Full Text of HB0174 100th General Assembly
HB0174ham001 100TH GENERAL ASSEMBLY | Rep. Robert Rita Filed: 10/17/2017
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| 1 | | AMENDMENT TO HOUSE BILL 174
| 2 | | AMENDMENT NO. ______. Amend House Bill 174 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Sections 5A-2, 5A-12.2, 5A-12.4, 5A-12.5, and 14-12 as | 6 | | follows: | 7 | | (305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2) | 8 | | (Section scheduled to be repealed on July 1, 2018) | 9 | | Sec. 5A-2. Assessment.
| 10 | | (a)(1)
Subject to Sections 5A-3 and 5A-10, for State fiscal | 11 | | years 2009 through 2018, an annual assessment on inpatient | 12 | | services is imposed on each hospital provider in an amount | 13 | | equal to $218.38 multiplied by the difference of the hospital's | 14 | | occupied bed days less the hospital's Medicare bed days, | 15 | | provided, however, that the amount of $218.38 shall be | 16 | | increased by a uniform percentage to generate an amount equal |
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| 1 | | to 75% of the State share of the payments authorized under | 2 | | Section 5A-12.5, with such increase only taking effect upon the | 3 | | date that a State share for such payments is required under | 4 | | federal law. For the period of April through June 2015, the | 5 | | amount of $218.38 used to calculate the assessment under this | 6 | | paragraph shall, by emergency rule under subsection (s) of | 7 | | Section 5-45 of the Illinois Administrative Procedure Act, be | 8 | | increased by a uniform percentage to generate $20,250,000 in | 9 | | the aggregate for that period from all hospitals subject to the | 10 | | annual assessment under this paragraph. | 11 | | (2) In addition to any other assessments imposed under this | 12 | | Article, effective July 1, 2016 and semi-annually thereafter | 13 | | through June 2018, in addition to any federally required State | 14 | | share as authorized under paragraph (1), the amount of $218.38 | 15 | | shall be increased by a uniform percentage to generate an | 16 | | amount equal to 75% of the ACA Assessment Adjustment, as | 17 | | defined in subsection (b-6) of this Section. | 18 | | For State fiscal years 2009 through 2014 and after, a | 19 | | hospital's occupied bed days and Medicare bed days shall be | 20 | | determined using the most recent data available from each | 21 | | hospital's 2005 Medicare cost report as contained in the | 22 | | Healthcare Cost Report Information System file, for the quarter | 23 | | ending on December 31, 2006, without regard to any subsequent | 24 | | adjustments or changes to such data. If a hospital's 2005 | 25 | | Medicare cost report is not contained in the Healthcare Cost | 26 | | Report Information System, then the Illinois Department may |
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| 1 | | obtain the hospital provider's occupied bed days and Medicare | 2 | | bed days from any source available, including, but not limited | 3 | | to, records maintained by the hospital provider, which may be | 4 | | inspected at all times during business hours of the day by the | 5 | | Illinois Department or its duly authorized agents and | 6 | | employees. | 7 | | (b) (Blank).
| 8 | | (b-5)(1) Subject to Sections 5A-3 and 5A-10, for the | 9 | | portion of State fiscal year 2012, beginning June 10, 2012 | 10 | | through June 30, 2012, and for State fiscal years 2013 through | 11 | | 2018, an annual assessment on outpatient services is imposed on | 12 | | each hospital provider in an amount equal to .008766 multiplied | 13 | | by the hospital's outpatient gross revenue, provided, however, | 14 | | that the amount of .008766 shall be increased by a uniform | 15 | | percentage to generate an amount equal to 25% of the State | 16 | | share of the payments authorized under Section 5A-12.5, with | 17 | | such increase only taking effect upon the date that a State | 18 | | share for such payments is required under federal law. For the | 19 | | period beginning June 10, 2012 through June 30, 2012, the | 20 | | annual assessment on outpatient services shall be prorated by | 21 | | multiplying the assessment amount by a fraction, the numerator | 22 | | of which is 21 days and the denominator of which is 365 days. | 23 | | For the period of April through June 2015, the amount of | 24 | | .008766 used to calculate the assessment under this paragraph | 25 | | shall, by emergency rule under subsection (s) of Section 5-45 | 26 | | of the Illinois Administrative Procedure Act, be increased by a |
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| 1 | | uniform percentage to generate $6,750,000 in the aggregate for | 2 | | that period from all hospitals subject to the annual assessment | 3 | | under this paragraph. | 4 | | (2) In addition to any other assessments imposed under this | 5 | | Article, effective July 1, 2016 and semi-annually thereafter | 6 | | through June 2018, in addition to any federally required State | 7 | | share as authorized under paragraph (1), the amount of .008766 | 8 | | shall be increased by a uniform percentage to generate an | 9 | | amount equal to 25% of the ACA Assessment Adjustment, as | 10 | | defined in subsection (b-6) of this Section. | 11 | | For the portion of State fiscal year 2012, beginning June | 12 | | 10, 2012 through June 30, 2012, and State fiscal years 2013 | 13 | | through 2018, a hospital's outpatient gross revenue shall be | 14 | | determined using the most recent data available from each | 15 | | hospital's 2009 Medicare cost report as contained in the | 16 | | Healthcare Cost Report Information System file, for the quarter | 17 | | ending on June 30, 2011, without regard to any subsequent | 18 | | adjustments or changes to such data. If a hospital's 2009 | 19 | | Medicare cost report is not contained in the Healthcare Cost | 20 | | Report Information System, then the Department may obtain the | 21 | | hospital provider's outpatient gross revenue from any source | 22 | | available, including, but not limited to, records maintained by | 23 | | the hospital provider, which may be inspected at all times | 24 | | during business hours of the day by the Department or its duly | 25 | | authorized agents and employees. | 26 | | (b-6)(1) As used in this Section, "ACA Assessment |
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| 1 | | Adjustment" means: | 2 | | (A) For the period of July 1, 2016 through December 31, | 3 | | 2016, the product of .19125 multiplied by the sum of the | 4 | | fee-for-service payments to hospitals as authorized under | 5 | | Section 5A-12.5 and the adjustments authorized under | 6 | | subsection (t) of Section 5A-12.2 to managed care | 7 | | organizations for hospital services due and payable in the | 8 | | month of April 2016 multiplied by 6. | 9 | | (B) For the period of January 1, 2017 through June 30, | 10 | | 2017, the product of .19125 multiplied by the sum of the | 11 | | fee-for-service payments to hospitals as authorized under | 12 | | Section 5A-12.5 and the adjustments authorized under | 13 | | subsection (t) of Section 5A-12.2 to managed care | 14 | | organizations for hospital services due and payable in the | 15 | | month of October 2016 multiplied by 6, except that the | 16 | | amount calculated under this subparagraph (B) shall be | 17 | | adjusted, either positively or negatively, to account for | 18 | | the difference between the actual payments issued under | 19 | | Section 5A-12.5 for the period beginning July 1, 2016 | 20 | | through December 31, 2016 and the estimated payments due | 21 | | and payable in the month of April 2016 multiplied by 6 as | 22 | | described in subparagraph (A). | 23 | | (C) For the period of July 1, 2017 through December 31, | 24 | | 2017, the product of .19125 multiplied by the sum of the | 25 | | fee-for-service payments to hospitals as authorized under | 26 | | Section 5A-12.5 and the adjustments authorized under |
