305 ILCS 5/5A-12.7
2021 Illinois Compiled Statutes|Chapter 305 - PUBLIC AID|305 ILCS 5/ - Illinois Public Aid Code.|Article V-A - Hospital Provider Funding

(Section scheduled to be repealed on December 31, 2022)Sec. 5A-12.7. Continuation of hospital access payments on and after July 1, 2020.(a)    To preserve and improve access to hospital services, for hospital services rendered on and after July 1, 2020, the Department shall, except for hospitals described in subsection (b) of Section 5A-3, make payments to hospitals or require capitated managed care organizations to make payments as set forth in this Section. Payments under this Section are not due and payable, however, until: (i) the methodologies described in this Section are approved by the federal government in an appropriate State Plan amendment or directed payment preprint; and (ii) the assessment imposed under this Article is determined to be a permissible tax under Title XIX of the Social Security Act. In determining the hospital access payments authorized under subsection (g) of this Section, if a hospital ceases to qualify for payments from the pool, the payments for all hospitals continuing to qualify for payments from such pool shall be uniformly adjusted to fully expend the aggregate net amount of the pool, with such adjustment being effective on the first day of the second month following the date the hospital ceases to receive payments from such pool.(b)   Amounts moved into claims-based rates and distributed in accordance with Section 14-12 shall remain in those claims-based rates.(c)    Graduate medical education.(1)    The calculation of graduate medical education     payments shall be based on the hospital's Medicare cost report ending in Calendar Year 2018, as reported in the Healthcare Cost Report Information System file, release date September 30, 2019.  An Illinois hospital reporting intern and resident cost on its Medicare cost report shall be eligible for graduate medical education payments.(2)    Each hospital's annualized Medicaid Intern     Resident Cost is calculated using annualized intern and resident total costs obtained from Worksheet B Part I, Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93, 96-98, and 105-112 multiplied by the percentage that the hospital's Medicaid days (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18, and 32) comprise of the hospital's total days (Worksheet S3 Part I, Column 8, Lines 14,  16-18, and 32).(3)    An annualized Medicaid indirect medical     education (IME) payment is calculated for each hospital using its IME payments (Worksheet E Part A, Line 29, Column 1) multiplied by the percentage that its Medicaid days (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18, and 32) comprise of its Medicare days (Worksheet S3 Part I, Column 6, Lines 2, 3, 4, 14, and 16-18).(4)    For each hospital, its annualized Medicaid     Intern Resident Cost and its annualized Medicaid IME payment are summed, and, except as capped at 120% of the average cost per intern and resident for all qualifying hospitals as calculated under this paragraph, is multiplied by 22.6% to determine the hospital's final graduate medical education payment. Each hospital's average cost per intern and resident shall be calculated by summing its total annualized Medicaid Intern Resident Cost plus its annualized Medicaid IME payment and dividing that amount by the hospital's total Full Time Equivalent Residents and Interns. If the hospital's average per intern and resident cost is greater than 120% of the same calculation for all qualifying hospitals, the hospital's per intern and resident cost shall be capped at 120% of the average cost for all qualifying hospitals.(d)    Fee-for-service supplemental payments. Each Illinois  hospital shall receive an annual payment equal to the amounts below, to be paid in 12 equal installments on or before the seventh State business day of each month, except that no payment shall be due within 30 days after the later of the date of notification of federal approval of the payment methodologies required under this Section or any waiver required under 42 CFR 433.68, at which time the sum of amounts required under this Section prior to the date of notification is due and payable.(1)   For critical access hospitals, $385 per covered     inpatient day contained in paid fee-for-service claims and $530 per paid fee-for-service outpatient claim for dates of service in Calendar Year 2019 in the Department's Enterprise Data Warehouse as of May 11, 2020.(2)   For safety-net hospitals, $960 per covered     inpatient day contained in paid fee-for-service claims and $625 per paid fee-for-service outpatient claim for dates of service in Calendar Year 2019 in the Department's Enterprise Data Warehouse as of May 11, 2020.(3)   For long term acute care hospitals, $295 per     covered inpatient day contained in paid fee-for-service claims for dates of service in Calendar Year 2019 in the Department's Enterprise Data Warehouse as of May 11, 2020.