reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 147 - REIMBURSEMENT FOR NURSING COSTS FOR GERIATRIC FACILITIES › Section 147.330 - Resource Utilization Groups (RUGs) Case Mix Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a) Activities of
			 Daily Living (ADL)
1) Documentation shall
			 support the ADL coded level as defined in the Resident Assessment Instrument
			 (RAI) Manual.
2) Documentation of
			 ADLs shall support the RAI requirement was met for coding Self Performance and
			 Support during the look-back period. It is the responsibility of the person
			 completing the assessment to consider all episodes of the activity that
			 occurred over a 24-hour period during each day of the 7-day look-back period.
			 There shall be signatures/initials of staff providing the ADL assistance and
			 dates to authenticate the services were provided as coded during the look-back
			 period. If using an ADL grid for supporting documentation, the key for
			 self-performance and support provided shall be equivalent to definitions to the
			 MDS key.
3) The ADL scores for
			 residents lacking documentation shall be reset to zero.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 147 - REIMBURSEMENT FOR NURSING COSTS FOR GERIATRIC FACILITIES › Section 147.340 - Minimum Data Set On-Site Reviews

Current through Register Vol. 48, No. 28, July 12, 2024
a)
			 The Department shall conduct reviews to determine the accuracy of the resident
			 assessment information transmitted in the Minimum Data Set (MDS) that are
			 relevant to the determination of reimbursement rates. The MDS data used by the
			 Department to set the reimbursement rate will be used to conduct the validation
			 reviews. Such reviews may, at the discretion of the Department, be conducted
			 electronically or onsite in the facility.
b) The Department may select, at random, a
			 number of facilities in which to conduct quarterly on-site reviews.
c) The Department may also select facilities
			 for on-site review based upon facility characteristics, atypical patterns of
			 scoring MDS items, non-submission or late submission of assessments, high
			 percentage of significant corrections, previous history of review changes, or
			 the Department's experience. The Department may also use the findings of the
			 licensing and certification survey conducted by the Department of Public Health
			 (DPH) indicating the facility is not accurately assessing residents.
d) In addition, the Department may conduct
			 reviews if the Department determines that circumstances exist that could alter
			 or affect the validity of case mix classifications of residents. These
			 circumstances include, but are not limited to, the following:
1) Frequent changes in administration or
			 management of the facility;
2) An
			 unusually high percentage of residents in a specific case mix classification or
			 high percentage of change in the number of residents in a specific case mix
			 classification;
3) Frequent
			 adjustments of case mix classification as result of reconsiderations, reviews,
			 or significant corrections submitted;
4) A criminal indictment alleging fraud;
			 and
5) Other similar factors that
			 relate to a facility's ability to conduct accurate assessments.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 147 - REIMBURSEMENT FOR NURSING COSTS FOR GERIATRIC FACILITIES › Section 147.345 - Quality Incentives

Current through Register Vol. 48, No. 28, July 12, 2024
Effective January 1, 2015, the Department shall allocate an
				amount for quality incentive payments. To establish baselines for these
				measures, the information shall be submitted beginning January 1, 2014. These
				measures may be included as part of the on-site reimbursement review. To
				receive the quality incentive payments for these measures, a facility shall
				meet the following criteria.
a) The
			 Department shall allocate an amount for staff retention. To receive the quality
			 incentive payment for this measure, the facility's staff retention rate shall
			 meet or exceed the threshold established and published by the Department based
			 upon statewide averages and must be at least 80 percent.
1) Retention relates to the extent to which
			 an employer retains its employees and shall be measured as the proportion of
			 employees with a specified length of service expressed as a percentage of
			 overall workforce numbers.
2) The
			 staff retentions shall reflect the percentage of individuals employed by the
			 facility on the last day of the previous calculation period who are still
			 employed by the facility on the last day of the following calculation
			 period.
3) Staff retention shall be
			 calculated on a semiannual basis.
A) The June
			 30 calculation will be based on the percentage of full-time (defined as 30 or
			 more hours per week) direct care staff employed by the nursing facility on
			 January 1 and still employed by the nursing facility on June 30. The deadline
			 for reporting this information shall be July 31. Direct care staff is defined
			 as Certified Nursing Assistants (CNAs).
B) The December 31 calculation shall be based
			 on the percentage of full-time direct care staff employed by the nursing
			 facility on July 1 and still employed by the nursing facility on December 31.
			 The deadline for reporting this information shall be January 31.
4) The staff retention rate is
			 calculated using full-time direct care staff employed in a facility.
5) Documentation in the employee's record
			 shall support the retention rate submitted.
6) Facilities shall submit the required
			 information to the Department in a format designated by the
			 Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 147 - REIMBURSEMENT FOR NURSING COSTS FOR GERIATRIC FACILITIES › Section 147.346 - Appeals of Nursing Rate Determination

