||||||||
|
|
$ |
- |
$ |
= |
$ |
|
||||||||||||||||
|
|
|
(E through K totaled, less |
|
|||||||||||||||||||
|
|
|
adjusted gross income) |
||||||||||||||||||||
|
|
|
|
||||||||||||||||||||
|
L. |
INCOME IN EXCESS |
|
||||||||||||||||||||
|
$ |
X .333 |
= |
$ |
||||||||||||||||||
|
|
|
|
||||||||||||||||||||
|
M. |
ENTER SMALLEST AMOUNT OF C or D or L |
$ |
||||||||||||||||||||
(Source: Added at 26 Ill. Reg. 4825, effective March 15, 2002)
Section 148.TABLE B Bureau of Labor Statistics Equivalence
Revised Scale of Equivalent Income for Urban Families of Different Size, Age and Composition (four person family – husband, age 35-54, wife, 2 children, oldest 6-15 = 100 percent)
|
|
|
|
|
|
AGE OF HEAD OF HOUSEHOLD |
||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||
|
SIZE AND TYPE OF FAMILY |
|
Under 35 |
35-54 |
55-64 |
65 and Over |
||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|||||||||||||||||||||||||
|
|
|
|
Percentages to be Applied to the Total Cost of a Budget |
|
|||||||||||||||||||||||||||||
|
|
|
|
(excluding State and local income taxes and disability payments) |
||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||||||||||
|
One Person |
................................................................... 37% |
..................... 38% |
................. 33% |
.................. 28% |
|||||||||||||||||||||||||||||
|
Two Persons: |
|||||||||||||||||||||||||||||||||
|
|
Husband and wife |
50% |
..................... 61% |
................. 60% |
.................. 51% |
||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||
|
|
One parent and child |
40% |
..................... 59% |
................. 62% |
.................. 58% |
||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||
|
Three persons: |
|
||||||||||||||||||||||||||||||||
|
|
Husband, wife, child under 6 |
62% |
..................... 69% |
................. 70% |
.................. 68% |
||||||||||||||||||||||||||||
|
|
Husband, wife, child 6-16 |
62% |
..................... 83% |
................. 89% |
.................. 81% |
||||||||||||||||||||||||||||
|
|
Husband, wife child 16-17 |
83% |
..................... 92% |
................. 89% |
.................. 78% |
||||||||||||||||||||||||||||
|
|
Husband, wife, child 18 or over |
82% |
..................... 83% |
................. 86% |
.................. 77% |
||||||||||||||||||||||||||||
|
|
One parent, 2 children |
68% |
..................... 77% |
................. 84% |
.................. 75% |
||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||
|
Four Persons: |
|||||||||||||||||||||||||||||||||
|
|
Husband, wife, 2 children, |
||||||||||||||||||||||||||||||||
|
|
|
oldest under 6 |
71% |
..................... 79% |
................. 80% |
.................. 80% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 2 children, |
||||||||||||||||||||||||||||||||
|
|
|
oldest 6-15 |
76% |
................... 100% |
............... 105% |
.................. 95% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 2 children |
||||||||||||||||||||||||||||||||
|
|
|
oldest 16-17 |
113% |
................... 114% |
............... 126% |
................ 110% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 2 children, |
||||||||||||||||||||||||||||||||
|
|
|
oldest 18 or over |
96% |
..................... 96% |
............... 110% |
.................. 89% |
|||||||||||||||||||||||||||
|
|
One parent, 3 children |
88% |
..................... 97% |
................. 97% |
.................. 87% |
||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||
|
Five persons: |
|||||||||||||||||||||||||||||||||
|
|
Husband, wife, 3 children, |
|
|||||||||||||||||||||||||||||||
|
|
|
oldest under 6 |
85% |
..................... 95% |
................. 97% |
..................... 0% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 3 children, |
||||||||||||||||||||||||||||||||
|
|
|
oldest 6-15 |
94% |
................... 115% |
............... 119% |
..................... 0% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 3 children, |
||||||||||||||||||||||||||||||||
|
|
|
oldest 16-17 |
128% |
................... 128% |
............... 138% |
..................... 0% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 3 children, |
||||||||||||||||||||||||||||||||
|
|
|
oldest 18 or over |
119% |
................... 118% |
............... 124% |
..................... 0% |
|||||||||||||||||||||||||||
|
|
One parent, 4 children |
108% |
................... 117% |
............... 118% |
..................... 0% |
||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||||
|
Six persons or more: |
|||||||||||||||||||||||||||||||||
|
|
Husband, wife, 4 children |
||||||||||||||||||||||||||||||||
|
|
|
oldest under 6 |
98% |
................... 114% |
............... 115% |
..................... 0% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 4 children or more, |
||||||||||||||||||||||||||||||||
|
|
|
oldest 6-15 |
107% |
................... 130% |
............... 139% |
..................... 0% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 4 children or more, |
||||||||||||||||||||||||||||||||
|
|
|
oldest 16-17 |
146% |
................... 145% |
............... 147% |
..................... 0% |
|||||||||||||||||||||||||||
|
|
Husband, wife, 4 children or more, |
||||||||||||||||||||||||||||||||
|
|
|
oldest 18 or over |
149% |
................... 149% |
............... 150% |
..................... 0% |
|||||||||||||||||||||||||||
|
|
One parent, 5 children or more |
124% |
................... 137% |
............... 138% |
..................... 0% |
||||||||||||||||||||||||||||
The scale values shown here are percentages to be applied to the total cost of a budget (excluding State and local income taxes, and disability payments) for the base family (4 persons-husband, age 35-54, wife, 2 children, oldest child 6-15 years) to estimate the total income required to provide the same level of living for urban families of different size, age, and composition. In addition to the cost of goods and services for family consumption, the total budget costs include gifts and contributions, life insurance, occupational expenses, employee contribution for social security, and federal income taxes. Estimates of personal taxes paid to State and local governments and of payments for disability insurance may be added in those urban areas where applicable.
(Source: Added at 26 Ill. Reg. 4825, effective March 15, 2002)
Section 148.TABLE C List of Metropolitan Counties by SMSA Definition
"SMSA" means Standard Metropolitan Statistical Area as defined by the U.S. Office of Management and Budget (OMB).
|
Boone |
Champaign |
Clinton |
Cook |
DuPage |
|
Henry |
Kane |
Kankakee |
Lake |
Macon |
|
Madison |
McHenry |
McLean |
Menard |
Monroe |
|
Peoria |
Rock Island |
Sangamon |
St. Clair |
Tazewell |
|
Will |
Winnebago |
Woodford |
|
|
(Source: Amended at 38 Ill. Reg. 15165, effective July 2, 2014)