reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.290 - Adjustments and Reductions to Total Payments

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) The adjustments described in this Section,
				as applicable, shall be made to reimbursement amounts calculated pursuant to
				Sections
				148.105,
				148.110,
				148.115,
				148.140,
				148.160,
				148.170,
				148.330 and 89 Ill.
				Adm. Code
				149.100
				prior to payment. The adjustments are to be applied in the order in which they
				are listed in this Section.
b)
				Adjustments to base rates made pursuant to 89 Ill. Adm. Code
				152.150.
c) Increases in Payments. Supplemental
				payments pursuant to the Long Term Acute Care Hospital Quality Improvement
				Transfer Program Act [210 ILCS 155 ] in accordance with Section
				148.115(f).
d) Reductions in Payments. The Department's
				payment obligation shall be reduced by:
1)
				Charges. Except for reimbursement calculated under Sections 148.140, 148.160
				and 148.170, payment shall not exceed the lesser of:
A) The reimbursement amount determined
				pursuant to subsections (a) and (b).
B) The allowable charges billed to the
				Department on the claim.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.300 - Payment

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) The Department will adjust
				rate methodologies used to reimburse hospitals to assure compliance with
				applicable aggregate and hospital-specific federal payment
				limitations.
b) Effect of Change of
				Ownership on Payments. When a hospital's ownership changes, payment for
				hospital services for each patient, including payment adjustments, will be made
				to the entity that is the legal owner on the date of discharge. Payment will
				not be prorated between the buyer and seller.
1) The owner on the date of discharge is
				entitled to submit a bill for all inpatient hospital services furnished
				regardless of when the client's coverage began or ended during a stay, or how
				long the stay lasted.
2) Each bill
				submitted must include all information necessary for the Department to compute
				the payment amount, whether some of the information is attributable to a period
				during which a different party legally owned the hospital.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.330 - Exemptions

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1, 2014,
				  nothing in this Part is intended to prevent a hospital from individually
				  negotiating with the Department to set up an alternate methodology for
				  reimbursement that results in an expenditure that does not exceed the
				  expenditure that would otherwise be made under this Part.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.340 - Subacute Alcoholism and Substance Abuse Treatment Services

Current through Register Vol. 48, No. 28, July 12, 2024
a) Payment may be
				made for subacute alcoholism and other substance abuse treatment services
				provided by:
1) A provider licensed by the
				Illinois Department of Human Services under the provisions of 77 Ill. Adm. Code
				2060.
2) A provider licensed by the
				Illinois Department of Public Health under the provisions of 77 Ill. Adm. Code
				250.2830(b)
				and (c).
3) Psychiatrists for ancillary diagnostic
				services.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.370 - Payment for Sub-acute Alcoholism and Substance Abuse Treatment Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) The amount approved for
				payment for sub-acute alcoholism and substance abuse treatment is based on the
				type and amount of services required by and actually delivered to a recipient.
				The amount is determined in accordance with prospective rates developed by the
				Department of Human Services and approved and adopted by the Department (see 77
				Ill. Adm. Code
				2090.70 ). The
				adopted rate shall not exceed the charges to the general public.
b) Rates are generated through the
				application of formal methodologies specific to each category in accordance
				with the specifications in 77 Ill. Adm. Code
				2090.35,
				2090.40 and
				2090.70. Rate appeals are allowable pursuant to the specifications in 77 Ill.
				Adm. Code
				2090.80.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.390 - Hearings

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) The Department may initiate
				administrative proceedings pursuant to 89 Ill. Adm. Code 104.Subpart C to
				suspend or terminate certification and eligibility to participate in the
				Illinois Medical Assistance Program where the provider:
1) Has failed to comply with 77 Ill. Adm.
				Code
				2090.40;
2) Does not have a valid license for an
				enrolled treatment service category;
3) Any of the grounds for payment recovery or
				termination set forth in 89 Ill. Adm. Code
				140.15
				or
				140.16
				or 89 Ill. Adm. Code 104.Subpart C are present.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.400 - Special Hospital Reporting Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
Corrective Action Plans. Effective for dates of service on or
				  after July 1, 2014, hospitals are responsible for assuring that services
				  provided to Medical Assistance Program participants meet or exceed the
				  appropriate standards for care. Any provider that is under any corrective
				  action plans, while enrolled with the Department, by any licensing,
				  certification and/or accreditation authority, including, but not limited to,
				  the Illinois Department of Public Health, the federal Department of Health and
				  Human Services, a peer review organization, or TJC or another Health and Human
				  Services Approved Accreditation Organization, must report the request for the
				  corrective action plans to the Department. Information submitted will remain
				  confidential.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.401 - Alzheimer's Treatment Access Payment