(4)   For freestanding psychiatric hospitals, $125     per covered inpatient day contained in paid fee-for-service claims and $130 per paid fee-for-service outpatient claim for dates of service in Calendar Year 2019 in the Department's Enterprise Data Warehouse as of May 11, 2020.(5)    For freestanding rehabilitation hospitals,     $355 per covered inpatient day contained in paid fee-for-service claims for dates of service in Calendar Year 2019 in the Department's Enterprise Data Warehouse as of May 11, 2020.(6)    For all general acute care hospitals and high     Medicaid hospitals as defined in subsection (f),  $350 per covered inpatient day for dates of service in Calendar Year 2019 contained in paid fee-for-service claims and $620 per paid fee-for-service outpatient claim in the Department's Enterprise Data Warehouse as of May 11, 2020.(7)    Alzheimer's treatment access payment. Each     Illinois academic medical center or teaching hospital, as defined in Section 5-5e.2 of this Code, that is identified as the primary hospital affiliate of one of the Regional Alzheimer's Disease Assistance Centers, as designated by the Alzheimer's Disease Assistance Act and identified in the Department of Public Health's Alzheimer's Disease State Plan dated December 2016, shall be paid an Alzheimer's treatment access payment equal to the product of the qualifying hospital's State Fiscal Year 2018 total inpatient fee-for-service days multiplied by the applicable Alzheimer's treatment rate of $226.30 for hospitals located in Cook County and $116.21 for hospitals located outside Cook County.(e)    The Department shall require managed care organizations (MCOs) to make directed payments and pass-through payments according to this Section. Each calendar year, the Department shall require MCOs to pay the maximum amount out of these funds as allowed as pass-through payments under federal regulations. The Department shall require MCOs to make such pass-through payments as specified in this Section.  The Department shall require the MCOs to pay the remaining amounts as directed Payments as specified in this Section. The Department shall issue payments to the Comptroller by the seventh business day of each month for all MCOs that are sufficient for MCOs to make the directed payments and pass-through payments according to this Section. The Department shall require the MCOs to make pass-through payments and directed payments using electronic funds transfers (EFT), if the hospital provides the information necessary to process such EFTs, in accordance with directions provided monthly by the Department, within 7 business days of the date the funds are paid to the MCOs, as indicated by the "Paid Date" on the website of the Office of the Comptroller if the funds are paid by EFT and the MCOs have received directed payment instructions. If funds are not paid through the Comptroller by EFT, payment must be made within 7 business days of the date actually received by the MCO. The MCO will be considered to have paid the pass-through payments when the payment remittance number is generated or the date the MCO sends the check to the hospital, if EFT information is not supplied. If an MCO is late in paying a pass-through payment or directed payment as required  under this Section (including any extensions granted by the Department), it shall pay a penalty, unless waived by the Department for reasonable cause, to the Department equal to 5% of the amount of the pass-through payment or directed payment not paid on or before the due date plus 5% of the portion thereof remaining unpaid on the last day of each 30-day period thereafter.  Payments to MCOs that would be paid consistent with actuarial certification and enrollment in the absence of the increased capitation payments under this Section shall not be reduced as a consequence of payments made under this subsection. The Department shall publish and maintain on its website for a period of no less than 8 calendar quarters, the quarterly calculation of directed payments and pass-through payments owed to each hospital from each MCO. All calculations  and reports shall be posted no later than the first day of the quarter for which the payments are to be issued.(f)(1)      For purposes of allocating the funds included in capitation payments to MCOs, Illinois hospitals shall be divided into the following classes as defined in administrative rules:(A)   Critical access hospitals.(B)   Safety-net hospitals, except that stand-alone     children's hospitals that are not specialty children's hospitals will not be included.(C)   Long term acute care hospitals.(D)    Freestanding psychiatric hospitals.(E)    Freestanding rehabilitation hospitals.