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| 1 | | subsection (t) of Section 5A-12.2 to managed care | 2 | | organizations for hospital services due and payable in the | 3 | | month of April 2017 multiplied by 6, except that the amount | 4 | | calculated under this subparagraph (C) shall be adjusted, | 5 | | either positively or negatively, to account for the | 6 | | difference between the actual payments issued under | 7 | | Section 5A-12.5 for the period beginning January 1, 2017 | 8 | | through June 30, 2017 and the estimated payments due and | 9 | | payable in the month of October 2016 multiplied by 6 as | 10 | | described in subparagraph (B). | 11 | | (D) For the period of January 1, 2018 through June 30, | 12 | | 2018, the product of .19125 multiplied by the sum of the | 13 | | fee-for-service payments to hospitals as authorized under | 14 | | Section 5A-12.5 and the adjustments authorized under | 15 | | subsection (t) of Section 5A-12.2 to managed care | 16 | | organizations for hospital services due and payable in the | 17 | | month of October 2017 multiplied by 6, except that: | 18 | | (i) the amount calculated under this subparagraph | 19 | | (D) shall be adjusted, either positively or | 20 | | negatively, to account for the difference between the | 21 | | actual payments issued under Section 5A-12.5 for the | 22 | | period of July 1, 2017 through December 31, 2017 and | 23 | | the estimated payments due and payable in the month of | 24 | | April 2017 multiplied by 6 as described in subparagraph | 25 | | (C); and | 26 | | (ii) the amount calculated under this subparagraph |
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| 1 | | (D) shall be adjusted to include the product of .19125 | 2 | | multiplied by the sum of the fee-for-service payments, | 3 | | if any, estimated to be paid to hospitals under | 4 | | subsection (b) of Section 5A-12.5. | 5 | | (2) The Department shall complete and apply a final | 6 | | reconciliation of the ACA Assessment Adjustment prior to June | 7 | | 30, 2018 to account for: | 8 | | (A) any differences between the actual payments issued | 9 | | or scheduled to be issued prior to June 30, 2018 as | 10 | | authorized in Section 5A-12.5 for the period of January 1, | 11 | | 2018 through June 30, 2018 and the estimated payments due | 12 | | and payable in the month of October 2017 multiplied by 6 as | 13 | | described in subparagraph (D); and | 14 | | (B) any difference between the estimated | 15 | | fee-for-service payments under subsection (b) of Section | 16 | | 5A-12.5 and the amount of such payments that are actually | 17 | | scheduled to be paid. | 18 | | The Department shall notify hospitals of any additional | 19 | | amounts owed or reduction credits to be applied to the June | 20 | | 2018 ACA Assessment Adjustment. This is to be considered the | 21 | | final reconciliation for the ACA Assessment Adjustment. | 22 | | (3) Notwithstanding any other provision of this Section, if | 23 | | for any reason the scheduled payments under subsection (b) of | 24 | | Section 5A-12.5 are not issued in full by the final day of the | 25 | | period authorized under subsection (b) of Section 5A-12.5, | 26 | | funds collected from each hospital pursuant to subparagraph (D) |
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| 1 | | of paragraph (1) and pursuant to paragraph (2), attributable to | 2 | | the scheduled payments authorized under subsection (b) of | 3 | | Section 5A-12.5 that are not issued in full by the final day of | 4 | | the period attributable to each payment authorized under | 5 | | subsection (b) of Section 5A-12.5, shall be refunded. | 6 | | (4) The increases authorized under paragraph (2) of | 7 | | subsection (a) and paragraph (2) of subsection (b-5) shall be | 8 | | limited to the federally required State share of the total | 9 | | payments authorized under Section 5A-12.5 if the sum of such | 10 | | payments yields an annualized amount equal to or less than | 11 | | $450,000,000, or if the adjustments authorized under | 12 | | subsection (t) of Section 5A-12.2 are found not to be | 13 | | actuarially sound; however, this limitation shall not apply to | 14 | | the fee-for-service payments described in subsection (b) of | 15 | | Section 5A-12.5. | 16 | | (c) (Blank).
| 17 | | (d) Notwithstanding any of the other provisions of this | 18 | | Section, the Department is authorized to adopt rules to reduce | 19 | | the rate of any annual assessment imposed under this Section, | 20 | | as authorized by Section 5-46.2 of the Illinois Administrative | 21 | | Procedure Act.
| 22 | | (e) Notwithstanding any other provision of this Section, | 23 | | any plan providing for an assessment on a hospital provider as | 24 | | a permissible tax under Title XIX of the federal Social | 25 | | Security Act and Medicaid-eligible payments to hospital | 26 | | providers from the revenues derived from that assessment shall |
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| 1 | | be reviewed by the Illinois Department of Healthcare and Family | 2 | | Services, as the Single State Medicaid Agency required by | 3 | | federal law, to determine whether those assessments and | 4 | | hospital provider payments meet federal Medicaid standards. If | 5 | | the Department determines that the elements of the plan may | 6 | | meet federal Medicaid standards and a related State Medicaid | 7 | | Plan Amendment is prepared in a manner and form suitable for | 8 | | submission, that State Plan Amendment shall be submitted in a | 9 | | timely manner for review by the Centers for Medicare and | 10 | | Medicaid Services of the United States Department of Health and | 11 | | Human Services and subject to approval by the Centers for | 12 | | Medicare and Medicaid Services of the United States Department | 13 | | of Health and Human Services. No such plan shall become | 14 | | effective without approval by the Illinois General Assembly by | 15 | | the enactment into law of related legislation. Notwithstanding | 16 | | any other provision of this Section, the Department is | 17 | | authorized to adopt rules to reduce the rate of any annual | 18 | | assessment imposed under this Section. Any such rules may be | 19 | | adopted by the Department under Section 5-50 of the Illinois | 20 | | Administrative Procedure Act. | 21 | | (f) Subject to federal approval and notwithstanding any | 22 | | other provision of this Code, for any redesign of any | 23 | | assessments authorized under this Section, the volume data used | 24 | | to redesign the distribution of payments shall include managed | 25 | | care organization denial payments or settlements between | 26 | | hospitals and managed care organizations. |
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| 1 | | (Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14; 99-2, | 2 | | eff. 3-26-15; 99-516, eff. 6-30-16.)
| 3 | | (305 ILCS 5/5A-12.2) | 4 | | (Section scheduled to be repealed on July 1, 2018) | 5 | | Sec. 5A-12.2. Hospital access payments on or after July 1, | 6 | | 2008. | 7 | | (a) To preserve and improve access to hospital services, | 8 | | for hospital services rendered on or after July 1, 2008, the | 9 | | Illinois Department shall, except for hospitals described in | 10 | | subsection (b) of Section 5A-3, make payments to hospitals as | 11 | | set forth in this Section. These payments shall be paid in 12 | 12 | | equal installments on or before the seventh State business day | 13 | | of each month, except that no payment shall be due within 100 | 14 | | days after the later of the date of notification of federal | 15 | | approval of the payment methodologies required under this | 16 | | Section or any waiver required under 42 CFR 433.68, at which | 17 | | time the sum of amounts required under this Section prior to | 18 | | the date of notification is due and payable. Payments under | 19 | | this Section are not due and payable, however, until (i) the | 20 | | methodologies described in this Section are approved by the | 21 | | federal government in an appropriate State Plan amendment and | 22 | | (ii) the assessment imposed under this Article is determined to | 23 | | be a permissible tax under Title XIX of the Social Security | 24 | | Act. | 25 | | (a-5) The Illinois Department may, when practicable, |