Current through Register Vol. 48, No. 28, July 12, 2024
a) Appeals must be submitted in writing to
			 the Department no later than 30 days after the date of the Department's notice
			 to the facility of the rate calculation resulting from the on-site review. The
			 revised rate shall be processed into the payment system 30 days after the date
			 of the Department's notice in order to allow time for submission of
			 appeals.
b) The appeal shall
			 contain clear and relevant supportive documentation. The facility must
			 succinctly address the area being appealed. Additional documentation not
			 presented to the HFS review team during the review, or at the time of exit,
			 will not be considered in the appeal process.
c) The Department will rule on all appeals
			 within 120 days after the date of appeal, except in rare instances where the
			 Department may require additional information from the facility. In this case,
			 the response period may be extended.
d) The appeal and supportive documentation
			 will go through several stages of review within the Department to ensure
			 fairness, objectivity and consistency with the appeal determination. The rate
			 resulting from the appeal determination will become effective the first day of
			 the applicable quarter.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 147 - REIMBURSEMENT FOR NURSING COSTS FOR GERIATRIC FACILITIES › Section 147.350 - Reimbursement for Additional Program Costs Associated With Providing Specialized Services for Individuals with Developmental Disabilities in Nursing Facilities

Current through Register Vol. 48, No. 28, July 12, 2024
a) Nursing
			 facilities (ICF and SNF) providing specialized services to individuals with
			 developmental disabilities, excluding state operated facilities for the
			 developmentally disabled, will be reimbursed for providing a specialized
			 services program for each client with developmental disabilities as specified
			 in 89 Ill. Adm. Code
			 144.50
			 through
			 144.250.
b) Beginning February 1, 1990, facility
			 reimbursement for providing specialized services to individuals with
			 developmental disabilities will be made upon conclusion of resident reviews
			 that are conducted by the state's mental health authority or their contracted
			 agent. Facility reimbursement for providing specialized services as a result of
			 resident reviews concluded prior to February 1, 1990, will begin with the
			 facility's February billing cycle.
c) The additional reimbursement for costs
			 associated with specialized services programs is based upon the presence of
			 three (3) determinants. The three determinants are:
1) Minimum Staffing
A) Direct Services - Facilities must be in
			 compliance with the Health Care Financing Administration's (HCFA) ( 42 CFR
			 442.201 or 42 CFR 442.302(1989) ) and the Illinois Department of Public
			 Health's (IDPH) (77 Ill. Adm. Code
			 300.1230 )
			 minimum staffing standards relative to facility type.
B) The number of additional direct services
			 staff necessary for delivering adequate specialized services programs for
			 individuals with developmental disabilities is based upon a full time
			 equivalent (FTE) staff to client ratio of 1:7.5.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart A - GENERAL PROVISIONS › Section 148.20 - Participation

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) Payment for hospital
				inpatient, outpatient and clinic services shall be made only when provided by a
				hospital, as described in Section
				148.25(b),
				or a distinct part unit, as described in Section
				148.25(c),
				for covered services, as described in Section
				148.50.
b) Payment for freestanding emergency center
				services shall only be made when provided by a freestanding emergency center as
				defined in Section
				148.25(e).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart A - GENERAL PROVISIONS › Section 148.25 - Definitions and Applicability