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service starting July 1, 2020, except
				  when specifically designated otherwise in this Section:
a) Qualifying Criteria. An Illinois academic
				medical center or teaching hospital as defined in Section
				148.25(h)
				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 [410 ILCS 405] and identified in the Illinois Department of
				Public Health Alzheimer's Disease State Plan dated December 2016.
b) Payment. A qualifying hospital shall
				receive a payment that is the product of the following factors:
1) The hospital's SFY 2018 inpatient days;
				and
2) The hospital's Alzheimer's
				Treatment Rate:
A) For qualifying hospitals
				located in Cook County: $226; and
B) For qualifying hospitals located outside
				of Cook County: $116.21.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.402 - Expensive Drugs and Devices Add-On Payment

Current through Register Vol. 48, No. 28, July 12, 2024
a) Qualifying Criteria: Beginning July 1,
				2018, in addition to the statewide standardized amounts for in-state hospitals
				as defined in 89 Ill. Adm Code
				149.100(i),
				the Department shall make an add-on payment for outpatient expensive devices
				and drugs. This add-on payment shall apply to claim lines that:
1) Are:
A)
				assigned with one of the following EAPGs: 490 or 1001 through 1020;
				and
B) coded with one of the
				following revenue codes: 0274 through 0276, 0278; or
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.403 - General Provisions - Inpatient

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service starting July 1, 2018, except
				  when specifically designated otherwise in this Section:
a) General Provisions. Unless otherwise
				indicated, the following apply to these Sections:
				148.401
				and
				148.421.
1) Payments
A) Effective July 1, 2018, payments shall be
				paid in 12 installments on or before the 7th State
				business day of the month.
B) The
				Department may adjust payments made under these Sections to comply with federal
				law or regulations regarding disproportionate share, hospital-specific payment
				limitations on government-owned or government-operated hospitals.
C) If the State or federal Centers for
				Medicare and Medicaid Services finds that any federal upper payment limit
				applicable to the payments under these Sections is exceeded, then the payments
				under these Sections that exceed the applicable federal upper payment limit
				shall be reduced uniformly to the extent necessary to comply with the federal
				limit.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.404 - General Provisions - Outpatient

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service starting July 1, 2018, except
				  when specifically designated otherwise in this Section:
a) General Provisions. Unless otherwise
				indicated, the following apply to Sections
				148.412,
				148.413,
				148.419,
				148.420,
				and
				148.423:
1) Payments
A) Effective July 1, 2018, payments shall be
				paid in 12 installments on or before the 7th State
				business day of the month.
B) The
				Department may adjust payments made under these Sections to comply with federal
				law or regulations regarding disproportionate share, hospital-specific payment
				limitations on government-owned or government-operated hospitals.
C) If the State or federal Centers for
				Medicare and Medicaid Services finds that any federal upper payment limit
				applicable to the payments under these Sections is exceeded, then the payments
				under these Sections that exceed the applicable federal upper payment limit
				shall be reduced uniformly to the extent necessary to comply with the federal
				limit.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.405 - Graduate Medical Education (GME) Payment

