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.  Payment for inpatient rehabilitation services provided by a rehabilitation hospital, as defined in Section 148.25(d)(2):

1)         For which the Department had no inpatient base period claims data, shall be the product of the following:

A)        80 percent of weighted average rehabilitation hospital rate; and

B)        The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).

2)         For which the Department had inpatient base period claims data, shall be the product of the following:

A)        The greater of:

i)          the hospital's rehabilitation rate, as determined in subsection (e); and

ii)         80 percent of the weighted average rehabilitation hospital rate.

B)        The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).

d)         Distinct Part Rehabilitation Unit.  Payment for inpatient rehabilitation services provided by a distinct part rehabilitation unit, as defined in Section 148.25(c)(2):

1)         For which the Department had no inpatient base period paid claims data, shall be the product of the following:

A)        The arithmetic mean rate for rehabilitation distinct part units.

B)        The length of stay, as defined in 89 Ill. Adm. Code 149.100(i).

2)         For which the Department had inpatient base period paid claims data, shall be the product of the following:

A)        The lesser of:

i)          The greater of:

●          The distinct part rehabilitation unit rate, as determined in subsection (e); and

●          80 percent of the arithmetic mean rate for rehabilitation distinct part units.

ii)         The arithmetic mean rehabilitation rate for rehabilitation distinct part units plus the value of one standard deviation of the rehabilitation rate for rehabilitation distinct part units.

e)         The rehabilitation rate is calculated as the sum of:

1)         The rehabilitation rate in effect on July 1, 2011;

2)         The quotient, rounded to the nearest hundredth, of the rehabilitation provider's allocated static payments divided by the rehabilitation provider's inpatient covered days in the inpatient base period paid claims data; and

3)         Effective July 1, 2018, plus $96.00.

f)         Definitions

"Allocated static payments" means the adjustment payments made to the hospital pursuant to 89 Ill. Adm. Code 148.105, 148.115, 148.126, 148.295, 148.296 and 148.298, during State fiscal year 2011, excluding those payments that continue after July 1, 2014, pursuant to the methodologies outlined in rule as of February 21, 2014 (see https://www.illinois.gov/hfs/medicalproviders/hospitals/ hospitalratereform/Pages/default.aspx), as determined by the Department, allocated to rehabilitation services based on the ratio of rehabilitation claim charges to total inpatient claim charges determined using inpatient base period claims data.

"Inpatient base period paid claims data" means SFY 2011 inpatient Medicaid fee-for-service paid claims data, excluding Medicare dual eligible claims, for rehabilitation payment for services provided in SFY 2015 and 2016.

"Weighted average rehabilitation hospital rate" means the sum of rehabilitation hospital inpatient base period paid claims data total reported payments, excluding Disproportionate Share Hospitals (DSH) and Medicaid Percentage Adjustment/Medicaid High Volume Adjustment (MPA/MHVA), plus rehabilitation hospital total allocated supplemental payments, divided by rehabilitation hospital inpatient base period paid claims data total covered days.

(Source:  Amended at 42 Ill. Reg. 22401, effective November 29, 2018)