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) The term "large public
				hospital" means a hospital:
1) Owned by and
				located in an Illinois county with a population exceeding three million;
				or
2) Organized under the
				University of Illinois Hospital Act; or
3) Maintained by the Illinois Department of
				Human Services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart A - GENERAL PROVISIONS › Section 148.30 - General Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) For the purpose of hospital
				inpatient, hospital outpatient and hospital-based clinic reimbursement, the
				following requirements must be met by a hospital to qualify for enrollment in
				the Illinois Medical Assistance Program:
b) The hospital must be certified for
				participation in the Medicare Program (Title XVIII) unless the provisions of
				subsection (c) apply.
c) If not
				eligible for or subject to Medicare certification, the hospital must be
				accredited by The Joint Commission (TJC) or another Health and Human Services
				Approved Accreditation Organization.
d) The hospital must agree to accept the
				Department's basis for reimbursement.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart A - GENERAL PROVISIONS › Section 148.40 - Special Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				  2014:
a) Inpatient Psychiatric Services
1) Payment for inpatient hospital psychiatric
				services shall be made only to:
A) A hospital
				that is a general hospital, as defined in Section
				148.25(b),
				with a functional unit, as defined in Section
				148.25(c)(1),
				that specializes in, and is enrolled with the Department to provide,
				psychiatric services; or
B) A
				hospital, as defined in Section
				148.25(b),
				that holds a valid license as, and is enrolled with the Department as, a
				psychiatric hospital, as defined in Section
				148.25(d)(1).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart A - GENERAL PROVISIONS › Section 148.50 - Covered Hospital Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of outpatient services on or after July
				  1, 2014 and inpatient discharges on or after July 1, 2014, unless a later
				  effective date is specified in this Section:
a) The Department shall pay hospitals for the
				essential provision of inpatient, outpatient, and clinic diagnostic and
				treatment services not otherwise excluded or limited that are provided by a
				hospital, as described in Section
				148.25(b),
				or a distinct part unit, as described in Section
				148.25(c),
				and that are provided in compliance with hospital licensing standards. Payment
				may be made for the following types of care subject to the special requirements
				described in Section
				148.40:
1) General/specialty services.
2) Psychiatric services.
3) Rehabilitation services.
4) End-Stage Renal Disease Treatment (ESRDT)
				services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart A - GENERAL PROVISIONS › Section 148.60 - Services Not Covered as Hospital Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1, 2014,
				  certain services, although included in the Medical Assistance Program and under
				  certain circumstances provided in the hospital setting or by an entity
				  associated with the hospital, are not reimbursed by the Department as hospital
				  services. In addition, certain services currently provided in the hospital
				  outpatient and hospital-based clinic setting are subject to fee-for-service
				  payment methodologies. This means that for these services, hospitals shall be
				  required to conform to the policies and billing procedures in effect for other
				  non-hospital providers of services. Payment for these services shall be based
				  on the same fee schedule that applies to these services when they are provided
				  in the non-hospital setting. Services not covered or reimbursed as hospital
				  services are as follows:
a) Private
				Duty Nursing Services. Private duty nursing services for hospitalized program
				participants are not covered under the Medical Assistance Program. Hospitals
				are expected to provide all required nursing services.
b) Sitter Services. Sitter services for
				hospitalized program participants are not covered under the Medical Assistance
				Program.
c) Dental Services.
				Hospitals may not enroll to provide dental services. When dental services are
				provided in the outpatient/clinic setting of a hospital, the dentist shall
				submit charges to the Department according to the provisions of the Dental
				Program.
d) Nurse Anesthetist
				Services. Payment for general anesthesia services not reimbursed under 89 Ill.
				Adm. Code
				140.400 shall be made
				only to hospitals that qualify for these payments under the Medicare Program
				and shall be made to such hospitals when provided by a hospital employed
				non-physician anesthetist (certified registered nurse anesthetist or
				"CRNA").
e) Pharmacy Services.
				Policy and reimbursement for pharmacy services are described in 89 Ill. Adm.
				Code
				140.440 through
				140.450.
				A hospital pharmacy may enroll on a fee-for-service basis for services provided
				to a patient in:
1) A specified bed or
				special hospital unit which is certified for skilled nursing facility services
				under the Medicare Program.
2) A
				special hospital unit or separate facility which is administratively associated
				with the hospital and is licensed as a long term care facility.
3) The outpatient/clinic setting when the
				services provided are not unique to the hospital setting.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.82 - Organ Transplant Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of outpatient services on or after July
				  1, 2014 and inpatient discharges on or after July 1, 2014:
a) Introduction
The Department will cover organ transplants as identified
				  under subsection (b) that are provided to United States citizens or aliens who
				  are lawfully admitted for permanent residence in the United States under color
				  of law pursuant to
				  42 USC
				  1396 a(a) and 1396b(v). These services must
				  be provided by certified organ transplant centers that meet the requirements
				  specified in subsections (c) through (g) of this Section.
b) Covered Services
1) Inpatient heart, heart/lung, lung (single
				or double), liver, pancreas or kidney/pancreas transplantation. Inpatient bone
				marrow transplants, inpatient and outpatient stem cell transplants.
2) Inpatient intestinal (small bowel or
				liver/small bowel) transplantation for children only (see subsection (d)(1)(H)
				of this Section).
3) Other types of
				transplant procedures may be covered when a hospital has been certified by the
				Department as a transplant center eligible to perform such transplants. Centers
				must complete the certification process established in subsection (c) and
				provide the necessary documentation of the number of transplant procedures
				performed and the survival rates.
4) Medically necessary work-up.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.100 - County Trauma Center Adjustment Payments