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service starting July 1, 2020, except
				  when specifically designated otherwise in this Section:
a) Definitions. As used in this Section,
				unless the context requires otherwise:
1)
				Medicare cost report ending in 2018, as reported in Medicare cost reports
				released on October 19, 2019, with data through September 30, 2019.
2) "Hospital's annualized Medicaid Intern
				Resident Cost" is the product of the following factors:
A) Annualized intern and resident costs
				obtained from Worksheet B Part I, Column 21 and 22 the sum of lines 30 through
				43, 50 through 76, 90 through 93,96 through 98, and 105 through 112;
B) A quotient of:
i) The numerator of which is the hospital's
				Medicaid days (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through
				18, and 32); and
ii) The
				denominator of which is the hospital's total days (Worksheet S3 Part I, Column
				8, Lines 14, 16 through 18, and 32); and
3) "Hospital Annualized Medicaid Indirect
				Medical Education (IME) payment" is the product of the following factors:
A) Hospital IME payments (Worksheet E Part A,
				Line 29, Col 1); and
B) A quotient
				of:
i) The numerator of which is the hospital
				Medicaid days (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through
				18, and 32); and
ii) The
				denominator of which is the hospital Medicare days (Worksheet S3 Part I, Column
				6, Lines 2 through 4, 14, and 16 through 18).
4) "Statewide average cost per intern and
				resident" is the quotient of subsection (a)(4)(A) divided by subsection
				(a)(4)(B).
A) The sum of:
i) All qualifying hospitals annualized
				Medicaid Intern Resident Cost; and
ii) All qualifying hospitals annualized
				Medicaid IME payment.
B)
				The sum of all qualifying hospitals interns and residents as reported on
				Worksheet S3, Part 1, Col 9, Line 14.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.406 - Graduate Medical Education (GME) Payment for Large Public Hospitals

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service starting July 1, 2018, except
				  when specifically designated otherwise in this Section:
a) Inpatient Graduate Medical Education (GME)
				Payment
1) Definitions. As used in this
				Section, unless the context requires otherwise:
A) "Medicare cost report" means the Medicare
				cost report ending in 2015, as reported in Medicare cost reports released on
				October 19, 2016, with data through September 30, 2016.
B) "Hospital's Annualized Medicaid Inpatient
				Intern Resident Cost" is the product of the following factors:
i) Annualized intern and resident costs
				obtained from Worksheet B Part I, Column 21 and 22 the sum of Lines 30 through
				43, 50 through 76, 90 through 93, 96 through 98, and 105 through112;
ii) A quotient of:
* The numerator of which is the hospital's Medicaid days
				  (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through 18, and 32);
				  and
* The denominator of which is the hospital's total days
				  (Worksheet S3 Part I, Column 8, Lines 14 and 16 through18);
				  and.
iii) The quotient of:
* The numerator of which is the hospital's total inpatient
				  charges; and
* The denominator of which is the hospital's total
				  charges.
C)
				"Hospital Annualized Medicaid Indirect Medical Education (IME) Payment" is the
				product of the following factors:
i) Hospital
				IME payments (Worksheet E Part A, Line 29, Col 1); and
ii) The quotient of:
* The numerator of which is the hospital Medicaid days
				  (Worksheet S3 Part I, Column 7, Lines 2 through 4, 14, 16 through 18, and 32),
				  and
* The denominator of which is the hospital Medicare days
				  (Worksheet S3 Part I, Column 6, Lines 2 through 4, 14, and 16 through
				  18).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.421 - Hospital Inpatient Adjustment

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Qualifying Criteria. Effective July 1, 2020, the following categories of
				non-large public hospitals located in Illinois shall qualify for a Hospital
				Inpatient Adjustment Payment:
1) General
				Acute Care Hospitals (see definition of "Hospital" in Section
				148.25);
2) Safety-Net Hospitals, as defined in
				subsection (c)(2);
3) Long Term
				Acute Care (LTAC) Hospitals, as defined in Section 148.25;
4) Psychiatric Hospitals, as defined in
				Section
				148.25(d)(1);
5) Rehabilitation Hospitals, as defined in
				Section 148.(d)(2); and
6) Critical
				Access Hospitals, as defined in 42 CFR 485, Subpart F.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.423 - Hospital Outpatient Adjustment

Current through Register Vol. 48, No. 28, July 12, 2024
a) Qualifying Criteria. Effective July 1,
				2020, the following categories of non-large public hospitals located in
				Illinois shall qualify for a Hospital Outpatient Adjustment Payment:
1) General Acute Care Hospitals, as defined
				in Section
				148.25;
2) Safety-Net Hospitals, as defined in
				subsection (c)(2);
3) Psychiatric
				Hospitals, as defined in Section
				148.25(d)(1);
				and
4) Critical Access Hospitals,
				as defined 42 CFR 485, Subpart F.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart B - REIMBURSEMENT AND RELATED PROVISIONS › Section 148.425 - Directed Payment Classifications

