Full Text of HB4741 103rd General Assembly
HB4741 103RD GENERAL ASSEMBLY | | | 103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024 HB4741 Introduced 2/6/2024, by Rep. Kam Buckner SYNOPSIS AS INTRODUCED: | | | Amends the Hospital Provider Funding Article of the Illinois Public Aid Code. In a provision requiring the Department of Healthcare and Family Services to create a pool of funding of at least $50,000,000 annually to be disbursed among safety-net hospitals that maintain perinatal designation from the Department of Public Health, provides that no safety-net hospital eligible for funds shall receive less than $5,000,000 annually. |
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| | A BILL FOR |
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| 1 | | AN ACT concerning public aid. | 2 | | Be it enacted by the People of the State of Illinois, | 3 | | represented in the General Assembly: | 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Section 5A-12.7 as follows: | 6 | | (305 ILCS 5/5A-12.7) | 7 | | (Section scheduled to be repealed on December 31, 2026) | 8 | | Sec. 5A-12.7. Continuation of hospital access payments on | 9 | | and after July 1, 2020. | 10 | | (a) To preserve and improve access to hospital services, | 11 | | for hospital services rendered on and after July 1, 2020, the | 12 | | Department shall, except for hospitals described in subsection | 13 | | (b) of Section 5A-3, make payments to hospitals or require | 14 | | capitated managed care organizations to make payments as set | 15 | | forth in this Section. Payments under this Section are not due | 16 | | and payable, however, until: (i) the methodologies described | 17 | | in this Section are approved by the federal government in an | 18 | | appropriate State Plan amendment or directed payment preprint; | 19 | | and (ii) the assessment imposed under this Article is | 20 | | determined to be a permissible tax under Title XIX of the | 21 | | Social Security Act. In determining the hospital access | 22 | | payments authorized under subsection (g) of this Section, if a | 23 | | hospital ceases to qualify for payments from the pool, the |
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| 1 | | payments for all hospitals continuing to qualify for payments | 2 | | from such pool shall be uniformly adjusted to fully expend the | 3 | | aggregate net amount of the pool, with such adjustment being | 4 | | effective on the first day of the second month following the | 5 | | date the hospital ceases to receive payments from such pool. | 6 | | (b) Amounts moved into claims-based rates and distributed | 7 | | in accordance with Section 14-12 shall remain in those | 8 | | claims-based rates. | 9 | | (c) Graduate medical education. | 10 | | (1) The calculation of graduate medical education | 11 | | payments shall be based on the hospital's Medicare cost | 12 | | report ending in Calendar Year 2018, as reported in the | 13 | | Healthcare Cost Report Information System file, release | 14 | | date September 30, 2019. An Illinois hospital reporting | 15 | | intern and resident cost on its Medicare cost report shall | 16 | | be eligible for graduate medical education payments. | 17 | | (2) Each hospital's annualized Medicaid Intern | 18 | | Resident Cost is calculated using annualized intern and | 19 | | resident total costs obtained from Worksheet B Part I, | 20 | | Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93, | 21 | | 96-98, and 105-112 multiplied by the percentage that the | 22 | | hospital's Medicaid days (Worksheet S3 Part I, Column 7, | 23 | | Lines 2, 3, 4, 14, 16-18, and 32) comprise of the | 24 | | hospital's total days (Worksheet S3 Part I, Column 8, | 25 | | Lines 14, 16-18, and 32). | 26 | | (3) An annualized Medicaid indirect medical education |
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| 1 | | (IME) payment is calculated for each hospital using its | 2 | | IME payments (Worksheet E Part A, Line 29, Column 1) | 3 | | multiplied by the percentage that its Medicaid days | 4 | | (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18, | 5 | | and 32) comprise of its Medicare days (Worksheet S3 Part | 6 | | I, Column 6, Lines 2, 3, 4, 14, and 16-18). | 7 | | (4) For each hospital, its annualized Medicaid Intern | 8 | | Resident Cost and its annualized Medicaid IME payment are | 9 | | summed, and, except as capped at 120% of the average cost | 10 | | per intern and resident for all qualifying hospitals as | 11 | | calculated under this paragraph, is multiplied by the | 12 | | applicable reimbursement factor as described in this | 13 | | paragraph, to determine the hospital's final graduate | 14 | | medical education payment. Each hospital's average cost | 15 | | per intern and resident shall be calculated by summing its | 16 | | total annualized Medicaid Intern Resident Cost plus its | 17 | | annualized Medicaid IME payment and dividing that amount | 18 | | by the hospital's total Full Time Equivalent Residents and | 19 | | Interns. If the hospital's average per intern and resident | 20 | | cost is greater than 120% of the same calculation for all | 21 | | qualifying hospitals, the hospital's per intern and | 22 | | resident cost shall be capped at 120% of the average cost | 23 | | for all qualifying hospitals. | 24 | | (A) For the period of July 1, 2020 through | 25 | | December 31, 2022, the applicable reimbursement factor | 26 | | shall be 22.6%. |
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| 1 | | (B) For the period of January 1, 2023 through | 2 | | December 31, 2026, the applicable reimbursement factor | 3 | | shall be 35% for all qualified safety-net hospitals, | 4 | | as defined in Section 5-5e.1 of this Code, and all | 5 | | hospitals with 100 or more Full Time Equivalent | 6 | | Residents and Interns, as reported on the hospital's | 7 | | Medicare cost report ending in Calendar Year 2018, and | 8 | | for all other qualified hospitals the applicable | 9 | | reimbursement factor shall be 30%. | 10 | | (d) Fee-for-service supplemental payments. For the period | 11 | | of July 1, 2020 through December 31, 2022, each Illinois | 12 | | hospital shall receive an annual payment equal to the amounts | 13 | | below, to be paid in 12 equal installments on or before the | 14 | | seventh State business day of each month, except that no | 15 | | payment shall be due within 30 days after the later of the date | 16 | | of notification of federal approval of the payment | 17 | | methodologies required under this Section or any waiver | 18 | | required under 42 CFR 433.68, at which time the sum of amounts | 19 | | required under this Section prior to the date of notification | 20 | | is due and payable. | 21 | | (1) For critical access hospitals, $385 per covered | 22 | | inpatient day contained in paid fee-for-service claims and | 23 | | $530 per paid fee-for-service outpatient claim for dates | 24 | | of service in Calendar Year 2019 in the Department's | 25 | | Enterprise Data Warehouse as of May 11, 2020. | 26 | | (2) For safety-net hospitals, $960 per covered |