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| 1 | | accelerate the schedule upon which payments authorized under | 2 | | this Section are made. | 3 | | (b) Across-the-board inpatient adjustment. | 4 | | (1) In addition to rates paid for inpatient hospital | 5 | | services, the Department shall pay to each Illinois general | 6 | | acute care hospital an amount equal to 40% of the total | 7 | | base inpatient payments paid to the hospital for services | 8 | | provided in State fiscal year 2005. | 9 | | (2) In addition to rates paid for inpatient hospital | 10 | | services, the Department shall pay to each freestanding | 11 | | Illinois specialty care hospital as defined in 89 Ill. Adm. | 12 | | Code 149.50(c)(1), (2), or (4) an amount equal to 60% of | 13 | | the total base inpatient payments paid to the hospital for | 14 | | services provided in State fiscal year 2005. | 15 | | (3) In addition to rates paid for inpatient hospital | 16 | | services, the Department shall pay to each freestanding | 17 | | Illinois rehabilitation or psychiatric hospital an amount | 18 | | equal to $1,000 per Medicaid inpatient day multiplied by | 19 | | the increase in the hospital's Medicaid inpatient | 20 | | utilization ratio (determined using the positive | 21 | | percentage change from the rate year 2005 Medicaid | 22 | | inpatient utilization ratio to the rate year 2007 Medicaid | 23 | | inpatient utilization ratio, as calculated by the | 24 | | Department for the disproportionate share determination). | 25 | | (4) In addition to rates paid for inpatient hospital | 26 | | services, the Department shall pay to each Illinois |
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| 1 | | children's hospital an amount equal to 20% of the total | 2 | | base inpatient payments paid to the hospital for services | 3 | | provided in State fiscal year 2005 and an additional amount | 4 | | equal to 20% of the base inpatient payments paid to the | 5 | | hospital for psychiatric services provided in State fiscal | 6 | | year 2005. | 7 | | (5) In addition to rates paid for inpatient hospital | 8 | | services, the Department shall pay to each Illinois | 9 | | hospital eligible for a pediatric inpatient adjustment | 10 | | payment under 89 Ill. Adm. Code 148.298, as in effect for | 11 | | State fiscal year 2007, a supplemental pediatric inpatient | 12 | | adjustment payment equal to: | 13 | | (i) For freestanding children's hospitals as | 14 | | defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5 | 15 | | multiplied by the hospital's pediatric inpatient | 16 | | adjustment payment required under 89 Ill. Adm. Code | 17 | | 148.298, as in effect for State fiscal year 2008. | 18 | | (ii) For hospitals other than freestanding | 19 | | children's hospitals as defined in 89 Ill. Adm. Code | 20 | | 149.50(c)(3)(B), 1.0 multiplied by the hospital's | 21 | | pediatric inpatient adjustment payment required under | 22 | | 89 Ill. Adm. Code 148.298, as in effect for State | 23 | | fiscal year 2008. | 24 | | (c) Outpatient adjustment. | 25 | | (1) In addition to the rates paid for outpatient | 26 | | hospital services, the Department shall pay each Illinois |
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| 1 | | hospital an amount equal to 2.2 multiplied by the | 2 | | hospital's ambulatory procedure listing payments for | 3 | | categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code | 4 | | 148.140(b), for State fiscal year 2005. | 5 | | (2) In addition to the rates paid for outpatient | 6 | | hospital services, the Department shall pay each Illinois | 7 | | freestanding psychiatric hospital an amount equal to 3.25 | 8 | | multiplied by the hospital's ambulatory procedure listing | 9 | | payments for category 5b, as defined in 89 Ill. Adm. Code | 10 | | 148.140(b)(1)(E), for State fiscal year 2005. | 11 | | (d) Medicaid high volume adjustment. In addition to rates | 12 | | paid for inpatient hospital services, the Department shall pay | 13 | | to each Illinois general acute care hospital that provided more | 14 | | than 20,500 Medicaid inpatient days of care in State fiscal | 15 | | year 2005 amounts as follows: | 16 | | (1) For hospitals with a case mix index equal to or | 17 | | greater than the 85th percentile of hospital case mix | 18 | | indices, $350 for each Medicaid inpatient day of care | 19 | | provided during that period; and | 20 | | (2) For hospitals with a case mix index less than the | 21 | | 85th percentile of hospital case mix indices, $100 for each | 22 | | Medicaid inpatient day of care provided during that period. | 23 | | (e) Capital adjustment. In addition to rates paid for | 24 | | inpatient hospital services, the Department shall pay an | 25 | | additional payment to each Illinois general acute care hospital | 26 | | that has a Medicaid inpatient utilization rate of at least 10% |
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| 1 | | (as calculated by the Department for the rate year 2007 | 2 | | disproportionate share determination) amounts as follows: | 3 | | (1) For each Illinois general acute care hospital that | 4 | | has a Medicaid inpatient utilization rate of at least 10% | 5 | | and less than 36.94% and whose capital cost is less than | 6 | | the 60th percentile of the capital costs of all Illinois | 7 | | hospitals, the amount of such payment shall equal the | 8 | | hospital's Medicaid inpatient days multiplied by the | 9 | | difference between the capital costs at the 60th percentile | 10 | | of the capital costs of all Illinois hospitals and the | 11 | | hospital's capital costs. | 12 | | (2) For each Illinois general acute care hospital that | 13 | | has a Medicaid inpatient utilization rate of at least | 14 | | 36.94% and whose capital cost is less than the 75th | 15 | | percentile of the capital costs of all Illinois hospitals, | 16 | | the amount of such payment shall equal the hospital's | 17 | | Medicaid inpatient days multiplied by the difference | 18 | | between the capital costs at the 75th percentile of the | 19 | | capital costs of all Illinois hospitals and the hospital's | 20 | | capital costs. | 21 | | (f) Obstetrical care adjustment. | 22 | | (1) In addition to rates paid for inpatient hospital | 23 | | services, the Department shall pay $1,500 for each Medicaid | 24 | | obstetrical day of care provided in State fiscal year 2005 | 25 | | by each Illinois rural hospital that had a Medicaid | 26 | | obstetrical percentage (Medicaid obstetrical days divided |
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| 1 | | by Medicaid inpatient days) greater than 15% for State | 2 | | fiscal year 2005. | 3 | | (2) In addition to rates paid for inpatient hospital | 4 | | services, the Department shall pay $1,350 for each Medicaid | 5 | | obstetrical day of care provided in State fiscal year 2005 | 6 | | by each Illinois general acute care hospital that was | 7 | | designated a level III perinatal center as of December 31, | 8 | | 2006, and that had a case mix index equal to or greater | 9 | | than the 45th percentile of the case mix indices for all | 10 | | level III perinatal centers. | 11 | | (3) In addition to rates paid for inpatient hospital | 12 | | services, the Department shall pay $900 for each Medicaid | 13 | | obstetrical day of care provided in State fiscal year 2005 | 14 | | by each Illinois general acute care hospital that was | 15 | | designated a level II or II+ perinatal center as of | 16 | | December 31, 2006, and that had a case mix index equal to | 17 | | or greater than the 35th percentile of the case mix indices | 18 | | for all level II and II+ perinatal centers. | 19 | | (g) Trauma adjustment. | 20 | | (1) In addition to rates paid for inpatient hospital | 21 | | services, the Department shall pay each Illinois general | 22 | | acute care hospital designated as a trauma center as of | 23 | | July 1, 2007, a payment equal to 3.75 multiplied by the | 24 | | hospital's State fiscal year 2005 Medicaid capital | 25 | | payments. | 26 | | (2) In addition to rates paid for inpatient hospital |
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| 1 | | services, the Department shall pay $400 for each Medicaid | 2 | | acute inpatient day of care provided in State fiscal year | 3 | | 2005 by each Illinois general acute care hospital that was | 4 | | designated a level II trauma center, as defined in 89 Ill. | 5 | | Adm. Code 148.295(a)(3) and 148.295(a)(4), as of July 1, | 6 | | 2007. | 7 | | (3) In addition to rates paid for inpatient hospital | 8 | | services, the Department shall pay $235 for each Illinois | 9 | | Medicaid acute inpatient day of care provided in State | 10 | | fiscal year 2005 by each level I pediatric trauma center | 11 | | located outside of Illinois that had more than 8,000 | 12 | | Illinois Medicaid inpatient days in State fiscal year 2005. | 13 | | (h) Supplemental tertiary care adjustment. In addition to | 14 | | rates paid for inpatient services, the Department shall pay to | 15 | | each Illinois hospital eligible for tertiary care adjustment | 16 | | payments under 89 Ill. Adm. Code 148.296, as in effect for | 17 | | State fiscal year 2007, a supplemental tertiary care adjustment | 18 | | payment equal to the tertiary care adjustment payment required | 19 | | under 89 Ill. Adm. Code 148.296, as in effect for State fiscal | 20 | | year 2007. | 21 | | (i) Crossover adjustment. In addition to rates paid for | 22 | | inpatient services, the Department shall pay each Illinois | 23 | | general acute care hospital that had a ratio of crossover days | 24 | | to total inpatient days for medical assistance programs | 25 | | administered by the Department (utilizing information from | 26 | | 2005 paid claims) greater than 50%, and a case mix index |