Current through Register Vol. 48, No. 28, July 12, 2024
a) For
				purposes of calculating quarterly directed payment amounts as described in
				Section 5A-12.7(g) and (h) of the Public Aid Code, effective July 1, 2020 and
				January 1 of each following calendar year, the Department shall classify
				Illinois Hospitals into the following classes:
1) Critical Access Hospitals as defined in
				Section
				148.25(g);
2) Safety-Net Hospitals as defined in 89 Ill.
				Adm. Code
				149.100(f)(4),
				except that stand-alone children's hospitals as defined in Section
				148.25(d)(3)(A)
				that are not children's specialty hospitals as defined in Section
				148.25(i)
				will not be included;
3) Long Term
				Acute Care Hospitals as defined in Section
				148.25(d)(4);
4) Freestanding Psychiatric Hospitals as
				defined in Section
				148.25(d)(1);
5) Freestanding Rehabilitation Hospitals as
				defined in Section
				148.25(d)(2);
6) High Medicaid Hospitals; and
7) Other General Acute Care
				Hospitals.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart C - SEXUAL ASSAULT EMERGENCY TREATMENT PROGRAM › Section 148.510 - Reimbursement

Current through Register Vol. 48, No. 28, July 12, 2024
When a hospital or ambulance provider furnishes emergency
				  services, a hospital or health care professional or laboratory provides
				  follow-up healthcare, or a pharmacy dispenses prescribed medications to any
				  sexual assault survivor who is neither eligible to receive those services under
				  the Illinois Public Aid Code [305 ILCS 5/5 ] nor covered for those services by
				  a policy of insurance, the hospital, ambulance provider, health care
				  professional, laboratory or pharmacy shall furnish the services without charge
				  to that person, and shall be entitled to be reimbursed in providing the
				  services, under the following conditions:
a) An Illinois hospital shall be eligible for
				reimbursement only after receiving Department of Public Health approval for
				participation as a Sexual Assault Treatment Facility or as a Sexual Assault
				Transfer Facility.
b) Charges for
				outpatient emergency care, physician, and ambulance transportation, and other
				related charges, shall be reimbursed as described in this subsection (b):
1) Physicians, ambulance providers, and other
				miscellaneous medical providers rendering services in the hospital emergency
				department shall be directly reimbursed by the Department of Healthcare and
				Family Services.
2) Charges for
				inpatient care shall not be reimbursed.
3) Charges must be directly related to care
				rendered for examinations, injuries, or trauma resulting from a sexual assault
				and/or the completion of sexual assault evidence collection through the use and
				application of the Illinois State Police Sexual Assault Evidence Collection
				Kit.
4) Emergency services must
				have been provided within the hospital emergency department or under the
				direction of an attending emergency room physician at the facility who
				supervised or provided the hospital emergency care of the sexual assault
				survivor, or during the ambulance transport of the sexual assault
				survivor.
5) Charges may include,
				but are not limited to, outpatient emergency care, physician, laboratory,
				x-ray, pharmacy and ambulance services, including charges for follow-up visits
				to the emergency department that are related to the sexual assault and occur
				within 90 days after the initial visit.
6) Services provided to sexual assault
				survivors shall be reimbursed at the Department's reimbursement
				rates.
7) Claims must be received
				by the Department within 180 days from the date of service to be eligible for
				payment pursuant to 89 Ill. Adm. Code
				140.20.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart D - STATE CHRONIC RENAL DISEASE PROGRAM › Section 148.600 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Department" means the Illinois Department of Healthcare and
				  Family Services.
"Dialysis Facility" means a facility that provides dialysis
				  treatments, such as in-facility and home dialysis, and is certified by the
				  federal Centers for Medicare and Medicaid Services as a Medicare-approved
				  dialysis facility.
"Dialysis Treatment" means the filtering of blood in order to
				  remove liquid and unwanted material so that fluid, electrolyte and acid-base
				  balance in the blood can be maintained.
"End Stage Renal Disease" means the level of renal impairment
				  that is irreversible and permanent, results in the kidneys losing their ability
				  to filter blood and excrete urine, and requires a regular course of dialysis or
				  kidney transplantation to maintain life.
"Patient" means an eligible person whose kidneys are
				  non-functioning or absent and who requires dialysis treatment to maintain
				  life.
"Program" means the Illinois Department of Healthcare and
				  Family Services State Chronic Renal Disease Program.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart D - STATE CHRONIC RENAL DISEASE PROGRAM › Section 148.610 - Scope of the Program