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| 1 | | inpatient day contained in paid fee-for-service claims and | 2 | | $625 per paid fee-for-service outpatient claim for dates | 3 | | of service in Calendar Year 2019 in the Department's | 4 | | Enterprise Data Warehouse as of May 11, 2020. | 5 | | (3) For long term acute care hospitals, $295 per | 6 | | covered inpatient day contained in paid fee-for-service | 7 | | claims for dates of service in Calendar Year 2019 in the | 8 | | Department's Enterprise Data Warehouse as of May 11, 2020. | 9 | | (4) For freestanding psychiatric hospitals, $125 per | 10 | | covered inpatient day contained in paid fee-for-service | 11 | | claims and $130 per paid fee-for-service outpatient claim | 12 | | for dates of service in Calendar Year 2019 in the | 13 | | Department's Enterprise Data Warehouse as of May 11, 2020. | 14 | | (5) For freestanding rehabilitation hospitals, $355 | 15 | | per covered inpatient day contained in paid | 16 | | fee-for-service claims for dates of service in Calendar | 17 | | Year 2019 in the Department's Enterprise Data Warehouse as | 18 | | of May 11, 2020. | 19 | | (6) For all general acute care hospitals and high | 20 | | Medicaid hospitals as defined in subsection (f), $350 per | 21 | | covered inpatient day for dates of service in Calendar | 22 | | Year 2019 contained in paid fee-for-service claims and | 23 | | $620 per paid fee-for-service outpatient claim in the | 24 | | Department's Enterprise Data Warehouse as of May 11, 2020. | 25 | | (7) Alzheimer's treatment access payment. Each | 26 | | Illinois academic medical center or teaching hospital, as |
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| 1 | | defined in Section 5-5e.2 of this Code, that is identified | 2 | | as the primary hospital affiliate of one of the Regional | 3 | | Alzheimer's Disease Assistance Centers, as designated by | 4 | | the Alzheimer's Disease Assistance Act and identified in | 5 | | the Department of Public Health's Alzheimer's Disease | 6 | | State Plan dated December 2016, shall be paid an | 7 | | Alzheimer's treatment access payment equal to the product | 8 | | of the qualifying hospital's State Fiscal Year 2018 total | 9 | | inpatient fee-for-service days multiplied by the | 10 | | applicable Alzheimer's treatment rate of $226.30 for | 11 | | hospitals located in Cook County and $116.21 for hospitals | 12 | | located outside Cook County. | 13 | | (d-2) Fee-for-service supplemental payments. Beginning | 14 | | January 1, 2023, each Illinois hospital shall receive an | 15 | | annual payment equal to the amounts listed below, to be paid in | 16 | | 12 equal installments on or before the seventh State business | 17 | | day of each month, except that no payment shall be due within | 18 | | 30 days after the later of the date of notification of federal | 19 | | approval of the payment methodologies required under this | 20 | | Section or any waiver required under 42 CFR 433.68, at which | 21 | | time the sum of amounts required under this Section prior to | 22 | | the date of notification is due and payable. The Department | 23 | | may adjust the rates in paragraphs (1) through (7) to comply | 24 | | with the federal upper payment limits, with such adjustments | 25 | | being determined so that the total estimated spending by | 26 | | hospital class, under such adjusted rates, remains |
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| 1 | | substantially similar to the total estimated spending under | 2 | | the original rates set forth in this subsection. | 3 | | (1) For critical access hospitals, as defined in | 4 | | subsection (f), $750 per covered inpatient day contained | 5 | | in paid fee-for-service claims and $750 per paid | 6 | | fee-for-service outpatient claim for dates of service in | 7 | | Calendar Year 2019 in the Department's Enterprise Data | 8 | | Warehouse as of August 6, 2021. | 9 | | (2) For safety-net hospitals, as described in | 10 | | subsection (f), $1,350 per inpatient day contained in paid | 11 | | fee-for-service claims and $1,350 per paid fee-for-service | 12 | | outpatient claim for dates of service in Calendar Year | 13 | | 2019 in the Department's Enterprise Data Warehouse as of | 14 | | August 6, 2021. | 15 | | (3) For long term acute care hospitals, $550 per | 16 | | covered inpatient day contained in paid fee-for-service | 17 | | claims for dates of service in Calendar Year 2019 in the | 18 | | Department's Enterprise Data Warehouse as of August 6, | 19 | | 2021. | 20 | | (4) For freestanding psychiatric hospitals, $200 per | 21 | | covered inpatient day contained in paid fee-for-service | 22 | | claims and $200 per paid fee-for-service outpatient claim | 23 | | for dates of service in Calendar Year 2019 in the | 24 | | Department's Enterprise Data Warehouse as of August 6, | 25 | | 2021. | 26 | | (5) For freestanding rehabilitation hospitals, $550 |