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| 1 | | greater than the 65th percentile of case mix indices for all | 2 | | Illinois hospitals, a rate of $1,125 for each Medicaid | 3 | | inpatient day including crossover days. | 4 | | (j) Magnet hospital adjustment. In addition to rates paid | 5 | | for inpatient hospital services, the Department shall pay to | 6 | | each Illinois general acute care hospital and each Illinois | 7 | | freestanding children's hospital that, as of February 1, 2008, | 8 | | was recognized as a Magnet hospital by the American Nurses | 9 | | Credentialing Center and that had a case mix index greater than | 10 | | the 75th percentile of case mix indices for all Illinois | 11 | | hospitals amounts as follows: | 12 | | (1) For hospitals located in a county whose eligibility | 13 | | growth factor is greater than the mean, $450 multiplied by | 14 | | the eligibility growth factor for the county in which the | 15 | | hospital is located for each Medicaid inpatient day of care | 16 | | provided by the hospital during State fiscal year 2005. | 17 | | (2) For hospitals located in a county whose eligibility | 18 | | growth factor is less than or equal to the mean, $225 | 19 | | multiplied by the eligibility growth factor for the county | 20 | | in which the hospital is located for each Medicaid | 21 | | inpatient day of care provided by the hospital during State | 22 | | fiscal year 2005. | 23 | | For purposes of this subsection, "eligibility growth | 24 | | factor" means the percentage by which the number of Medicaid | 25 | | recipients in the county increased from State fiscal year 1998 | 26 | | to State fiscal year 2005. |
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| 1 | | (k) For purposes of this Section, a hospital that is | 2 | | enrolled to provide Medicaid services during State fiscal year | 3 | | 2005 shall have its utilization and associated reimbursements | 4 | | annualized prior to the payment calculations being performed | 5 | | under this Section. | 6 | | (l) For purposes of this Section, the terms "Medicaid | 7 | | days", "ambulatory procedure listing services", and | 8 | | "ambulatory procedure listing payments" do not include any | 9 | | days, charges, or services for which Medicare or a managed care | 10 | | organization reimbursed on a capitated basis was liable for | 11 | | payment, except where explicitly stated otherwise in this | 12 | | Section. | 13 | | (m) For purposes of this Section, in determining the | 14 | | percentile ranking of an Illinois hospital's case mix index or | 15 | | capital costs, hospitals described in subsection (b) of Section | 16 | | 5A-3 shall be excluded from the ranking. | 17 | | (n) Definitions. Unless the context requires otherwise or | 18 | | unless provided otherwise in this Section, the terms used in | 19 | | this Section for qualifying criteria and payment calculations | 20 | | shall have the same meanings as those terms have been given in | 21 | | the Illinois Department's administrative rules as in effect on | 22 | | March 1, 2008. Other terms shall be defined by the Illinois | 23 | | Department by rule. | 24 | | As used in this Section, unless the context requires | 25 | | otherwise: | 26 | | "Base inpatient payments" means, for a given hospital, the |
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| 1 | | sum of base payments for inpatient services made on a per diem | 2 | | or per admission (DRG) basis, excluding those portions of per | 3 | | admission payments that are classified as capital payments. | 4 | | Disproportionate share hospital adjustment payments, Medicaid | 5 | | Percentage Adjustments, Medicaid High Volume Adjustments, and | 6 | | outlier payments, as defined by rule by the Department as of | 7 | | January 1, 2008, are not base payments. | 8 | | "Capital costs" means, for a given hospital, the total | 9 | | capital costs determined using the most recent 2005 Medicare | 10 | | cost report as contained in the Healthcare Cost Report | 11 | | Information System file, for the quarter ending on December 31, | 12 | | 2006, divided by the total inpatient days from the same cost | 13 | | report to calculate a capital cost per day. The resulting | 14 | | capital cost per day is inflated to the midpoint of State | 15 | | fiscal year 2009 utilizing the national hospital market price | 16 | | proxies (DRI) hospital cost index. If a hospital's 2005 | 17 | | Medicare cost report is not contained in the Healthcare Cost | 18 | | Report Information System, the Department may obtain the data | 19 | | necessary to compute the hospital's capital costs from any | 20 | | source available, including, but not limited to, records | 21 | | maintained by the hospital provider, which may be inspected at | 22 | | all times during business hours of the day by the Illinois | 23 | | Department or its duly authorized agents and employees. | 24 | | "Case mix index" means, for a given hospital, the sum of | 25 | | the DRG relative weighting factors in effect on January 1, | 26 | | 2005, for all general acute care admissions for State fiscal |
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| 1 | | year 2005, excluding Medicare crossover admissions and | 2 | | transplant admissions reimbursed under 89 Ill. Adm. Code | 3 | | 148.82, divided by the total number of general acute care | 4 | | admissions for State fiscal year 2005, excluding Medicare | 5 | | crossover admissions and transplant admissions reimbursed | 6 | | under 89 Ill. Adm. Code 148.82. | 7 | | "Medicaid inpatient day" means, for a given hospital, the | 8 | | sum of days of inpatient hospital days provided to recipients | 9 | | of medical assistance under Title XIX of the federal Social | 10 | | Security Act, excluding days for individuals eligible for | 11 | | Medicare under Title XVIII of that Act (Medicaid/Medicare | 12 | | crossover days), as tabulated from the Department's paid claims | 13 | | data for admissions occurring during State fiscal year 2005 | 14 | | that was adjudicated by the Department through March 23, 2007. | 15 | | "Medicaid obstetrical day" means, for a given hospital, the | 16 | | sum of days of inpatient hospital days grouped by the | 17 | | Department to DRGs of 370 through 375 provided to recipients of | 18 | | medical assistance under Title XIX of the federal Social | 19 | | Security Act, excluding days for individuals eligible for | 20 | | Medicare under Title XVIII of that Act (Medicaid/Medicare | 21 | | crossover days), as tabulated from the Department's paid claims | 22 | | data for admissions occurring during State fiscal year 2005 | 23 | | that was adjudicated by the Department through March 23, 2007. | 24 | | "Outpatient ambulatory procedure listing payments" means, | 25 | | for a given hospital, the sum of payments for ambulatory | 26 | | procedure listing services, as described in 89 Ill. Adm. Code |
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| 1 | | 148.140(b), provided to recipients of medical assistance under | 2 | | Title XIX of the federal Social Security Act, excluding | 3 | | payments for individuals eligible for Medicare under Title | 4 | | XVIII of the Act (Medicaid/Medicare crossover days), as | 5 | | tabulated from the Department's paid claims data for services | 6 | | occurring in State fiscal year 2005 that were adjudicated by | 7 | | the Department through March 23, 2007. | 8 | | (o) The Department may adjust payments made under this | 9 | | Section 5A-12.2 to comply with federal law or regulations | 10 | | regarding hospital-specific payment limitations on | 11 | | government-owned or government-operated hospitals. | 12 | | (p) Notwithstanding any of the other provisions of this | 13 | | Section, the Department is authorized to adopt rules that | 14 | | change the hospital access improvement payments specified in | 15 | | this Section, but only to the extent necessary to conform to | 16 | | any federally approved amendment to the Title XIX State plan. | 17 | | Any such rules shall be adopted by the Department as authorized | 18 | | by Section 5-50 of the Illinois Administrative Procedure Act. | 19 | | Notwithstanding any other provision of law, any changes | 20 | | implemented as a result of this subsection (p) shall be given | 21 | | retroactive effect so that they shall be deemed to have taken | 22 | | effect as of the effective date of this Section. | 23 | | (q) (Blank). | 24 | | (r) On and after July 1, 2012, the Department shall reduce | 25 | | any rate of reimbursement for services or other payments or | 26 | | alter any methodologies authorized by this Code to reduce any |