Current through Register Vol. 48, No. 28, July 12, 2024
General Description
The Illinois Department of Healthcare and Family Services
				  State Chronic Renal Disease Program assists patients with End Stage Renal
				  Disease who have not qualified for benefits under Medical Assistance or All
				  Kids. The Program assists eligible patients suffering from chronic renal
				  diseases who require lifesaving care and treatment for such renal diseases, but
				  who are unable to pay for the necessary services on a continuing basis. The
				  Program is supplementary to all other resources, including Medicare, private
				  insurance and private income. Services under the State Chronic Renal Disease
				  Program are not available as emergency medical services to ineligible
				  non-citizens. The Program will assist in connecting individuals with health
				  coverage through Medicaid or the Illinois Health Insurance Marketplace under
				  the Affordable Care Act (
				  42
				  USC 18001 et seq.).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart D - STATE CHRONIC RENAL DISEASE PROGRAM › Section 148.620 - Assistance Level and Reimbursement

Current through Register Vol. 48, No. 28, July 12, 2024
a) Only approved dialysis facilities that are
				enrolled with the Department shall be reimbursed for dialysis treatments
				received by eligible patients.
b)
				The Department shall reimburse dialysis facilities for a portion of the costs
				of dialysis treatments provided to eligible patients. The Department will
				determine annually the rate of reimbursement to be used for the fiscal year,
				based on Medicare's Composite Payment Rates.
c) Assistance for chronic outpatient dialysis
				patients who are Medicare eligible, but who also qualify for the Program for
				both in-facility dialysis and home dialysis, will not exceed 15 percent of the
				Medicare rate.
d) New patients who
				qualify for chronic outpatient dialysis assistance during the waiting period
				for Medicare eligibility (60 to 90 days from the date of first dialysis) will
				be assisted at a maximum of 95 percent or less of the rate established under
				subsection (b) of this Section.
e)
				Patients who will never be eligible or qualify for Medicare will be assisted at
				a maximum of 95 percent or a minimum of 80 percent of the rate established
				under subsection (b).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart D - STATE CHRONIC RENAL DISEASE PROGRAM › Section 148.630 - Criteria and Information Required to Establish Eligibility

Current through Register Vol. 48, No. 28, July 12, 2024
a) An eligible person shall:
1) Be a resident of the State of Illinois as
				provided in 305 ILCS 5/2-10;
2) Meet requirements of citizenship as
				provided in
				305 ILCS 5/1-11;
				and
3) Meet the requirements of the
				Patient Protection and Affordable Care Act (ACA) (
				26 USC
				5000 A ) by obtaining health coverage.
				Payment of a tax penalty for not obtaining insurance does not meet the
				requirement.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart D - STATE CHRONIC RENAL DISEASE PROGRAM › Section 148.640 - Covered Services