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| 1 | | per covered inpatient day contained in paid | 2 | | fee-for-service claims and $125 per paid fee-for-service | 3 | | outpatient claim for dates of service in Calendar Year | 4 | | 2019 in the Department's Enterprise Data Warehouse as of | 5 | | August 6, 2021. | 6 | | (6) For all general acute care hospitals and high | 7 | | Medicaid hospitals as defined in subsection (f), $500 per | 8 | | covered inpatient day for dates of service in Calendar | 9 | | Year 2019 contained in paid fee-for-service claims and | 10 | | $500 per paid fee-for-service outpatient claim in the | 11 | | Department's Enterprise Data Warehouse as of August 6, | 12 | | 2021. | 13 | | (7) For public hospitals, as defined in subsection | 14 | | (f), $275 per covered inpatient day contained in paid | 15 | | fee-for-service claims and $275 per paid fee-for-service | 16 | | outpatient claim for dates of service in Calendar Year | 17 | | 2019 in the Department's Enterprise Data Warehouse as of | 18 | | August 6, 2021. | 19 | | (8) Alzheimer's treatment access payment. Each | 20 | | Illinois academic medical center or teaching hospital, as | 21 | | defined in Section 5-5e.2 of this Code, that is identified | 22 | | as the primary hospital affiliate of one of the Regional | 23 | | Alzheimer's Disease Assistance Centers, as designated by | 24 | | the Alzheimer's Disease Assistance Act and identified in | 25 | | the Department of Public Health's Alzheimer's Disease | 26 | | State Plan dated December 2016, shall be paid an |
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| 1 | | Alzheimer's treatment access payment equal to the product | 2 | | of the qualifying hospital's Calendar Year 2019 total | 3 | | inpatient fee-for-service days, in the Department's | 4 | | Enterprise Data Warehouse as of August 6, 2021, multiplied | 5 | | by the applicable Alzheimer's treatment rate of $244.37 | 6 | | for hospitals located in Cook County and $312.03 for | 7 | | hospitals located outside Cook County. | 8 | | (e) The Department shall require managed care | 9 | | organizations (MCOs) to make directed payments and | 10 | | pass-through payments according to this Section. Each calendar | 11 | | year, the Department shall require MCOs to pay the maximum | 12 | | amount out of these funds as allowed as pass-through payments | 13 | | under federal regulations. The Department shall require MCOs | 14 | | to make such pass-through payments as specified in this | 15 | | Section. The Department shall require the MCOs to pay the | 16 | | remaining amounts as directed Payments as specified in this | 17 | | Section. The Department shall issue payments to the | 18 | | Comptroller by the seventh business day of each month for all | 19 | | MCOs that are sufficient for MCOs to make the directed | 20 | | payments and pass-through payments according to this Section. | 21 | | The Department shall require the MCOs to make pass-through | 22 | | payments and directed payments using electronic funds | 23 | | transfers (EFT), if the hospital provides the information | 24 | | necessary to process such EFTs, in accordance with directions | 25 | | provided monthly by the Department, within 7 business days of | 26 | | the date the funds are paid to the MCOs, as indicated by the |
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| 1 | | "Paid Date" on the website of the Office of the Comptroller if | 2 | | the funds are paid by EFT and the MCOs have received directed | 3 | | payment instructions. If funds are not paid through the | 4 | | Comptroller by EFT, payment must be made within 7 business | 5 | | days of the date actually received by the MCO. The MCO will be | 6 | | considered to have paid the pass-through payments when the | 7 | | payment remittance number is generated or the date the MCO | 8 | | sends the check to the hospital, if EFT information is not | 9 | | supplied. If an MCO is late in paying a pass-through payment or | 10 | | directed payment as required under this Section (including any | 11 | | extensions granted by the Department), it shall pay a penalty, | 12 | | unless waived by the Department for reasonable cause, to the | 13 | | Department equal to 5% of the amount of the pass-through | 14 | | payment or directed payment not paid on or before the due date | 15 | | plus 5% of the portion thereof remaining unpaid on the last day | 16 | | of each 30-day period thereafter. Payments to MCOs that would | 17 | | be paid consistent with actuarial certification and enrollment | 18 | | in the absence of the increased capitation payments under this | 19 | | Section shall not be reduced as a consequence of payments made | 20 | | under this subsection. The Department shall publish and | 21 | | maintain on its website for a period of no less than 8 calendar | 22 | | quarters, the quarterly calculation of directed payments and | 23 | | pass-through payments owed to each hospital from each MCO. All | 24 | | calculations and reports shall be posted no later than the | 25 | | first day of the quarter for which the payments are to be | 26 | | issued. |
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| 1 | | (f)(1) For purposes of allocating the funds included in | 2 | | capitation payments to MCOs, Illinois hospitals shall be | 3 | | divided into the following classes as defined in | 4 | | administrative rules: | 5 | | (A) Beginning July 1, 2020 through December 31, 2022, | 6 | | critical access hospitals. Beginning January 1, 2023, | 7 | | "critical access hospital" means a hospital designated by | 8 | | the Department of Public Health as a critical access | 9 | | hospital, excluding any hospital meeting the definition of | 10 | | a public hospital in subparagraph (F). | 11 | | (B) Safety-net hospitals, except that stand-alone | 12 | | children's hospitals that are not specialty children's | 13 | | hospitals will not be included. For the calendar year | 14 | | beginning January 1, 2023, and each calendar year | 15 | | thereafter, assignment to the safety-net class shall be | 16 | | based on the annual safety-net rate year beginning 15 | 17 | | months before the beginning of the first Payout Quarter of | 18 | | the calendar year. | 19 | | (C) Long term acute care hospitals. | 20 | | (D) Freestanding psychiatric hospitals. | 21 | | (E) Freestanding rehabilitation hospitals. | 22 | | (F) Beginning January 1, 2023, "public hospital" means | 23 | | a hospital that is owned or operated by an Illinois | 24 | | Government body or municipality, excluding a hospital | 25 | | provider that is a State agency, a State university, or a | 26 | | county with a population of 3,000,000 or more. |