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) County Trauma Center
				Adjustment (TCA) Payments. Illinois hospitals that, on the first day of July
				preceding the TCA rate period, are recognized as Level I or Level II trauma
				centers by DPH, shall receive an adjustment that shall be calculated as
				follows:
1) The available funds from the
				Trauma Center Fund each quarter shall be divided by the number of each eligible
				hospital's (as defined in subsection (a)(4)) Medicaid trauma admissions in the
				same quarter of the TCA base period to determine the adjustment for the TCA
				rate period. The result of this calculation shall be the County TCA adjustment
				per Medicaid trauma admission for the applicable quarter.
2) The TCA payments shall not be treated as
				payments for hospital services under Title XIX of the Social Security Act for
				purposes of the calculation of the intergovernmental transfer provided for in
				Section 15-3(a) of the Illinois Public Aid Code.
3) The trauma center adjustments shall be
				paid to eligible hospitals on a quarterly basis.
4) Trauma Center Adjustment Limitations.
				Hospitals that qualify for trauma center adjustments under this Section shall
				not be eligible for the total trauma center adjustment if, during the TCA rate
				period, the hospital is no longer recognized by DPH, or the appropriate
				licensing agency, as a Level I or Level II trauma center as required for the
				adjustments described in subsection (a)(1). In these instances, the adjustments
				calculated under this subsection (a)(4) shall be pro-rated as applicable, based
				upon the date that recognition ceased.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.105 - Reimbursement Methodologies for Inpatient Rehabilitation Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective with discharges on or after July 1, 2014:
a) Inpatient rehabilitation services not
				excluded from the DRG PPS pursuant to 89 Ill. Adm. Code
				149.50(b)
				shall be reimbursed through the DRG PPS.
b) Inpatient rehabilitation services excluded
				from the DRG PPS shall be reimbursed a hospital-specific rate paid per day of
				covered inpatient care, determined pursuant to subsection (c) or (d), as
				applicable. The total payment for an inpatient stay will equal the sum of:
1) the payment determined in this Section;
				and
2) any applicable adjustments
				to payment specified in Section
				148.290.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.110 - Reimbursement Methodologies for Inpatient Psychiatric Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				  2014:
a) Inpatient psychiatric
				services not excluded from the DRG PPS pursuant to 89 Ill. Adm. Code
				149.50(b) 
				shall be reimbursed through the DRG PPS.
b) Inpatient psychiatric services excluded
				from the DRG PPS shall be reimbursed a hospital-specific rate paid per day of
				covered inpatient care, determined pursuant to subsection (c), (d) or (g), as
				applicable. The total payment for an inpatient stay will equal the sum of:
1) the payment determined in this Section;
				and
2) any applicable adjustments
				to the payment specified in Section
				148.290.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.112 - Medicaid High Volume Adjustment Payments

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) The Department shall make
				Medicaid High Volume Adjustments (MHVA) to hospitals that are eligible to
				receive the adjustment payments described in Section
				148.122.
b) Calculation of Medicaid High Volume
				Adjustments
1) A children's hospital, as
				defined in Section
				148.25(d)(3),
				shall receive an MHVA payment adjustment of $120.
2) Any hospital other than a children's
				hospital meeting the criteria specified in subsection (a) shall receive an MHVA
				payment adjustment of $60.
3) The
				amount calculated pursuant to subsections (b)(1) and (b)(2) shall be adjusted
				as authorized in Section 5-5.02 of the Illinois Public Aid Code.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.115 - Reimbursement Methodologies for Long Term Acute Care Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective with discharges on or after July 1, 2014:
a) Inpatient long term acute care psychiatric
				services excluded from the DRG PPS pursuant to 89 Ill. Adm. Code
				149.50(b)
				shall be reimbursed under the inpatient psychiatric services methodologies
				specified in Section
				148.110.
b) Inpatient long term acute care services
				excluded from the DRG PPS shall be reimbursed a hospital-specific rate paid per
				day of covered inpatient care, determined pursuant to this Section. The total
				payment for an inpatient stay will equal the sum of:
1) the payment determined in this Section;
				and
2) any applicable adjustments
				to payment specified in Section
				148.290.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.116 - Reimbursement Methodologies for Children's Specialty Hospitals