Current through Register Vol. 48, No. 28, July 12, 2024
Assistance may be provided for eligible patients for costs
				  associated with:
a) Prescribed
				medication related to chronic renal disease treatment;
b) Transportation to and from the site of
				dialysis or the site of out-patient post transplantation care when such needs
				are defined as emergency situations by the physician and social worker in the
				approved facility; and
c)
				Laboratory tests, not otherwise covered, that are related to the patient's
				status after a transplantation procedure. The laboratory tests are covered for
				three years after the date of transplantation.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart E - INSTITUTION FOR MENTAL DISEASES PROVISIONS FOR HOSPITALS › Section 148.700 - General Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
Section 1905(a)(16) and (a)(28)(B) of the Social Security Act
				  provides that federal financial participation (FFP) is not available for any
				  medical assistance under Title XIX for services provided to any individual who
				  is older than 21 years of age and under 65 years of age and who is a patient in
				  an IMD. The purpose of this Subpart E is to set forth the process by which the
				  Department shall collect information necessary to assure federal
				  compliance.
a) The Department shall
				request certain data elements from participating hospitals that include but are
				not limited to daily census information as described in provider notices to
				hospitals.
b) Participating
				hospitals shall be notified no less than 90 days before the effective reporting
				period.
c) If a hospital does not
				provide the required information within the required deadline as defined
				through a provider notice, the Department may suspend payments for covered
				services until the required information is received.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.800 - General Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
This Subpart F is promulgated to establish an emergency
				  psychiatric demonstration project (hereinafter referred to as the Program) to
				  serve adults 21 through 64 years of age with specified mental illnesses. The
				  State of Illinois was selected by the federal Centers for Medicare and Medicaid
				  Services (CMMS) to establish the Program pursuant to the provisions of section
				  2707 of the federal Patient Protection and Affordable Care Act (
				  PL
				  111-148 ) and subject to the terms of federal
				  demonstration. The program, entitled Community Connect, shall be in effect from
				  December 1, 2012 through June 30, 2015 or for the duration of federal funding
				  should it end earlier. During that time period, participating non-governmental
				  Community Connect IMD hospitals may receive Medicaid payment for providing
				  EMTALA (Emergency Medical Treatment and Active Labor Act) related emergency
				  services to Medicaid recipients 21 through 64 years of age who have expressed
				  suicidal or homicidal thoughts or gestures or who are determined to be
				  dangerous to themselves or others. The Program will promote an integrated
				  approach to evidence-based community resources and emergency room and inpatient
				  hospital care. The Program goals are to improve access to quality inpatient
				  care, reduce unnecessary admissions and readmissions, reduce psychiatric
				  boarding, and enhance coordination of services with community mental health
				  centers. The Department will assess the results of the Program during and at
				  the end of the demonstration. The assessment will be the basis to guide changes
				  for the larger adult population with mental illness, such as potential
				  restructuring of mental health targeted case management; potential adult
				  screening of persons with mental illness presenting for psychiatric
				  hospitalization; potential payment and incentive policies; and potential broad
				  implementation of improved interventions by the hospital and
				  community.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.810 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
For the purposes of this Part, the following terms shall be
				  defined as follows:
"Community Connect Targeted Case Management Agency" or
				  "Community Connect TCM Agency" means the community mental health center that
				  will act as the crisis team, determination of appropriate level of care agent,
				  linkage agent and care coordination entity for participants in the Emergency
				  Psychiatric Demonstration Program.
"Department" means the Illinois Department of Healthcare and
				  Family Services.
"Emergency Psychiatric Demonstration Program" or "Program"
				  means the program under which psychiatric hospitals, general hospitals, and
				  community mental health providers will work to develop new service models to
				  increase the overall quality of service delivery to participants with a
				  psychiatric emergency medical condition.
"EMTALA" means the federal Emergency Medical Treatment and
				  Active Labor Act (
				  42 USC
				  1395 dd ) that requires any hospital that
				  accepts payments from Medicare to provide care to any patient who arrives in
				  its emergency department for treatment, regardless of the patient's
				  citizenship, legal status in the United States or ability to pay for the
				  services. EMTALA applies to ambulance and hospital care.
"IMD" means an institution for mental disease and is defined
				  as a hospital, nursing facility, or other institution of 17 or more beds that
				  is primarily engaged in providing diagnosis, treatment or care of persons with
				  mental diseases, including medical attention, nursing care and related
				  services. As used in this Subpart, IMD refers to a hospital.
"IMR" means Illness Management and Recovery and is an
				  evidence-based psychiatric rehabilitation practice. The primary aim of the IMR
				  is to empower consumers to manage their illnesses, find their own goals for
				  recovery, and make informed decisions about their treatment through the
				  necessary knowledge and skills.
"Psychiatric Emergency Medical Condition" means a condition
				  in which an individual is expressing suicidal or homicidal thoughts or gestures
				  or is dangerous to self or others.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.820 - Individual Eligibility for the Program