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| 1 | | (G) High Medicaid hospitals. | 2 | | (i) As used in this Section, "high Medicaid | 3 | | hospital" means a general acute care hospital that: | 4 | | (I) For the payout periods July 1, 2020 | 5 | | through December 31, 2022, is not a safety-net | 6 | | hospital or critical access hospital and that has | 7 | | a Medicaid Inpatient Utilization Rate above 30% or | 8 | | a hospital that had over 35,000 inpatient Medicaid | 9 | | days during the applicable period. For the period | 10 | | July 1, 2020 through December 31, 2020, the | 11 | | applicable period for the Medicaid Inpatient | 12 | | Utilization Rate (MIUR) is the rate year 2020 MIUR | 13 | | and for the number of inpatient days it is State | 14 | | fiscal year 2018. Beginning in calendar year 2021, | 15 | | the Department shall use the most recently | 16 | | determined MIUR, as defined in subsection (h) of | 17 | | Section 5-5.02, and for the inpatient day | 18 | | threshold, the State fiscal year ending 18 months | 19 | | prior to the beginning of the calendar year. For | 20 | | purposes of calculating MIUR under this Section, | 21 | | children's hospitals and affiliated general acute | 22 | | care hospitals shall be considered a single | 23 | | hospital. | 24 | | (II) For the calendar year beginning January | 25 | | 1, 2023, and each calendar year thereafter, is not | 26 | | a public hospital, safety-net hospital, or |
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| 1 | | critical access hospital and that qualifies as a | 2 | | regional high volume hospital or is a hospital | 3 | | that has a Medicaid Inpatient Utilization Rate | 4 | | (MIUR) above 30%. As used in this item, "regional | 5 | | high volume hospital" means a hospital which ranks | 6 | | in the top 2 quartiles based on total hospital | 7 | | services volume, of all eligible general acute | 8 | | care hospitals, when ranked in descending order | 9 | | based on total hospital services volume, within | 10 | | the same Medicaid managed care region, as | 11 | | designated by the Department, as of January 1, | 12 | | 2022. As used in this item, "total hospital | 13 | | services volume" means the total of all Medical | 14 | | Assistance hospital inpatient admissions plus all | 15 | | Medical Assistance hospital outpatient visits. For | 16 | | purposes of determining regional high volume | 17 | | hospital inpatient admissions and outpatient | 18 | | visits, the Department shall use dates of service | 19 | | provided during State Fiscal Year 2020 for the | 20 | | Payout Quarter beginning January 1, 2023. The | 21 | | Department shall use dates of service from the | 22 | | State fiscal year ending 18 month before the | 23 | | beginning of the first Payout Quarter of the | 24 | | subsequent annual determination period. | 25 | | (ii) For the calendar year beginning January 1, | 26 | | 2023, the Department shall use the Rate Year 2022 |
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| 1 | | Medicaid inpatient utilization rate (MIUR), as defined | 2 | | in subsection (h) of Section 5-5.02. For each | 3 | | subsequent annual determination, the Department shall | 4 | | use the MIUR applicable to the rate year ending | 5 | | September 30 of the year preceding the beginning of | 6 | | the calendar year. | 7 | | (H) General acute care hospitals. As used under this | 8 | | Section, "general acute care hospitals" means all other | 9 | | Illinois hospitals not identified in subparagraphs (A) | 10 | | through (G). | 11 | | (2) Hospitals' qualification for each class shall be | 12 | | assessed prior to the beginning of each calendar year and the | 13 | | new class designation shall be effective January 1 of the next | 14 | | year. The Department shall publish by rule the process for | 15 | | establishing class determination. | 16 | | (3) Beginning January 1, 2024, the Department may reassign | 17 | | hospitals or entire hospital classes as defined above, if | 18 | | federal limits on the payments to the class to which the | 19 | | hospitals are assigned based on the criteria in this | 20 | | subsection prevent the Department from making payments to the | 21 | | class that would otherwise be due under this Section. The | 22 | | Department shall publish the criteria and composition of each | 23 | | new class based on the reassignments, and the projected impact | 24 | | on payments to each hospital under the new classes on its | 25 | | website by November 15 of the year before the year in which the | 26 | | class changes become effective. |
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| 1 | | (g) Fixed pool directed payments. Beginning July 1, 2020, | 2 | | the Department shall issue payments to MCOs which shall be | 3 | | used to issue directed payments to qualified Illinois | 4 | | safety-net hospitals and critical access hospitals on a | 5 | | monthly basis in accordance with this subsection. Prior to the | 6 | | beginning of each Payout Quarter beginning July 1, 2020, the | 7 | | Department shall use encounter claims data from the | 8 | | Determination Quarter, accepted by the Department's Medicaid | 9 | | Management Information System for inpatient and outpatient | 10 | | services rendered by safety-net hospitals and critical access | 11 | | hospitals to determine a quarterly uniform per unit add-on for | 12 | | each hospital class. | 13 | | (1) Inpatient per unit add-on. A quarterly uniform per | 14 | | diem add-on shall be derived by dividing the quarterly | 15 | | Inpatient Directed Payments Pool amount allocated to the | 16 | | applicable hospital class by the total inpatient days | 17 | | contained on all encounter claims received during the | 18 | | Determination Quarter, for all hospitals in the class. | 19 | | (A) Each hospital in the class shall have a | 20 | | quarterly inpatient directed payment calculated that | 21 | | is equal to the product of the number of inpatient days | 22 | | attributable to the hospital used in the calculation | 23 | | of the quarterly uniform class per diem add-on, | 24 | | multiplied by the calculated applicable quarterly | 25 | | uniform class per diem add-on of the hospital class. | 26 | | (B) Each hospital shall be paid 1/3 of its |