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of outpatient services on or after July
				  1, 2014 and inpatient discharges on or after July 1, 2014:
a) Inpatient general acute care services
				provided by a children's specialty hospital located in Illinois, as defined in
				Section
				148.25(i)
				and excluded from the DRG PPS pursuant to 89 Ill. Adm. Code
				149.50(b),
				shall, per day of covered inpatient care, be reimbursed as follows:
1) For a hospital that would not have met the
				definition of a children's specialty hospital as of July 1, 2013, $1,400.00 per
				day.
2) For a hospital that would
				have met the definition of a children's specialty hospital as of July 1, 2013,
				a rate equal to the per diem base rate in place on July 1, 2013, multiplied by
				a factor of 1.37.
3) The total
				payment for inpatient stay will equal the sum of:
A) The payment determined in this subsection;
				and
B) Any applicable adjustments
				to payment specified in Section
				148.290.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.120 - Disproportionate Share Hospital (DSH) Adjustments

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) Qualified Disproportionate
				Share Hospitals (DSH). The Department shall make adjustment payments to
				hospitals that are deemed as disproportionate share by the Department. A
				hospital may qualify for a DSH adjustment in one of the following ways:
1) The hospital's Medicaid inpatient
				utilization rate (MIUR), as defined in subsection (i)(4), is at least one
				standard deviation above the mean Medicaid utilization rate, as defined in
				subsection (i)(3).
2) The
				hospital's low income utilization rate, as defined in subsection (i)(6),
				exceeds 25 per centum.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.122 - Medicaid Percentage Adjustments

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1, 2014,
				  unless another date is specified, the Department shall make an annual
				  determination of those hospitals qualified for adjustments under this Section
				  effective October 1 of each year unless otherwise noted.
a) Qualified Medicaid Percentage Hospitals.
				The Department shall make adjustment payments to hospitals that are deemed as a
				Medicaid percentage hospital by the Department. A hospital, except those that
				are owned or operated by a unit of government, may qualify for a Medicaid
				Percentage Adjustment (MPA) in one of the following ways:
1) The hospital's Medicaid inpatient
				utilization rate (MIUR), as defined in Section
				148.120(i)(4),
				is at least one-half standard deviation above the mean Medicaid utilization
				rate, as defined in Section
				148.120(i)(3).
2) The hospital's low income utilization
				rate, as defined in Section
				148.120(i)(6),
				exceeds 25 per centum.
3) Illinois
				hospitals that, on July 1, 1991, had an MIUR, as defined in Section
				148.120(i)(4),
				that was at least the mean Medicaid inpatient utilization rate, as defined in
				Section 148.120(i)(3),
				and that were located in a planning area with one-third or fewer excess beds as
				determined by the Illinois Health Facilities Planning Board (see 77 Ill. Adm.
				Code 1100), and that, as of June 30, 1992, were located in a federally
				designated Health Manpower Shortage Area (see
				42 CFR
				5 (1989)).
4) Illinois hospitals that meet the following
				criteria:
A) Have an MIUR, as defined in
				Section 148.120(i)(4),
				that is at least the mean Medicaid inpatient utilization rate, as defined in
				Section 148.120(i)(3).
B) Have a Medicaid obstetrical inpatient
				utilization rate, as defined in subsection (g)(3), that is at least one
				standard deviation above the mean Medicaid obstetrical inpatient utilization
				rate, as defined in subsection (g)(2).
5) Any children's hospital, as defined in
				Section 148.25(d)(3).
6) Out of state hospitals meeting the
				criteria in Section 148.120(e).
7) A hospital that reopened a previously
				closed hospital facility, which includes hospitals that have been terminated
				from participation in the medical assistance program in accordance with
				305 ILCS
				5/12-4.25, within 4 calendar years of the hospital
				facility's closure.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.130 - Outlier Adjustments for Exceptionally Costly Stays