(F)   High Medicaid hospitals. As used in this     Section,  "high Medicaid hospital" means a general acute care hospital that is not a safety-net hospital or critical access hospital and that has a Medicaid Inpatient Utilization Rate above 30% or a hospital that had over 35,000 inpatient Medicaid days during the applicable period. For the period July 1, 2020 through December 31, 2020, the applicable period for the Medicaid Inpatient Utilization Rate (MIUR) is the rate year 2020 MIUR and for the number of inpatient days it is State fiscal year 2018. Beginning in calendar year 2021, the Department shall use the most  recently determined MIUR, as defined in subsection (h) of Section 5-5.02, and for the inpatient day threshold, the State fiscal year ending 18 months prior to the beginning of the calendar year. For purposes of calculating MIUR under this Section, children's hospitals and affiliated general acute care hospitals shall  be considered a single hospital.(G)    General acute care hospitals. As used under     this Section, "general acute care hospitals" means all other Illinois hospitals not identified in subparagraphs (A) through (F).(2)    Hospitals' qualification for each class shall be assessed prior to the beginning of each calendar year and the new class designation shall be effective January 1 of the next year.  The Department shall publish by rule the process for establishing class determination.(g)    Fixed pool directed payments. Beginning July 1, 2020, the Department shall issue payments to MCOs which shall be used to issue directed payments to qualified Illinois safety-net hospitals and critical access hospitals on a monthly basis in accordance with this subsection. Prior to the beginning of each Payout Quarter beginning July 1, 2020, the Department shall use encounter claims data from the Determination Quarter, accepted by the Department's Medicaid Management Information System for inpatient and outpatient services rendered by safety-net hospitals and critical access hospitals to determine a quarterly uniform per unit add-on for each hospital class.(1)    Inpatient per unit add-on. A quarterly uniform     per diem add-on shall be derived by dividing the quarterly Inpatient Directed Payments Pool amount allocated to the applicable hospital class by the total inpatient days contained on all encounter claims received during the Determination Quarter, for all hospitals in the class.(A)    Each hospital in the class shall have a         quarterly inpatient directed payment calculated that is equal to the product of the number of inpatient days attributable to the hospital used in the calculation of the quarterly uniform class per diem add-on, multiplied by the calculated applicable quarterly uniform class per diem add-on of the hospital class.(B)    Each hospital shall be paid 1/3 of its         quarterly inpatient directed payment in each of the 3 months of the Payout Quarter, in accordance with directions provided to each MCO by the Department.(2)    Outpatient per unit add-on. A quarterly     uniform per claim add-on shall be derived by dividing the quarterly Outpatient Directed Payments Pool amount allocated to the applicable hospital class by the total outpatient encounter claims received during the Determination Quarter, for all hospitals in the class.(A)    Each hospital in the class shall have a         quarterly outpatient directed payment calculated that is equal to the product of the number of outpatient encounter claims attributable to the hospital used in the calculation of the quarterly uniform class per claim add-on, multiplied by the calculated applicable quarterly uniform class per claim add-on of the hospital class.(B)   Each hospital shall be paid 1/3 of its         quarterly outpatient directed payment in each of the 3 months of the Payout Quarter, in  accordance with directions provided to each MCO by the Department.(3)   Each MCO shall pay each hospital the Monthly     Directed Payment as identified by the Department on its quarterly determination report.(4)   Definitions. As used in this subsection:(A)   "Payout Quarter" means each 3 month         calendar quarter, beginning July 1, 2020.(B)    "Determination Quarter" means each 3 month         calendar quarter, which ends 3 months prior to the first day of each Payout Quarter.(5)    For the period July 1, 2020 through December     2020, the following amounts shall be allocated to the following hospital class directed payment pools for the quarterly development of a uniform per unit add-on:(A)    $2,894,500 for hospital inpatient services         for critical access hospitals.(B)    $4,294,374 for hospital outpatient         services for critical access hospitals.(C)   $29,109,330 for hospital inpatient services         for safety-net hospitals.(D)    $35,041,218 for hospital outpatient         services for safety-net hospitals.(h)      Fixed rate directed payments. Effective July 1, 2020, the Department shall issue payments to MCOs which shall be used to issue directed payments to Illinois hospitals not identified in paragraph (g) on a monthly basis. Prior to the beginning of each Payout Quarter beginning July 1, 2020, the Department shall use encounter claims data from the Determination Quarter, accepted by the Department's Medicaid Management Information System for inpatient and outpatient services rendered by hospitals in each hospital class identified in paragraph (f) and not identified in paragraph (g). For the period July 1, 2020 through December 2020, the Department shall direct MCOs to make payments as follows:(1)  For general acute care hospitals an amount equal     to $1,750 multiplied by the hospital's category of service 20 case mix index for the determination quarter multiplied by the hospital's total number of inpatient admissions for category of service 20 for the determination quarter.