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| 1 | | quarterly inpatient directed payment in each of the 3 | 2 | | months of the Payout Quarter, in accordance with | 3 | | directions provided to each MCO by the Department. | 4 | | (2) Outpatient per unit add-on. A quarterly uniform | 5 | | per claim add-on shall be derived by dividing the | 6 | | quarterly Outpatient Directed Payments Pool amount | 7 | | allocated to the applicable hospital class by the total | 8 | | outpatient encounter claims received during the | 9 | | Determination Quarter, for all hospitals in the class. | 10 | | (A) Each hospital in the class shall have a | 11 | | quarterly outpatient directed payment calculated that | 12 | | is equal to the product of the number of outpatient | 13 | | encounter claims attributable to the hospital used in | 14 | | the calculation of the quarterly uniform class per | 15 | | claim add-on, multiplied by the calculated applicable | 16 | | quarterly uniform class per claim add-on of the | 17 | | hospital class. | 18 | | (B) Each hospital shall be paid 1/3 of its | 19 | | quarterly outpatient directed payment in each of the 3 | 20 | | months of the Payout Quarter, in accordance with | 21 | | directions provided to each MCO by the Department. | 22 | | (3) Each MCO shall pay each hospital the Monthly | 23 | | Directed Payment as identified by the Department on its | 24 | | quarterly determination report. | 25 | | (4) Definitions. As used in this subsection: | 26 | | (A) "Payout Quarter" means each 3 month calendar |
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| 1 | | quarter, beginning July 1, 2020. | 2 | | (B) "Determination Quarter" means each 3 month | 3 | | calendar quarter, which ends 3 months prior to the | 4 | | first day of each Payout Quarter. | 5 | | (5) For the period July 1, 2020 through December 2020, | 6 | | the following amounts shall be allocated to the following | 7 | | hospital class directed payment pools for the quarterly | 8 | | development of a uniform per unit add-on: | 9 | | (A) $2,894,500 for hospital inpatient services for | 10 | | critical access hospitals. | 11 | | (B) $4,294,374 for hospital outpatient services | 12 | | for critical access hospitals. | 13 | | (C) $29,109,330 for hospital inpatient services | 14 | | for safety-net hospitals. | 15 | | (D) $35,041,218 for hospital outpatient services | 16 | | for safety-net hospitals. | 17 | | (6) For the period January 1, 2023 through December | 18 | | 31, 2023, the Department shall establish the amounts that | 19 | | shall be allocated to the hospital class directed payment | 20 | | fixed pools identified in this paragraph for the quarterly | 21 | | development of a uniform per unit add-on. The Department | 22 | | shall establish such amounts so that the total amount of | 23 | | payments to each hospital under this Section in calendar | 24 | | year 2023 is projected to be substantially similar to the | 25 | | total amount of such payments received by the hospital | 26 | | under this Section in calendar year 2021, adjusted for |
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| 1 | | increased funding provided for fixed pool directed | 2 | | payments under subsection (g) in calendar year 2022, | 3 | | assuming that the volume and acuity of claims are held | 4 | | constant. The Department shall publish the directed | 5 | | payment fixed pool amounts to be established under this | 6 | | paragraph on its website by November 15, 2022. | 7 | | (A) Hospital inpatient services for critical | 8 | | access hospitals. | 9 | | (B) Hospital outpatient services for critical | 10 | | access hospitals. | 11 | | (C) Hospital inpatient services for public | 12 | | hospitals. | 13 | | (D) Hospital outpatient services for public | 14 | | hospitals. | 15 | | (E) Hospital inpatient services for safety-net | 16 | | hospitals. | 17 | | (F) Hospital outpatient services for safety-net | 18 | | hospitals. | 19 | | (7) Semi-annual rate maintenance review. The | 20 | | Department shall ensure that hospitals assigned to the | 21 | | fixed pools in paragraph (6) are paid no less than 95% of | 22 | | the annual initial rate for each 6-month period of each | 23 | | annual payout period. For each calendar year, the | 24 | | Department shall calculate the annual initial rate per day | 25 | | and per visit for each fixed pool hospital class listed in | 26 | | paragraph (6), by dividing the total of all applicable |
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| 1 | | inpatient or outpatient directed payments issued in the | 2 | | preceding calendar year to the hospitals in each fixed | 3 | | pool class for the calendar year, plus any increase | 4 | | resulting from the annual adjustments described in | 5 | | subsection (i), by the actual applicable total service | 6 | | units for the preceding calendar year which were the basis | 7 | | of the total applicable inpatient or outpatient directed | 8 | | payments issued to the hospitals in each fixed pool class | 9 | | in the calendar year, except that for calendar year 2023, | 10 | | the service units from calendar year 2021 shall be used. | 11 | | (A) The Department shall calculate the effective | 12 | | rate, per day and per visit, for the payout periods of | 13 | | January to June and July to December of each year, for | 14 | | each fixed pool listed in paragraph (6), by dividing | 15 | | 50% of the annual pool by the total applicable | 16 | | reported service units for the 2 applicable | 17 | | determination quarters. | 18 | | (B) If the effective rate calculated in | 19 | | subparagraph (A) is less than 95% of the annual | 20 | | initial rate assigned to the class for each pool under | 21 | | paragraph (6), the Department shall adjust the payment | 22 | | for each hospital to a level equal to no less than 95% | 23 | | of the annual initial rate, by issuing a retroactive | 24 | | adjustment payment for the 6-month period under review | 25 | | as identified in subparagraph (A). | 26 | | (h) Fixed rate directed payments. Effective July 1, 2020, |