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| 1 | | rate of reimbursement for services or other payments in | 2 | | accordance with Section 5-5e. | 3 | | (s) On or after January 1, 2016, and no less than annually | 4 | | thereafter, the Department shall increase capitation payments | 5 | | to capitated managed care organizations (MCOs) to equal the | 6 | | aggregate reduction of payments made in this Section and in | 7 | | Section 5A-12.4 by a uniform percentage on a regional basis to | 8 | | preserve access to hospital services for recipients under the | 9 | | Illinois Medical Assistance Program. The aggregate amount of | 10 | | all increased capitation payments to all MCOs for a fiscal year | 11 | | shall be the amount needed to avoid reduction in payments | 12 | | authorized under Section 5A-15. Payments to MCOs under this | 13 | | Section shall be consistent with actuarial certification and | 14 | | shall be published by the Department each year. Each MCO shall | 15 | | only expend the increased capitation payments it receives under | 16 | | this Section to support the availability of hospital services | 17 | | and to ensure access to hospital services, with such | 18 | | expenditures being made within 15 calendar days from when the | 19 | | MCO receives the increased capitation payment. The Department | 20 | | shall make available, on a monthly basis, a report of the | 21 | | capitation payments that are made to each MCO pursuant to this | 22 | | subsection, including the number of enrollees for which such | 23 | | payment is made, the per enrollee amount of the payment, and | 24 | | any adjustments that have been made. Payments made under this | 25 | | subsection shall be guaranteed by a surety bond obtained by the | 26 | | MCO in an amount established by the Department to approximate |
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| 1 | | one month's liability of payments authorized under this | 2 | | subsection. The Department may advance the payments guaranteed | 3 | | by the surety bond. Payments to MCOs that would be paid | 4 | | consistent with actuarial certification and enrollment in the | 5 | | absence of the increased capitation payments under this Section | 6 | | shall not be reduced as a consequence of payments made under | 7 | | this subsection. | 8 | | As used in this subsection, "MCO" means an entity which | 9 | | contracts with the Department to provide services where payment | 10 | | for medical services is made on a capitated basis. | 11 | | (t) On or after July 1, 2014, the Department may increase | 12 | | capitation payments to capitated managed care organizations | 13 | | (MCOs) to equal the aggregate reduction of payments made in | 14 | | Section 5A-12.5 to preserve access to hospital services for | 15 | | recipients under the Illinois Medical Assistance Program. | 16 | | Effective January 1, 2016, the Department shall increase | 17 | | capitation payments to MCOs to include the payments authorized | 18 | | under Section 5A-12.5 to preserve access to hospital services | 19 | | for recipients under the Illinois Medical Assistance Program by | 20 | | ensuring that the reimbursement provided for Affordable Care | 21 | | Act adults enrolled in a MCO is equivalent to the reimbursement | 22 | | provided for Affordable Care Act adults enrolled in a | 23 | | fee-for-service program. Payments to MCOs under this Section | 24 | | shall be consistent with actuarial certification and federal | 25 | | approval (which may be retrospectively determined) and shall be | 26 | | published by the Department each year. Each MCO shall only |
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| 1 | | expend the increased capitation payments it receives under this | 2 | | Section to support the availability of hospital services and to | 3 | | ensure access to hospital services, with such expenditures | 4 | | being made within 15 calendar days from when the MCO receives | 5 | | the increased capitation payment. Payments made under this | 6 | | subsection may be guaranteed by a surety bond obtained by the | 7 | | MCO in an amount established by the Department to approximate | 8 | | one month's liability of payments authorized under this | 9 | | subsection. The Department may advance the payments to | 10 | | hospitals under this subsection, in the event the MCO fails to | 11 | | make such payments. The Department shall make available, on a | 12 | | monthly basis, a report of the capitation payments that are | 13 | | made to each MCO pursuant to this subsection, including the | 14 | | number of enrollees for which such payment is made, the per | 15 | | enrollee amount of the payment, and any adjustments that have | 16 | | been made. Payments to MCOs that would be paid consistent with | 17 | | actuarial certification and enrollment in the absence of the | 18 | | increased capitation payments under this subsection shall not | 19 | | be reduced as a consequence of payments made under this | 20 | | subsection. | 21 | | As used in this subsection, "MCO" means an entity which | 22 | | contracts with the Department to provide services where payment | 23 | | for medical services is made on a capitated basis. | 24 | | (u) Subject to federal approval and notwithstanding any | 25 | | other provision of this Code, for any redesign of any payments | 26 | | authorized under this Section, the volume data used to redesign |
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| 1 | | the distribution of payments shall include managed care | 2 | | organization denial payments or settlements between hospitals | 3 | | and managed care organizations. | 4 | | (Source: P.A. 98-651, eff. 6-16-14; 99-516, eff. 6-30-16.) | 5 | | (305 ILCS 5/5A-12.4) | 6 | | (Section scheduled to be repealed on July 1, 2018) | 7 | | Sec. 5A-12.4. Hospital access improvement payments on or | 8 | | after June 10, 2012. | 9 | | (a) Hospital access improvement payments. To preserve and | 10 | | improve access to hospital services, for hospital and physician | 11 | | services rendered on or after June 10, 2012, the Illinois | 12 | | Department shall, except for hospitals described in subsection | 13 | | (b) of Section 5A-3, make payments to hospitals as set forth in | 14 | | this Section. These payments shall be paid in 12 equal | 15 | | installments on or before the 7th State business day of each | 16 | | month, except that no payment shall be due within 100 days | 17 | | after the later of the date of notification of federal approval | 18 | | of the payment methodologies required under this Section or any | 19 | | waiver required under 42 CFR 433.68, at which time the sum of | 20 | | amounts required under this Section prior to the date of | 21 | | notification is due and payable. Payments under this Section | 22 | | are not due and payable, however, until (i) the methodologies | 23 | | described in this Section are approved by the federal | 24 | | government in an appropriate State Plan amendment and (ii) the | 25 | | assessment imposed under subsection (b-5) of Section 5A-2 of |