Current through Register Vol. 48, No. 28, July 12, 2024
a) Outlier Adjustments. Outlier adjustments
				are provided for exceptionally costly stays provided by hospitals or distinct
				part units reimbursed on a per diem basis or hospitals reimbursed in accordance
				with Section
				148.82(g)
				for discharges before July 1, 2014. For discharges on or after July 1, 2014,
				this Section shall not be utilized for the basis of any hospital
				payments.
b) The determination of
				those services qualified for an outlier adjustment shall be made as follows for
				services provided on and after October 1, 1992, and for each subsequent rate
				period, as defined in Section
				148.25(g)(2)(B),
				for hospitals or distinct part units reimbursed on a per diem basis or
				hospitals reimbursed in accordance with Section
				148.82(g):
1) The services must have been provided on or
				after October 1, 1992; and
2) The
				services must have been provided to:
A)
				Children who have not attained the age of six years by hospitals defined by the
				Department as DSH hospitals under Section
				148.120(a);
				or
B) Infants who have not attained
				the age of one year by hospitals that do not meet the definition of a DSH
				hospital under Section
				148.120(a);
				or
C) Children who have not
				attained the age of 19 on the date of admission for services provided on or
				after January 1, 2008 by a hospital devoted exclusively to the care of children
				as defined in 89 Ill. Adm. Code
				149.50(c)(3)(A);
				or
D) Children who have not
				attained the age of 19 on the date of admission for services provided on or
				after July 1, 2009 by a Children's Hospital as defined in 89 Ill. Adm. Code
				149.50(c)(3)(B).
3) Claims with total covered
				charges equal to or above the mean total covered charges plus one standard
				deviation shall be considered for outlier adjustments once the following
				calculations have been performed:
A) Total
				covered charges (less charges attributable to medical education) equal to or
				exceeding one standard deviation above the mean shall be multiplied by the
				hospital's cost to charge ratio.
B)
				The hospital's rate for services provided on the claim shall be multiplied by
				the number of covered days on the claim.
C) The product of subsection (b)(3)(B) shall
				be subtracted from the product of subsection (b)(3)(A).
D) The difference of subsection (b)(3)(C)
				shall be multiplied by .25, the product of which shall be the outlier
				adjustment for the claim.
E) Third
				party payments (credits) shall be applied to the final payment made on the
				claim.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.140 - Hospital Outpatient and Clinic Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1, 2014,
				  unless another date is specified:
a)
				Fee-For-Service Professional Services Reimbursement. Effective for dates of
				service on or after July 1, 2020, all fee-for-service hospital outpatient
				professional services will be reimbursed in accordance with subsection (b)(1)
				except for end stage renal disease treatment (ESRDT) services, as described in
				subsection (g).
b) EAPG PPS
				Reimbursement. Reimbursement under EAPG PPS, described in subsection (c), shall
				be all-inclusive for all services provided by the hospital, without regard to
				the amount charged by a hospital. Except as provided in subsection (b)(3), no
				separate reimbursement will be made for ancillary services or the services of
				hospital personnel.
1) Outpatient hospital
				services reimbursed through the EAPG PPS shall include:
A) Surgical services.
B) Diagnostic and therapeutic
				services.
C) Emergency department
				services.
D) Observation
				services.
E) Psychiatric treatment
				services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.150 - Public Law 103-66 Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				All cost reporting hospitals are required to submit annually, on or before
				August 15 of the rate year in a form or format specified by the Department, at
				least the following information separated by inpatient and outpatient
				(including hospital-based clinic services) to the Department:
1) The dollar amount of Illinois Medicaid
				charges rendered in the base year.
2) The dollar amount of hospital charity care
				charges rendered in the base year for uninsured patients.
3) The dollar amount of hospital bad debt,
				less any recoveries, rendered in the base year for uninsured
				patients.
4) The dollar amount of
				Illinois total hospital charges for care rendered in the base year.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.160 - Payment Methodology for County-Owned Large Public Hospitals

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective for
				dates of outpatient services on or after July 1, 2014 and inpatient discharges
				on July 1, 2014 through December 31, 2015:
1)
				Inpatient Reimbursement Methodology
In accordance with 89 Ill. Adm. Code
				  149.50(b)(5),
				  county-owned hospitals, as defined in Section
				  148.25(a)(1),
				  are excluded from the DRG PPS for reimbursement for inpatient hospital services
				  and are reimbursed on a per diem basis.
A) Inpatient Per Diem Rate Calculation
County-owned hospital inpatient per diem rates are calculated
				  as follows:
i) Each county-owned
				hospital's inpatient base year costs, including operating capital and direct
				medical education costs, shall be calculated using inpatient base period claims
				data and Medicare cost report data with reporting periods matching the
				inpatient base period. Effective July 1, 2018, direct and indirect medical
				education costs shall be reduced from the inpatient base year cost.
ii) The inpatient base year costs shall be
				inflated from the midpoint of the inpatient base period claims data to the
				midpoint of the time period for which rates are being set (rate period) based
				on an inflation methodology determined by the Department and approved by
				Centers for Medicare and Medicaid Services (CMMS).
iii) Calculate the sum of:
* The total hospital inflated base year costs, excluding
				  non-Medicare crossover claims, in the inpatient base period claims data;
				  and
* Total uncovered Medicare crossover claim cost in the
				  inpatient base period claims data.
iv) The inpatient per diem rate shall be the
				quotient of:
* Combined inflated base year cost and uncovered Medicare
				  crossover claims cost, per subsection (a)(1)(C); and
* Total hospital base year covered days, excluding
				  non-Medicare crossover claims, in the inpatient base period claims data.
v) The inpatient per diem rates
				shall be reduced if resulting payments exceed available Department funding or
				the CMMS Upper Payment Limit.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.170 - Payment Methodology for University-Owned Large Public Hospitals