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| 1 | | the Department shall issue payments to MCOs which shall be | 2 | | used to issue directed payments to Illinois hospitals not | 3 | | identified in paragraph (g) on a monthly basis. Prior to the | 4 | | beginning of each Payout Quarter beginning July 1, 2020, the | 5 | | Department shall use encounter claims data from the | 6 | | Determination Quarter, accepted by the Department's Medicaid | 7 | | Management Information System for inpatient and outpatient | 8 | | services rendered by hospitals in each hospital class | 9 | | identified in paragraph (f) and not identified in paragraph | 10 | | (g). For the period July 1, 2020 through December 2020, the | 11 | | Department shall direct MCOs to make payments as follows: | 12 | | (1) For general acute care hospitals an amount equal | 13 | | to $1,750 multiplied by the hospital's category of service | 14 | | 20 case mix index for the determination quarter multiplied | 15 | | by the hospital's total number of inpatient admissions for | 16 | | category of service 20 for the determination quarter. | 17 | | (2) For general acute care hospitals an amount equal | 18 | | to $160 multiplied by the hospital's category of service | 19 | | 21 case mix index for the determination quarter multiplied | 20 | | by the hospital's total number of inpatient admissions for | 21 | | category of service 21 for the determination quarter. | 22 | | (3) For general acute care hospitals an amount equal | 23 | | to $80 multiplied by the hospital's category of service 22 | 24 | | case mix index for the determination quarter multiplied by | 25 | | the hospital's total number of inpatient admissions for | 26 | | category of service 22 for the determination quarter. |
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| 1 | | (4) For general acute care hospitals an amount equal | 2 | | to $375 multiplied by the hospital's category of service | 3 | | 24 case mix index for the determination quarter multiplied | 4 | | by the hospital's total number of category of service 24 | 5 | | paid EAPG (EAPGs) for the determination quarter. | 6 | | (5) For general acute care hospitals an amount equal | 7 | | to $240 multiplied by the hospital's category of service | 8 | | 27 and 28 case mix index for the determination quarter | 9 | | multiplied by the hospital's total number of category of | 10 | | service 27 and 28 paid EAPGs for the determination | 11 | | quarter. | 12 | | (6) For general acute care hospitals an amount equal | 13 | | to $290 multiplied by the hospital's category of service | 14 | | 29 case mix index for the determination quarter multiplied | 15 | | by the hospital's total number of category of service 29 | 16 | | paid EAPGs for the determination quarter. | 17 | | (7) For high Medicaid hospitals an amount equal to | 18 | | $1,800 multiplied by the hospital's category of service 20 | 19 | | case mix index for the determination quarter multiplied by | 20 | | the hospital's total number of inpatient admissions for | 21 | | category of service 20 for the determination quarter. | 22 | | (8) For high Medicaid hospitals an amount equal to | 23 | | $160 multiplied by the hospital's category of service 21 | 24 | | case mix index for the determination quarter multiplied by | 25 | | the hospital's total number of inpatient admissions for | 26 | | category of service 21 for the determination quarter. |
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| 1 | | (9) For high Medicaid hospitals an amount equal to $80 | 2 | | multiplied by the hospital's category of service 22 case | 3 | | mix index for the determination quarter multiplied by the | 4 | | hospital's total number of inpatient admissions for | 5 | | category of service 22 for the determination quarter. | 6 | | (10) For high Medicaid hospitals an amount equal to | 7 | | $400 multiplied by the hospital's category of service 24 | 8 | | case mix index for the determination quarter multiplied by | 9 | | the hospital's total number of category of service 24 paid | 10 | | EAPG outpatient claims for the determination quarter. | 11 | | (11) For high Medicaid hospitals an amount equal to | 12 | | $240 multiplied by the hospital's category of service 27 | 13 | | and 28 case mix index for the determination quarter | 14 | | multiplied by the hospital's total number of category of | 15 | | service 27 and 28 paid EAPGs for the determination | 16 | | quarter. | 17 | | (12) For high Medicaid hospitals an amount equal to | 18 | | $290 multiplied by the hospital's category of service 29 | 19 | | case mix index for the determination quarter multiplied by | 20 | | the hospital's total number of category of service 29 paid | 21 | | EAPGs for the determination quarter. | 22 | | (13) For long term acute care hospitals the amount of | 23 | | $495 multiplied by the hospital's total number of | 24 | | inpatient days for the determination quarter. | 25 | | (14) For psychiatric hospitals the amount of $210 | 26 | | multiplied by the hospital's total number of inpatient |
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| 1 | | days for category of service 21 for the determination | 2 | | quarter. | 3 | | (15) For psychiatric hospitals the amount of $250 | 4 | | multiplied by the hospital's total number of outpatient | 5 | | claims for category of service 27 and 28 for the | 6 | | determination quarter. | 7 | | (16) For rehabilitation hospitals the amount of $410 | 8 | | multiplied by the hospital's total number of inpatient | 9 | | days for category of service 22 for the determination | 10 | | quarter. | 11 | | (17) For rehabilitation hospitals the amount of $100 | 12 | | multiplied by the hospital's total number of outpatient | 13 | | claims for category of service 29 for the determination | 14 | | quarter. | 15 | | (18) Effective for the Payout Quarter beginning | 16 | | January 1, 2023, for the directed payments to hospitals | 17 | | required under this subsection, the Department shall | 18 | | establish the amounts that shall be used to calculate such | 19 | | directed payments using the methodologies specified in | 20 | | this paragraph. The Department shall use a single, uniform | 21 | | rate, adjusted for acuity as specified in paragraphs (1) | 22 | | through (12), for all categories of inpatient services | 23 | | provided by each class of hospitals and a single uniform | 24 | | rate, adjusted for acuity as specified in paragraphs (1) | 25 | | through (12), for all categories of outpatient services | 26 | | provided by each class of hospitals. The Department shall |