(2)   For general acute care hospitals an amount     equal to $160 multiplied by the hospital's category of service 21 case mix index for the determination quarter multiplied by the hospital's total number of  inpatient admissions for category of service 21 for the determination quarter.(3)   For general acute care hospitals an amount     equal to $80 multiplied by the hospital's category of service 22 case mix index for the determination quarter multiplied by the hospital's total number of  inpatient admissions for category of service 22 for the determination quarter.(4)  For general acute care hospitals an amount equal     to $375 multiplied by the hospital's category of service 24 case mix index for the determination quarter multiplied by the hospital's total number of  category of service 24 paid EAPG (EAPGs) for the determination quarter.(5)   For general acute care hospitals an amount     equal to $240 multiplied by the hospital's category of service 27 and 28 case mix index for the determination quarter multiplied by the hospital's total number of  category of service 27 and 28 paid EAPGs for the determination quarter.(6)   For general acute care hospitals an amount     equal to $290 multiplied by the hospital's category of service 29 case mix index for the determination quarter multiplied by the hospital's total number of  category of service 29 paid EAPGs for the determination quarter.(7)   For high Medicaid hospitals an amount equal to     $1,800 multiplied by the hospital's category of service 20 case mix index for the determination quarter multiplied by the hospital's total number of  inpatient admissions for category of service 20 for the determination quarter.(8)    For high Medicaid hospitals an amount equal to     $160 multiplied by the hospital's category of service 21 case mix index for the determination quarter multiplied by the hospital's total number of  inpatient admissions for category of service 21 for the determination quarter.(9)   For high Medicaid hospitals an amount equal to     $80 multiplied by the hospital's category of service 22 case mix index for the determination quarter multiplied by the hospital's total number of  inpatient admissions for category of service 22 for the determination quarter.(10)  For high Medicaid hospitals an amount equal to     $400 multiplied by the hospital's category of service 24 case mix index for the determination quarter multiplied by the hospital's total number of  category of service 24 paid EAPG outpatient claims for the determination quarter.(11)   For high Medicaid hospitals an amount equal to     $240 multiplied by the hospital's category of service 27 and 28 case mix index for the determination quarter multiplied by the hospital's total number of  category of service 27 and 28 paid EAPGs for the determination quarter.(12)    For high Medicaid hospitals an amount equal     to $290 multiplied by the hospital's category of service 29 case mix index for the determination quarter multiplied by the hospital's total number of  category of service 29 paid EAPGs for the determination quarter.(13)  For long term acute care hospitals the amount     of $495 multiplied by the hospital's total number of  inpatient days for the determination quarter.(14)  For psychiatric hospitals the amount of $210     multiplied by the hospital's total number of  inpatient days for category of service 21 for the determination quarter.(15)   For psychiatric hospitals the amount of $250     multiplied by the hospital's total number of  outpatient claims for category of service 27 and 28 for the determination quarter.(16)   For rehabilitation hospitals the amount of     $410 multiplied by the hospital's total number of  inpatient days for category of service 22 for the determination quarter.(17)  For rehabilitation hospitals the amount of $100     multiplied by the hospital's total number of  outpatient claims for category of service 29 for the determination quarter.(18)   Each hospital shall be paid 1/3 of their     quarterly inpatient and outpatient directed payment in each of the 3 months of the Payout Quarter, in  accordance with directions provided to each MCO by the Department.(19)  Each MCO shall pay each hospital the Monthly     Directed Payment amount as identified by the Department on its quarterly determination report.Notwithstanding any other provision of this subsection, if the Department determines that the actual total hospital utilization data that is used to calculate the fixed rate directed payments is substantially different than anticipated when the rates in this subsection were initially determined (for unforeseeable circumstances such as the COVID-19 pandemic), the Department may adjust the rates specified in this subsection so that the total directed payments approximate the total spending amount anticipated when the rates were initially established.Definitions. As used in this subsection:(A)   "Payout Quarter" means each calendar         quarter, beginning July 1, 2020.