Current through Register Vol. 48, No. 28, July 12, 2024
a) Effective for
				dates of outpatient services on or after July 1, 2014 and inpatient discharges
				on July 1, 2014 through December 31, 2015:
1)
				Inpatient Reimbursement Methodology
In accordance with 89 Ill. Adm. Code
				  149.50(b)(5),
				  a large public hospital, as defined in Section
				  148.25(a)(2),
				  is excluded from the DRG PPS for reimbursement for inpatient hospital services
				  and shall be reimbursed on a per diem basis.
A) Inpatient Per Diem Rate Calculation
University-owned hospital inpatient per diem rates are
				  calculated as follows:
i) Each
				University-owned hospital's inpatient base year costs, including operating,
				capital and direct medical education costs, shall be calculated using inpatient
				base period claims data and Medicare cost report data with reporting periods
				matching the inpatient base period. Effective July 1, 2018, direct and indirect
				medical education costs shall be reduced from the inpatient base year
				cost.
ii) The inpatient base year
				costs shall be inflated from the midpoint of the inpatient base period claims
				data to the midpoint of the time period, for which rates are being set (rate
				period) based on an inflation methodology determined by the Department and
				approved by the Center for Medicare and Medicaid Services (CMMS).
iii) Calculate the sum of:
* The total hospital inflated base year costs, excluding
				  non-Medicare crossover claims, in the inpatient base period claims data;
				  and
* Total uncovered Medicare crossover claim cost in the
				  inpatient base period claims data.
iv) The inpatient per diem rate shall be the
				quotient of:
* Combined inflated base year cost and uncovered Medicare
				  crossover claims cost, per subsection (a)(1)(A)(iii); and
* Total hospital base year covered days, excluding
				  non-Medicare crossover claims, in the inpatient base period claims data.
v) The inpatient per diem rates
				shall be reduced if resulting payments exceed available Department funding or
				the CMMS Upper Payment Limit.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.180 - Payment for Pre-operative Days and Patient Specific Orders

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				  2014:
a) Pre-operative Days. For
				hospitals and distinct part units reimbursed on a per diem basis under Sections
				148.105,
				148.110,
				148.116,
				148.160
				or
				148.170,
				payment for pre-operative days shall be limited to the day immediately
				preceding surgery unless the attending physician has documented the medical
				necessity of an additional day or days. The documentation must be kept in the
				patient's medical record and must consist of a written notation made by the
				physician which documents that more than one pre-operative day is medically
				necessary.
b) Ancillary Services
				and Tests
1) Ancillary services and routine
				tests (those services other than routine room and board and nursing which are
				required because of the patient's medical condition, including lab tests and
				x-rays) shall not be covered unless there is a patient specific written order
				for the test from the attending or operating physician responsible for the care
				and treatment of the patient. The attending or operating physician responsible
				for the care and treatment of the patient is required to sign all applicable
				sections for each test ordered in the appropriate place in the medical record.
				The order must be legible and explain completely all services or tests to be
				performed. Standing orders are not acceptable.
2) Upon completion of the service or test, a
				fully documented description of results with findings, or the administration of
				medication, must be maintained in the patient medical records. Radiological
				services must have the actual x-rays and the interpretation report;
				laboratory/pathological tests must have the specific findings for each test;
				and drugs and pharmaceutical supplies must indicate strength, dosages and
				durations.
3) Charges for any and
				all such services or tests cannot exceed those charged to the general public.
				The failure to maintain and provide records as described in this Section shall
				result in the disallowance of the applicable charges upon audit.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.190 - Copayments

Current through Register Vol. 48, No. 28, July 12, 2024
The following implements cost sharing in compliance with
				  42
				  USC 1396o (section 1916 of the Social
				  Security Act):
a) With the exception
				of those classes of individuals identified in 89 Ill. Adm. Code
				140.402(d)
				and those services identified in 89 Ill. Adm. Code
				140.402(e),
				copayments will be assessed on inpatient services provided under all Medical
				Assistance Programs administered by the Department, as provided in the Illinois
				Public Aid Code [305 ILCS 5]. Effective July 1, 2012 through August 31, 2019,
				copayments will be in the following amounts:
1) Inpatient hospital services: a daily
				copayment amount as defined in federal regulations at
				42 CFR
				447.50 et seq., which, for dates of service
				beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1,
				2013 through August 31, 2019, the nominal copayment amount is $3.90.
2) Non-emergency services defined as
				Non-emergency/Screening Level in Section
				148.140(b)
				rendered in an emergency room: a nominal copayment amount as defined in federal
				regulations at
				42 CFR
				447.50 et seq., which, for dates of service
				beginning July 1, 2012 through March 31, 2013, is $3.65. Beginning April 1,
				2013 through August 31, 2019, the nominal copayment amount is $3.90.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.210 - Filing Cost Reports