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| 1 | | this Article is determined to be a permissible tax under Title | 2 | | XIX of the Social Security Act. The Illinois Department shall | 3 | | take all actions necessary to implement the payments under this | 4 | | Section effective June 10, 2012, including but not limited to | 5 | | providing public notice pursuant to federal requirements, the | 6 | | filing of a State Plan amendment, and the adoption of | 7 | | administrative rules. For State fiscal year 2013, payments | 8 | | under this Section shall be increased by 21/365ths. The funding | 9 | | source for these additional payments shall be from the | 10 | | increased assessment under subsection (b-5) of Section 5A-2 | 11 | | that was received from hospital providers under Section 5A-4 | 12 | | for the portion of State fiscal year 2012 beginning June 10, | 13 | | 2012 through June 30, 2012. | 14 | | (a-5) Accelerated schedule. The Illinois Department may, | 15 | | when practicable, accelerate the schedule upon which payments | 16 | | authorized under this Section are made. | 17 | | (b) Magnet and perinatal hospital adjustment. In addition | 18 | | to rates paid for inpatient hospital services, the Department | 19 | | shall pay to each Illinois general acute care hospital that, as | 20 | | of August 25, 2011, was recognized as a Magnet hospital by the | 21 | | American Nurses Credentialing Center and that, as of September | 22 | | 14, 2011, was designated as a level III perinatal center | 23 | | amounts as follows: | 24 | | (1) For hospitals with a case mix index equal to or | 25 | | greater than the 80th percentile of case mix indices for | 26 | | all Illinois hospitals, $470 for each Medicaid general |
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| 1 | | acute care inpatient day of care provided by the hospital | 2 | | during State fiscal year 2009. | 3 | | (2) For all other hospitals, $170 for each Medicaid | 4 | | general acute care inpatient day of care provided by the | 5 | | hospital during State fiscal year 2009. | 6 | | (c) Trauma level II adjustment. In addition to rates paid | 7 | | for inpatient hospital services, the Department shall pay to | 8 | | each Illinois general acute care hospital that, as of July 1, | 9 | | 2011, was designated as a level II trauma center amounts as | 10 | | follows: | 11 | | (1) For hospitals with a case mix index equal to or | 12 | | greater than the 50th percentile of case mix indices for | 13 | | all Illinois hospitals, $470 for each Medicaid general | 14 | | acute care inpatient day of care provided by the hospital | 15 | | during State fiscal year 2009. | 16 | | (2) For all other hospitals, $170 for each Medicaid | 17 | | general acute care inpatient day of care provided by the | 18 | | hospital during State fiscal year 2009. | 19 | | (3) For the purposes of this adjustment, hospitals | 20 | | located in the same city that alternate their trauma center | 21 | | designation as defined in 89 Ill. Adm. Code 148.295(a)(2) | 22 | | shall have the adjustment provided under this Section | 23 | | divided between the 2 hospitals. | 24 | | (d) Dual-eligible adjustment. In addition to rates paid for | 25 | | inpatient services, the Department shall pay each Illinois | 26 | | general acute care hospital that had a ratio of crossover days |
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| 1 | | to total inpatient days for programs under Title XIX of the | 2 | | Social Security Act administered by the Department (utilizing | 3 | | information from 2009 paid claims) greater than 50%, and a case | 4 | | mix index equal to or greater than the 75th percentile of case | 5 | | mix indices for all Illinois hospitals, a rate of $400 for each | 6 | | Medicaid inpatient day during State fiscal year 2009 including | 7 | | crossover days. | 8 | | (e) Medicaid volume adjustment. In addition to rates paid | 9 | | for inpatient hospital services, the Department shall pay to | 10 | | each Illinois general acute care hospital that provided more | 11 | | than 10,000 Medicaid inpatient days of care in State fiscal | 12 | | year 2009, has a Medicaid inpatient utilization rate of at | 13 | | least 29.05% as calculated by the Department for the Rate Year | 14 | | 2011 Disproportionate Share determination, and is not eligible | 15 | | for Medicaid Percentage Adjustment payments in rate year 2011 | 16 | | an amount equal to $135 for each Medicaid inpatient day of care | 17 | | provided during State fiscal year 2009. | 18 | | (f) Outpatient service adjustment. In addition to the rates | 19 | | paid for outpatient hospital services, the Department shall pay | 20 | | each Illinois hospital an amount at least equal to $100 | 21 | | multiplied by the hospital's outpatient ambulatory procedure | 22 | | listing services (excluding categories 3B and 3C) and by the | 23 | | hospital's end stage renal disease treatment services provided | 24 | | for State fiscal year 2009. | 25 | | (g) Ambulatory service adjustment. | 26 | | (1) In addition to the rates paid for outpatient |
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| 1 | | hospital services provided in the emergency department, | 2 | | the Department shall pay each Illinois hospital an amount | 3 | | equal to $105 multiplied by the hospital's outpatient | 4 | | ambulatory procedure listing services for categories 3A, | 5 | | 3B, and 3C for State fiscal year 2009. | 6 | | (2) In addition to the rates paid for outpatient | 7 | | hospital services, the Department shall pay each Illinois | 8 | | freestanding psychiatric hospital an amount equal to $200 | 9 | | multiplied by the hospital's ambulatory procedure listing | 10 | | services for category 5A for State fiscal year 2009. | 11 | | (h) Specialty hospital adjustment. In addition to the rates | 12 | | paid for outpatient hospital services, the Department shall pay | 13 | | each Illinois long term acute care hospital and each Illinois | 14 | | hospital devoted exclusively to the treatment of cancer, an | 15 | | amount equal to $700 multiplied by the hospital's outpatient | 16 | | ambulatory procedure listing services and by the hospital's end | 17 | | stage renal disease treatment services (including services | 18 | | provided to individuals eligible for both Medicaid and | 19 | | Medicare) provided for State fiscal year 2009. | 20 | | (h-1) ER Safety Net Payments. In addition to rates paid for | 21 | | outpatient services, the Department shall pay to each Illinois | 22 | | general acute care hospital with an emergency room ratio equal | 23 | | to or greater than 55%, that is not eligible for Medicaid | 24 | | percentage adjustments payments in rate year 2011, with a case | 25 | | mix index equal to or greater than the 20th percentile, and | 26 | | that is not designated as a trauma center by the Illinois |
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| 1 | | Department of Public Health on July 1, 2011, as follows: | 2 | | (1) Each hospital with an emergency room ratio equal to | 3 | | or greater than 74% shall receive a rate of $225 for each | 4 | | outpatient ambulatory procedure listing and end-stage | 5 | | renal disease treatment service provided for State fiscal | 6 | | year 2009. | 7 | | (2) For all other hospitals, $65 shall be paid for each | 8 | | outpatient ambulatory procedure listing and end-stage | 9 | | renal disease treatment service provided for State fiscal | 10 | | year 2009. | 11 | | (i) Physician supplemental adjustment. In addition to the | 12 | | rates paid for physician services, the Department shall make an | 13 | | adjustment payment for services provided by physicians as | 14 | | follows: | 15 | | (1) Physician services eligible for the adjustment | 16 | | payment are those provided by physicians employed by or who | 17 | | have a contract to provide services to patients of the | 18 | | following hospitals: (i) Illinois general acute care | 19 | | hospitals that provided at least 17,000 Medicaid inpatient | 20 | | days of care in State fiscal year 2009 and are eligible for | 21 | | Medicaid Percentage Adjustment Payments in rate year 2011; | 22 | | and (ii) Illinois freestanding children's hospitals, as | 23 | | defined in 89 Ill. Adm. Code 149.50(c)(3)(A). | 24 | | (2) The amount of the adjustment for each eligible | 25 | | hospital under this subsection (i) shall be determined by | 26 | | rule by the Department to spend a total pool of at least |