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| 1 | | establish such amounts so that the total amount of | 2 | | payments to each hospital under this Section in calendar | 3 | | year 2023 is projected to be substantially similar to the | 4 | | total amount of such payments received by the hospital | 5 | | under this Section in calendar year 2021, adjusted for | 6 | | increased funding provided for fixed pool directed | 7 | | payments under subsection (g) in calendar year 2022, | 8 | | assuming that the volume and acuity of claims are held | 9 | | constant. The Department shall publish the directed | 10 | | payment amounts to be established under this subsection on | 11 | | its website by November 15, 2022. | 12 | | (19) Each hospital shall be paid 1/3 of their | 13 | | quarterly inpatient and outpatient directed payment in | 14 | | each of the 3 months of the Payout Quarter, in accordance | 15 | | with directions provided to each MCO by the Department. | 16 | | ( 20 ) Each MCO shall pay each hospital the Monthly | 17 | | Directed Payment amount as identified by the Department on | 18 | | its quarterly determination report. | 19 | | Notwithstanding any other provision of this subsection, if | 20 | | the Department determines that the actual total hospital | 21 | | utilization data that is used to calculate the fixed rate | 22 | | directed payments is substantially different than anticipated | 23 | | when the rates in this subsection were initially determined | 24 | | for unforeseeable circumstances (such as the COVID-19 pandemic | 25 | | or some other public health emergency), the Department may | 26 | | adjust the rates specified in this subsection so that the |
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| 1 | | total directed payments approximate the total spending amount | 2 | | anticipated when the rates were initially established. | 3 | | Definitions. As used in this subsection: | 4 | | (A) "Payout Quarter" means each calendar quarter, | 5 | | beginning July 1, 2020. | 6 | | (B) "Determination Quarter" means each calendar | 7 | | quarter which ends 3 months prior to the first day of | 8 | | each Payout Quarter. | 9 | | (C) "Case mix index" means a hospital specific | 10 | | calculation. For inpatient claims the case mix index | 11 | | is calculated each quarter by summing the relative | 12 | | weight of all inpatient Diagnosis-Related Group (DRG) | 13 | | claims for a category of service in the applicable | 14 | | Determination Quarter and dividing the sum by the | 15 | | number of sum total of all inpatient DRG admissions | 16 | | for the category of service for the associated claims. | 17 | | The case mix index for outpatient claims is calculated | 18 | | each quarter by summing the relative weight of all | 19 | | paid EAPGs in the applicable Determination Quarter and | 20 | | dividing the sum by the sum total of paid EAPGs for the | 21 | | associated claims. | 22 | | (i) Beginning January 1, 2021, the rates for directed | 23 | | payments shall be recalculated in order to spend the | 24 | | additional funds for directed payments that result from | 25 | | reduction in the amount of pass-through payments allowed under | 26 | | federal regulations. The additional funds for directed |
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| 1 | | payments shall be allocated proportionally to each class of | 2 | | hospitals based on that class' proportion of services. | 3 | | (1) Beginning January 1, 2024, the fixed pool directed | 4 | | payment amounts and the associated annual initial rates | 5 | | referenced in paragraph (6) of subsection (f) for each | 6 | | hospital class shall be uniformly increased by a ratio of | 7 | | not less than, the ratio of the total pass-through | 8 | | reduction amount pursuant to paragraph (4) of subsection | 9 | | (j), for the hospitals comprising the hospital fixed pool | 10 | | directed payment class for the next calendar year, to the | 11 | | total inpatient and outpatient directed payments for the | 12 | | hospitals comprising the hospital fixed pool directed | 13 | | payment class paid during the preceding calendar year. | 14 | | (2) Beginning January 1, 2024, the fixed rates for the | 15 | | directed payments referenced in paragraph (18) of | 16 | | subsection (h) for each hospital class shall be uniformly | 17 | | increased by a ratio of not less than, the ratio of the | 18 | | total pass-through reduction amount pursuant to paragraph | 19 | | (4) of subsection (j), for the hospitals comprising the | 20 | | hospital directed payment class for the next calendar | 21 | | year, to the total inpatient and outpatient directed | 22 | | payments for the hospitals comprising the hospital fixed | 23 | | rate directed payment class paid during the preceding | 24 | | calendar year. | 25 | | (j) Pass-through payments. | 26 | | (1) For the period July 1, 2020 through December 31, |
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| 1 | | 2020, the Department shall assign quarterly pass-through | 2 | | payments to each class of hospitals equal to one-fourth of | 3 | | the following annual allocations: | 4 | | (A) $390,487,095 to safety-net hospitals. | 5 | | (B) $62,553,886 to critical access hospitals. | 6 | | (C) $345,021,438 to high Medicaid hospitals. | 7 | | (D) $551,429,071 to general acute care hospitals. | 8 | | (E) $27,283,870 to long term acute care hospitals. | 9 | | (F) $40,825,444 to freestanding psychiatric | 10 | | hospitals. | 11 | | (G) $9,652,108 to freestanding rehabilitation | 12 | | hospitals. | 13 | | (2) For the period of July 1, 2020 through December | 14 | | 31, 2020, the pass-through payments shall at a minimum | 15 | | ensure hospitals receive a total amount of monthly | 16 | | payments under this Section as received in calendar year | 17 | | 2019 in accordance with this Article and paragraph (1) of | 18 | | subsection (d-5) of Section 14-12, exclusive of amounts | 19 | | received through payments referenced in subsection (b). | 20 | | (3) For the calendar year beginning January 1, 2023, | 21 | | the Department shall establish the annual pass-through | 22 | | allocation to each class of hospitals and the pass-through | 23 | | payments to each hospital so that the total amount of | 24 | | payments to each hospital under this Section in calendar | 25 | | year 2023 is projected to be substantially similar to the | 26 | | total amount of such payments received by the hospital |