Current through Register Vol. 48, No. 28, July 12, 2024
a) Excepting
				those operated by an agency of the United States government, all hospitals in
				Illinois and hospitals in contiguous states providing 100 or more paid acute
				inpatient days of care to the Illinois Medicaid Program shall be required to
				file Medicaid and Medicare cost reports within 150 days after the close of that
				provider's fiscal year. Any hospital accredited by TJC or another Health and
				Human Services Approved Accreditation Organization not eligible for or subject
				to Medicare certification shall be required to file financial statements, a
				statement of revenues and expenses by program and census logs by program and
				financial class. The Bureau of Health Finance may request an audit of the
				financial statements by an independent Certified Public Accountant (CPA) firm
				if the financial statements are to be used as the base year for rate
				analysis.
b) No extension of the
				Medicaid cost report due date will be granted by the Department unless the
				Centers for Medicare and Medicaid Services (CMMS) grants an extension of the
				due date for the related Medicare cost report. Should CMMS extend the Medicare
				cost report due date, the Department will extend the Medicaid and Medicare cost
				reports due date by an equivalent period of time.
c) If the hospital has not filed the required
				Medicaid cost reports within 150 days after the close of the hospital's fiscal
				year, the Department shall suspend payment for covered medical services until
				the Department receives the required information.
e) Cost Report Reviews
The Bureau of Health Finance shall audit the information
				  shown on the cost reports. The audit shall be made in accordance with generally
				  accepted auditing standards and shall include tests of the accounting and
				  statistical records and applicable auditing procedures. Hospitals shall be
				  notified of the results of the final audited cost report, which may contain
				  adjustments and revisions that may have resulted from the audited Medicare Cost
				  Report. Hospitals shall have the opportunity to request a review of the final
				  audited cost report. The request must be received in writing by the Department
				  within 45 days after the date of the Department's notice to the hospital of the
				  results of the finalized audit. The request shall include all items of
				  documentation and analysis that support the request for review. No additional
				  data shall be accepted after the 45 day period.
f) Hospitals described in Section
				148.25(a)(1) and
				(a)(2) shall be required to submit outpatient
				cost reports to the Department within 150 days after the close of the
				facility's fiscal year.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.240 - Utilization Review and Furnishing of Inpatient Hospital Services Directly or Under Arrangements

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				  2014:
a) Utilization Review
The Department, or its designated peer review organization,
				  shall conduct utilization review in compliance with Section 1152 of the Social
				  Security (42 U.S.C.
				  1320c-1) and 42 (Chapter IV, Subchapter F
				  (October 1, 2013). A peer review shall be conducted by a Physician Peer
				  Reviewer who is licensed to practice medicine in all its branches, engaged in
				  the active practice of medicine, board certified or board eligible in the
				  physician's specialty and has admitting privileges in one or more Illinois
				  hospitals. Payment will only be made for those admissions and days approved by
				  the Department or its designated peer review organization. Utilization review
				  may consist of, but not be limited to, preadmission, concurrent, pre-payment,
				  and post-payment reviews to determine, pursuant to
				  42 CFR
				  476, Subpart C (October 1, 2013), the
				  following:
1) Whether the services are
				or were reasonable and medically necessary for the diagnosis and treatment of
				illness or injury;
2) The medical
				necessity, reasonableness and appropriateness of hospital admissions and
				discharges, including, but not limited to, the coordination of care
				requirements defined in Section
				148.40(a)(9)
				for the Children's Mental Health Screening, Assessment and Support Services
				(SASS) Program;
3) Through DRG
				validation, the validity of diagnostic and procedural information supplied by
				the hospital;
4) The completeness,
				adequacy and quality of hospital care provided;
5) Whether the quality of the services meets
				professionally recognized standards of health care; or
6) Whether those services furnished or
				proposed to be furnished on an inpatient basis could, consistent with the
				provisions of appropriate medical care, be effectively furnished more
				economically on an outpatient basis or in an inpatient health care facility of
				a different type.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.270 - Determination of Alternate Cost Per Diem Rates For All Hospitals; Payment Rates for Certain Exempt Hospital Units; and Payment Rates for Certain Other Hospitals (Repealed)

Current through Register Vol. 48, No. 28, July 12, 2024