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| 1 | | $6,960,000 annually. This pool shall be allocated among the | 2 | | eligible hospitals based on the difference between the | 3 | | upper payment limit for what could have been paid under | 4 | | Medicaid for physician services provided during State | 5 | | fiscal year 2009 by physicians employed by or who had a | 6 | | contract with the hospital and the amount that was paid | 7 | | under Medicaid for such services, provided however, that in | 8 | | no event shall physicians at any individual hospital | 9 | | collectively receive an annual, aggregate adjustment in | 10 | | excess of $435,000, except that any amount that is not | 11 | | distributed to a hospital because of the upper payment | 12 | | limit shall be reallocated among the remaining eligible | 13 | | hospitals that are below the upper payment limitation, on a | 14 | | proportionate basis. | 15 | | (i-5) For any children's hospital which did not charge for | 16 | | its services during the base period, the Department shall use | 17 | | data supplied by the hospital to determine payments using | 18 | | similar methodologies for freestanding children's hospitals | 19 | | under this Section or Section 5A-12.2. | 20 | | (j) For purposes of this Section, a hospital that is | 21 | | enrolled to provide Medicaid services during State fiscal year | 22 | | 2009 shall have its utilization and associated reimbursements | 23 | | annualized prior to the payment calculations being performed | 24 | | under this Section. | 25 | | (k) For purposes of this Section, the terms "Medicaid | 26 | | days", "ambulatory procedure listing services", and |
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| 1 | | "ambulatory procedure listing payments" do not include any | 2 | | days, charges, or services for which Medicare or a managed care | 3 | | organization reimbursed on a capitated basis was liable for | 4 | | payment, except where explicitly stated otherwise in this | 5 | | Section. | 6 | | (l) Definitions. Unless the context requires otherwise or | 7 | | unless provided otherwise in this Section, the terms used in | 8 | | this Section for qualifying criteria and payment calculations | 9 | | shall have the same meanings as those terms have been given in | 10 | | the Illinois Department's administrative rules as in effect on | 11 | | October 1, 2011. Other terms shall be defined by the Illinois | 12 | | Department by rule. | 13 | | As used in this Section, unless the context requires | 14 | | otherwise: | 15 | | "Case mix index" means, for a given hospital, the sum of
| 16 | | the per admission (DRG) relative weighting factors in effect on | 17 | | January 1, 2005, for all general acute care admissions for | 18 | | State fiscal year 2009, excluding Medicare crossover | 19 | | admissions and transplant admissions reimbursed under 89 Ill. | 20 | | Adm. Code 148.82, divided by the total number of general acute | 21 | | care admissions for State fiscal year 2009, excluding Medicare | 22 | | crossover admissions and transplant admissions reimbursed | 23 | | under 89 Ill. Adm. Code 148.82. | 24 | | "Emergency room ratio" means, for a given hospital, a | 25 | | fraction, the denominator of which is the number of the | 26 | | hospital's outpatient ambulatory procedure listing and |
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| 1 | | end-stage renal disease treatment services provided for State | 2 | | fiscal year 2009 and the numerator of which is the hospital's | 3 | | outpatient ambulatory procedure listing services for | 4 | | categories 3A, 3B, and 3C for State fiscal year 2009. | 5 | | "Medicaid inpatient day" means, for a given hospital, the
| 6 | | sum of days of inpatient hospital days provided to recipients | 7 | | of medical assistance under Title XIX of the federal Social | 8 | | Security Act, excluding days for individuals eligible for | 9 | | Medicare under Title XVIII of that Act (Medicaid/Medicare | 10 | | crossover days), as tabulated from the Department's paid claims | 11 | | data for admissions occurring during State fiscal year 2009 | 12 | | that was adjudicated by the Department through June 30, 2010. | 13 | | "Outpatient ambulatory procedure listing services" means, | 14 | | for a given hospital, ambulatory procedure listing services, as | 15 | | described in 89 Ill. Adm. Code 148.140(b), provided to | 16 | | recipients of medical assistance under Title XIX of the federal | 17 | | Social Security Act, excluding services for individuals | 18 | | eligible for Medicare under Title XVIII of the Act | 19 | | (Medicaid/Medicare crossover days), as tabulated from the | 20 | | Department's paid claims data for services occurring in State | 21 | | fiscal year 2009 that were adjudicated by the Department | 22 | | through September 2, 2010. | 23 | | "Outpatient end-stage renal disease treatment services" | 24 | | means, for a given hospital, the services, as described in 89 | 25 | | Ill. Adm. Code 148.140(c), provided to recipients of medical | 26 | | assistance under Title XIX of the federal Social Security Act, |
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| 1 | | excluding payments for individuals eligible for Medicare under | 2 | | Title XVIII of the Act (Medicaid/Medicare crossover days), as | 3 | | tabulated from the Department's paid claims data for services | 4 | | occurring in State fiscal year 2009 that were adjudicated by | 5 | | the Department through September 2, 2010. | 6 | | (m) The Department may adjust payments made under this | 7 | | Section 5A-12.4 to comply with federal law or regulations | 8 | | regarding hospital-specific payment limitations on | 9 | | government-owned or government-operated hospitals. | 10 | | (n) Notwithstanding any of the other provisions of this | 11 | | Section, the Department is authorized to adopt rules that | 12 | | change the hospital access improvement payments specified in | 13 | | this Section, but only to the extent necessary to conform to | 14 | | any federally approved amendment to the Title XIX State plan. | 15 | | Any such rules shall be adopted by the Department as authorized | 16 | | by Section 5-50 of the Illinois Administrative Procedure Act. | 17 | | Notwithstanding any other provision of law, any changes | 18 | | implemented as a result of this subsection (n) shall be given | 19 | | retroactive effect so that they shall be deemed to have taken | 20 | | effect as of the effective date of this Section. | 21 | | (o) The Department of Healthcare and Family Services must | 22 | | submit a State Medicaid Plan Amendment to the Centers for | 23 | | Medicare and Medicaid Services to implement the payments under | 24 | | this Section.
| 25 | | (p) Subject to federal approval and notwithstanding any | 26 | | other provision of this Code, for any redesign of any payments |
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| 1 | | authorized under this Section, the volume data used to redesign | 2 | | the distribution of payments shall include managed care | 3 | | organization denial payments or settlements between hospitals | 4 | | and managed care organizations. | 5 | | (Source: P.A. 97-688, eff. 6-14-12; 98-104, eff. 7-22-13; | 6 | | 98-463, eff. 8-16-13; 98-756, eff. 7-16-14.) | 7 | | (305 ILCS 5/5A-12.5) | 8 | | Sec. 5A-12.5. Affordable Care Act adults; hospital access | 9 | | payments. | 10 | | (a) The Department shall, subject to federal approval, | 11 | | mirror the Medical Assistance hospital reimbursement | 12 | | methodology for Affordable Care Act adults who are enrolled | 13 | | under a fee-for-service or capitated managed care program, | 14 | | including hospital access payments as defined in Section | 15 | | 5A-12.2 of this Article and hospital access improvement | 16 | | payments as defined in Section 5A-12.4 of this Article, in | 17 | | compliance with the equivalent rate provisions of the | 18 | | Affordable Care Act. | 19 | | (b) If the fee-for-service payments authorized under this | 20 | | Section are deemed to be increases to payments for a prior | 21 | | period, the Department shall seek federal approval to issue | 22 | | such increases for the payments made through the period ending | 23 | | on June 30, 2018, even if such increases are paid out during an | 24 | | extended payment period beyond such date. Payment of such | 25 | | increases beyond such date is subject to federal approval. |
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| 1 | | (b-5) Subject to federal approval and notwithstanding any | 2 | | other provision of this Code, for any redesign of any payments | 3 | | authorized under this Section, the volume data used to redesign | 4 | | the distribution of payments shall include managed care | 5 | | organization denial payments or settlements between hospitals | 6 | | and managed care organizations. | 7 | | (c) As used in this Section, "Affordable Care Act" is the | 8 | | collective term for the Patient Protection and Affordable Care | 9 | | Act (Pub. L. 111-148) and the Health Care and Education | 10 | | Reconciliation Act of 2010 (Pub. L. 111-152).