(B)    "Determination Quarter" means each         calendar quarter  which ends 3 months prior to the first day of each Payout Quarter.(C)   "Case mix index" means a hospital specific         calculation. For inpatient claims the case mix index is calculated each quarter by summing the relative weight of all inpatient Diagnosis-Related Group (DRG) claims for a category of service in the applicable Determination Quarter and dividing the sum by the number of sum total of all inpatient DRG admissions for the category of service for the associated claims. The case mix index for outpatient claims is calculated each quarter by summing the relative weight of all paid EAPGs in the applicable Determination Quarter and dividing the sum by the sum total of paid EAPGs for the associated claims.(i) Beginning January 1, 2021, the rates for directed payments shall be recalculated in order to spend the additional funds for directed payments that result from reduction in the amount of pass-through payments allowed under federal regulations. The additional funds for directed payments shall be allocated proportionally to each class of hospitals based on that class' proportion of services.(j) Pass-through payments.(1)   For the period July 1, 2020 through December     31, 2020, the Department shall assign quarterly pass-through payments to each class of hospitals equal to one-fourth of the following annual allocations:(A)   $390,487,095 to safety-net hospitals.(B)   $62,553,886 to critical access hospitals.(C)   $345,021,438 to high Medicaid hospitals.(D)   $551,429,071 to general acute care         hospitals.(E)   $27,283,870 to long term acute care         hospitals.(F)   $40,825,444 to freestanding psychiatric         hospitals.(G)   $9,652,108 to freestanding rehabilitation         hospitals.(2)   The pass-through payments shall at a minimum     ensure  hospitals receive a total amount of monthly payments under this Section as received in calendar year 2019 in accordance with  this Article and paragraph (1) of subsection (d-5) of Section 14-12, exclusive of amounts received through payments referenced in subsection (b).(3)   For the calendar year beginning January 1,     2021, and each calendar year thereafter, each hospital's pass-through payment amount shall be reduced proportionally to the reduction of all pass-through payments required by federal regulations.(k) At least 30 days prior to each calendar year, the Department shall notify each hospital of changes to the payment methodologies in this Section, including, but not limited to, changes in the fixed rate directed payment rates, the aggregate pass-through payment amount for all hospitals, and the hospital's pass-through payment amount for the upcoming calendar year.(l) Notwithstanding any other provisions of this Section, the Department may adopt rules to change the methodology for directed and pass-through payments as set forth in this Section, but only to the extent necessary to obtain federal approval of a necessary State Plan amendment or Directed Payment Preprint or to otherwise conform to federal law or federal regulation.(m) As used in this subsection, "managed care organization" or "MCO" means an entity which contracts with the Department to provide services where payment for medical services is made on a capitated basis, excluding contracted entities for dual eligible or Department of Children and Family Services youth populations.(n) In order to address the escalating infant mortality rates among minority communities in Illinois, the State shall, subject to appropriation, 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. The funding shall be used to preserve or enhance OB/GYN services or other specialty services at the receiving hospital, with the distribution of funding to be established by rule and with consideration to perinatal hospitals with safe birthing levels and quality metrics for healthy mothers and babies.(o) In order to address the growing challenges of providing stable access to healthcare in rural Illinois, including perinatal services, behavioral healthcare including substance use disorder services (SUDs) and other specialty services, and to expand access to telehealth services among rural communities in Illinois, the Department of Healthcare and Family Services, subject to appropriation, shall administer a program to provide at least $10,000,000 in financial support annually to critical access hospitals for delivery of perinatal and OB/GYN services, behavioral healthcare including SUDS, other specialty services and telehealth services. The funding shall be used to preserve or enhance perinatal and OB/GYN services, behavioral healthcare including SUDS, other specialty services, as well as the explanation of telehealth services by the receiving hospital, with the distribution of funding to be established by rule. (Source: P.A. 101-650, eff. 7-7-20; 102-4, eff. 4-27-21; 102-16, eff. 6-17-21.)