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| 1 | | under this Section in calendar year 2021, adjusted for | 2 | | increased funding provided for fixed pool directed | 3 | | payments under subsection (g) in calendar year 2022, | 4 | | assuming that the volume and acuity of claims are held | 5 | | constant. The Department shall publish the pass-through | 6 | | allocation to each class and the pass-through payments to | 7 | | each hospital to be established under this subsection on | 8 | | its website by November 15, 2022. | 9 | | (4) For the calendar years beginning January 1, 2021 | 10 | | and January 1, 2022, each hospital's pass-through payment | 11 | | amount shall be reduced proportionally to the reduction of | 12 | | all pass-through payments required by federal regulations. | 13 | | Beginning January 1, 2024, the Department shall reduce | 14 | | total pass-through payments by the minimum amount | 15 | | necessary to comply with federal regulations. Pass-through | 16 | | payments to safety-net hospitals , as defined in Section | 17 | | 5-5e.1 of this Code, shall not be reduced until all | 18 | | pass-through payments to other hospitals have been | 19 | | eliminated. All other hospitals shall have their | 20 | | pass-through payments reduced proportionally. | 21 | | (k) At least 30 days prior to each calendar year, the | 22 | | Department shall notify each hospital of changes to the | 23 | | payment methodologies in this Section, including, but not | 24 | | limited to, changes in the fixed rate directed payment rates, | 25 | | the aggregate pass-through payment amount for all hospitals, | 26 | | and the hospital's pass-through payment amount for the |
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| 1 | | upcoming calendar year. | 2 | | (l) Notwithstanding any other provisions of this Section, | 3 | | the Department may adopt rules to change the methodology for | 4 | | directed and pass-through payments as set forth in this | 5 | | Section, but only to the extent necessary to obtain federal | 6 | | approval of a necessary State Plan amendment or Directed | 7 | | Payment Preprint or to otherwise conform to federal law or | 8 | | federal regulation. | 9 | | (m) As used in this subsection, "managed care | 10 | | organization" or "MCO" means an entity which contracts with | 11 | | the Department to provide services where payment for medical | 12 | | services is made on a capitated basis, excluding contracted | 13 | | entities for dual eligible or Department of Children and | 14 | | Family Services youth populations. | 15 | | (n) In order to address the escalating infant mortality | 16 | | rates among minority communities in Illinois, the State shall, | 17 | | subject to appropriation, create a pool of funding of at least | 18 | | $50,000,000 annually to be disbursed among safety-net | 19 | | hospitals that maintain perinatal designation from the | 20 | | Department of Public Health. No safety-net hospital eligible | 21 | | for funds under this subsection shall receive less than | 22 | | $5,000,000 annually. The funding shall be used to preserve or | 23 | | enhance OB/GYN services or other specialty services at the | 24 | | receiving hospital, with the distribution of funding to be | 25 | | established by rule and with consideration to perinatal | 26 | | hospitals with safe birthing levels and quality metrics for |
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| 1 | | healthy mothers and babies. | 2 | | (o) In order to address the growing challenges of | 3 | | providing stable access to healthcare in rural Illinois, | 4 | | including perinatal services, behavioral healthcare including | 5 | | substance use disorder services (SUDs) and other specialty | 6 | | services, and to expand access to telehealth services among | 7 | | rural communities in Illinois, the Department of Healthcare | 8 | | and Family Services shall administer a program to provide at | 9 | | least $10,000,000 in financial support annually to critical | 10 | | access hospitals for delivery of perinatal and OB/GYN | 11 | | services, behavioral healthcare including SUDS, other | 12 | | specialty services and telehealth services. The funding shall | 13 | | be used to preserve or enhance perinatal and OB/GYN services, | 14 | | behavioral healthcare including SUDS, other specialty | 15 | | services, as well as the explanation of telehealth services by | 16 | | the receiving hospital, with the distribution of funding to be | 17 | | established by rule. | 18 | | (p) For calendar year 2023, the final amounts, rates, and | 19 | | payments under subsections (c), (d-2), (g), (h), and (j) shall | 20 | | be established by the Department, so that the sum of the total | 21 | | estimated annual payments under subsections (c), (d-2), (g), | 22 | | (h), and (j) for each hospital class for calendar year 2023, is | 23 | | no less than: | 24 | | (1) $858,260,000 to safety-net hospitals. | 25 | | (2) $86,200,000 to critical access hospitals. | 26 | | (3) $1,765,000,000 to high Medicaid hospitals. |
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| 1 | | (4) $673,860,000 to general acute care hospitals. | 2 | | (5) $48,330,000 to long term acute care hospitals. | 3 | | (6) $89,110,000 to freestanding psychiatric hospitals. | 4 | | (7) $24,300,000 to freestanding rehabilitation | 5 | | hospitals. | 6 | | (8) $32,570,000 to public hospitals. | 7 | | (q) Hospital Pandemic Recovery Stabilization Payments. The | 8 | | Department shall disburse a pool of $460,000,000 in stability | 9 | | payments to hospitals prior to April 1, 2023. The allocation | 10 | | of the pool shall be based on the hospital directed payment | 11 | | classes and directed payments issued, during Calendar Year | 12 | | 2022 with added consideration to safety net hospitals, as | 13 | | defined in subdivision (f)(1)(B) of this Section, and critical | 14 | | access hospitals. | 15 | | (Source: P.A. 102-4, eff. 4-27-21; 102-16, eff. 6-17-21; | 16 | | 102-886, eff. 5-17-22; 102-1115, eff. 1-9-23; 103-102, eff. | 17 | | 6-16-23; revised 9-21-23.) |
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