| 11 | | (Source: P.A. 98-651, eff. 6-16-14; 99-516, eff. 6-30-16.) | 12 | | (305 ILCS 5/14-12) | 13 | | Sec. 14-12. Hospital rate reform payment system. The | 14 | | hospital payment system pursuant to Section 14-11 of this | 15 | | Article shall be as follows: | 16 | | (a) Inpatient hospital services. Effective for discharges | 17 | | on and after July 1, 2014, reimbursement for inpatient general | 18 | | acute care services shall utilize the All Patient Refined | 19 | | Diagnosis Related Grouping (APR-DRG) software, version 30, | 20 | | distributed by 3M TM Health Information System. | 21 | | (1) The Department shall establish Medicaid weighting | 22 | | factors to be used in the reimbursement system established | 23 | | under this subsection. Initial weighting factors shall be | 24 | | the weighting factors as published by 3M Health Information | 25 | | System, associated with Version 30.0 adjusted for the |
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| 1 | | Illinois experience. | 2 | | (2) The Department shall establish a | 3 | | statewide-standardized amount to be used in the inpatient | 4 | | reimbursement system. The Department shall publish these | 5 | | amounts on its website no later than 10 calendar days prior | 6 | | to their effective date. | 7 | | (3) In addition to the statewide-standardized amount, | 8 | | the Department shall develop adjusters to adjust the rate | 9 | | of reimbursement for critical Medicaid providers or | 10 | | services for trauma, transplantation services, perinatal | 11 | | care, and Graduate Medical Education (GME). | 12 | | (4) The Department shall develop add-on payments to | 13 | | account for exceptionally costly inpatient stays, | 14 | | consistent with Medicare outlier principles. Outlier fixed | 15 | | loss thresholds may be updated to control for excessive | 16 | | growth in outlier payments no more frequently than on an | 17 | | annual basis, but at least triennially. Upon updating the | 18 | | fixed loss thresholds, the Department shall be required to | 19 | | update base rates within 12 months. | 20 | | (5) The Department shall define those hospitals or | 21 | | distinct parts of hospitals that shall be exempt from the | 22 | | APR-DRG reimbursement system established under this | 23 | | Section. The Department shall publish these hospitals' | 24 | | inpatient rates on its website no later than 10 calendar | 25 | | days prior to their effective date. | 26 | | (6) Beginning July 1, 2014 and ending on June 30, 2018, |
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| 1 | | in addition to the statewide-standardized amount, the | 2 | | Department shall develop an adjustor to adjust the rate of | 3 | | reimbursement for safety-net hospitals defined in Section | 4 | | 5-5e.1 of this Code excluding pediatric hospitals. | 5 | | (7) Beginning July 1, 2014 and ending on June 30, 2018, | 6 | | in addition to the statewide-standardized amount, the | 7 | | Department shall develop an adjustor to adjust the rate of | 8 | | reimbursement for Illinois freestanding inpatient | 9 | | psychiatric hospitals that are not designated as | 10 | | children's hospitals by the Department but are primarily | 11 | | treating patients under the age of 21. | 12 | | (b) Outpatient hospital services. Effective for dates of | 13 | | service on and after July 1, 2014, reimbursement for outpatient | 14 | | services shall utilize the Enhanced Ambulatory Procedure | 15 | | Grouping (E-APG) software, version 3.7 distributed by 3M TM | 16 | | Health Information System. | 17 | | (1) The Department shall establish Medicaid weighting | 18 | | factors to be used in the reimbursement system established | 19 | | under this subsection. The initial weighting factors shall | 20 | | be the weighting factors as published by 3M Health | 21 | | Information System, associated with Version 3.7. | 22 | | (2) The Department shall establish service specific | 23 | | statewide-standardized amounts to be used in the | 24 | | reimbursement system. | 25 | | (A) The initial statewide standardized amounts, | 26 | | with the labor portion adjusted by the Calendar Year |
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| 1 | | 2013 Medicare Outpatient Prospective Payment System | 2 | | wage index with reclassifications, shall be published | 3 | | by the Department on its website no later than 10 | 4 | | calendar days prior to their effective date. | 5 | | (B) The Department shall establish adjustments to | 6 | | the statewide-standardized amounts for each Critical | 7 | | Access Hospital, as designated by the Department of | 8 | | Public Health in accordance with 42 CFR 485, Subpart F. | 9 | | The EAPG standardized amounts are determined | 10 | | separately for each critical access hospital such that | 11 | | simulated EAPG payments using outpatient base period | 12 | | paid claim data plus payments under Section 5A-12.4 of | 13 | | this Code net of the associated tax costs are equal to | 14 | | the estimated costs of outpatient base period claims | 15 | | data with a rate year cost inflation factor applied. | 16 | | (3) In addition to the statewide-standardized amounts, | 17 | | the Department shall develop adjusters to adjust the rate | 18 | | of reimbursement for critical Medicaid hospital outpatient | 19 | | providers or services, including outpatient high volume or | 20 | | safety-net hospitals. | 21 | | (c) In consultation with the hospital community, the | 22 | | Department is authorized to replace 89 Ill. Admin. Code 152.150 | 23 | | as published in 38 Ill. Reg. 4980 through 4986 within 12 months | 24 | | of the effective date of this amendatory Act of the 98th | 25 | | General Assembly. If the Department does not replace these | 26 | | rules within 12 months of the effective date of this amendatory |
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| 1 | | Act of the 98th General Assembly, the rules in effect for | 2 | | 152.150 as published in 38 Ill. Reg. 4980 through 4986 shall | 3 | | remain in effect until modified by rule by the Department. | 4 | | Nothing in this subsection shall be construed to mandate that | 5 | | the Department file a replacement rule. | 6 | | (d) Transition period.
There shall be a transition period | 7 | | to the reimbursement systems authorized under this Section that | 8 | | shall begin on the effective date of these systems and continue | 9 | | until June 30, 2018, unless extended by rule by the Department. | 10 | | To help provide an orderly and predictable transition to the | 11 | | new reimbursement systems and to preserve and enhance access to | 12 | | the hospital services during this transition, the Department | 13 | | shall allocate a transitional hospital access pool of at least | 14 | | $290,000,000 annually so that transitional hospital access | 15 | | payments are made to hospitals. | 16 | | (1) After the transition period, the Department may | 17 | | begin incorporating the transitional hospital access pool | 18 | | into the base rate structure. | 19 | | (2) After the transition period, if the Department | 20 | | reduces payments from the transitional hospital access | 21 | | pool, it shall increase base rates, develop new adjustors, | 22 | | adjust current adjustors, develop new hospital access | 23 | | payments based on updated information, or any combination | 24 | | thereof by an amount equal to the decreases proposed in the | 25 | | transitional hospital access pool payments, ensuring that | 26 | | the entire transitional hospital access pool amount shall |
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| 1 | | continue to be used for hospital payments. | 2 | | Subject to federal approval and notwithstanding any other | 3 | | provision of this Code, for any redesign of transitional | 4 | | hospital access payments authorized under this Section, the | 5 | | volume data used to redesign the distribution of payments shall | 6 | | include managed care organization denial payments or | 7 | | settlements between hospitals and managed care organizations. | 8 | | (e) Beginning 36 months after initial implementation, the | 9 | | Department shall update the reimbursement components in | 10 | | subsections (a) and (b), including standardized amounts and | 11 | | weighting factors, and at least triennially and no more | 12 | | frequently than annually thereafter. The Department shall | 13 | | publish these updates on its website no later than 30 calendar | 14 | | days prior to their effective date. | 15 | | (f) Continuation of supplemental payments. Any | 16 | | supplemental payments authorized under Illinois Administrative | 17 | | Code 148 effective January 1, 2014 and that continue during the | 18 | | period of July 1, 2014 through December 31, 2014 shall remain | 19 | | in effect as long as the assessment imposed by Section 5A-2 is | 20 | | in effect. | 21 | | (g) Notwithstanding subsections (a) through (f) of this | 22 | | Section and notwithstanding the changes authorized under | 23 | | Section 5-5b.1, any updates to the system shall not result in | 24 | | any diminishment of the overall effective rates of | 25 | | reimbursement as of the implementation date of the new system | 26 | | (July 1, 2014). These updates shall not preclude variations in |
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| 1 | | any individual component of the system or hospital rate | 2 | | variations. Nothing in this Section shall prohibit the | 3 | | Department from increasing the rates of reimbursement or | 4 | | developing payments to ensure access to hospital services. | 5 | | Nothing in this Section shall be construed to guarantee a | 6 | | minimum amount of spending in the aggregate or per hospital as | 7 | | spending may be impacted by factors including but not limited | 8 | | to the number of individuals in the medical assistance program | 9 | | and the severity of illness of the individuals. | 10 | | (h) The Department shall have the authority to modify by | 11 | | rulemaking any changes to the rates or methodologies in this | 12 | | Section as required by the federal government to obtain federal | 13 | | financial participation for expenditures made under this | 14 | | Section. | 15 | | (i) Except for subsections (g) and (h) of this Section, the | 16 | | Department shall, pursuant to subsection (c) of Section 5-40 of | 17 | | the Illinois Administrative Procedure Act, provide for | 18 | | presentation at the June 2014 hearing of the Joint Committee on | 19 | | Administrative Rules (JCAR) additional written notice to JCAR | 20 | | of the following rules in order to commence the second notice | 21 | | period for the following rules: rules published in the Illinois | 22 | | Register, rule dated February 21, 2014 at 38 Ill. Reg. 4559 | 23 | | (Medical Payment), 4628 (Specialized Health Care Delivery | 24 | | Systems), 4640 (Hospital Services), 4932 (Diagnostic Related | 25 | | Grouping (DRG) Prospective Payment System (PPS)), and 4977 | 26 | | (Hospital Reimbursement Changes), and published in the |
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| 1 | | Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499 | 2 | | (Specialized Health Care Delivery Systems) and 6505 (Hospital | 3 | | Services).
| 4 | | (Source: P.A. 98-651, eff. 6-16-14; 99-2, eff. 3-26-15.)
| 5 | | Section 99. Effective date. This Act takes effect upon | 6 | | becoming law.".
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