Current through Register Vol. 48, No. 28, July 12, 2024
a) For the purposes of this Subpart, only
				Medicaid eligible individuals 21 through 64 years of age, with a serious mental
				illness, who present at a participating or partnering hospital with suicidal or
				homicidal thoughts or gestures, or who are a danger to self or others, will be
				eligible to participate. Individuals enrolled in a care coordination program
				[305 ILCS 5/5-30
				], as well as those individuals who have Medicare coverage, are excluded from
				participation.
b) Participation
				shall also be limited to the maximum number of IMD admissions funded by CMMS
				and the number of deflections to community services before reaching the maximum
				IMD number funded as provided in the supplemental provider agreement.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.830 - Providers Participating in the Program

Current through Register Vol. 48, No. 28, July 12, 2024
a) Hospitals that may participate in the
				Program are limited to those included in the funded demonstration application.
				A hospital participating in the Program will be designated a Community Connect
				IMD hospital.
b) In order to
				participate in the Program, the Community Connect IMD hospital must comply with
				all of the Department rules, policies and licensure requirements and,
				additionally, must meet each of the following criteria:
1) Establish a Network Guidance Group
				consisting of a representative from each of the following: Illinois Department
				of Healthcare and Family Services; Illinois Department of Human
				Services-Division of Mental Health; the Community Connect IMD hospital; the
				Community Connect TCM agency; and representatives from participating emergency
				departments, local law enforcement, consumers, and other individuals as
				determined by the Community Connect IMD hospital. The Network Guidance Group
				shall meet at least quarterly to review the Program operations.
2) Accept Community Connect eligible
				participants on a priority basis.
3) Include the Community Connect TCM agency
				in staffing and discharge planning.
4) Not discharge Community Connect
				participants unless a discharge plan ensures the patient has a place to go and
				appropriate services will be implemented.
5) Establish a collaborative working
				relationship with a dedicated community mental health center to function as the
				Community Connect TCM agency.
6)
				Contact the Community Connect TCM agency to perform a level of care assessment
				prior to admission.
7) Update the
				collaborating Community Connect TCM agency on bed census every day.
8) Enter into a supplemental provider
				agreement with the Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.840 - Stabilization and Discharge Practices

Current through Register Vol. 48, No. 28, July 12, 2024
The admitting hospital must establish a stabilization plan
				  for the individual within 48 hours after admission. To ensure continuity of
				  treatment services, a participating Community Connect IMD hospital will not
				  discharge an individual unless the discharge plan ensures the individual has a
				  place to go and appropriate services will be implemented.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.850 - Medication Management

Current through Register Vol. 48, No. 28, July 12, 2024
On the day of discharge from an inpatient admission, the
				  Community Connect TCM agency will ensure the individual accesses a 30-day
				  supply of medically necessary medication to ensure continuity of this aspect of
				  treatment and medication adherence.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.860 - Community Connect IMD Hospital Payment

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of service on or after July 1,
				  2014:
a) The Community Connect IMD
				hospital in the demonstration program will be reimbursed on an incentive-driven
				basis. The Department will reimburse the initial claim for the psychiatric
				admission at 80% of the psychiatric hospital rate. The remainder of the full
				100% of the psychiatric hospital rate will be paid if the individual remains
				stable in the community with no further psychiatric hospitalization for 45 days
				after the level of care assessment.
b) Payment for any individual who cannot be
				discharged because the individual does not have a place to go and appropriate
				services cannot be implemented, but who is not an inpatient based on medical
				necessity, will be 50% of the alternate cost per diem rate as defined in
				Section
				148.270
				and 89 Ill. Adm. Code
				152.200
				on July 1, 2012.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.870 - Community Connect TCM Agency Payment

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Community Connect TCM agency monthly
				reimbursement rate for each individual will be established in the supplemental
				provider agreement.
b) The
				Community Connect TCM agency will be reimbursed on an incentive driven basis
				for each individual each month. The Department will reimburse the initial claim
				at 80% of the individual per month rate. The remainder of the full 100% of the
				individual per month rate will be paid if the individual deflected to community
				services or hospitalized at the Community Connect IMD remains stable in the
				community without further psychiatric hospitalization for 45 days after the
				level of care assessment.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Section 148.880 - Program Reporting

Current through Register Vol. 48, No. 28, July 12, 2024
Each Community Connect IMD and each Community Connect TCM
				  agency will submit periodic reports to the Department in the form and format
				  specified by the Department.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Table A - Renal Participation Fee Worksheet

Current through Register Vol. 48, No. 28, July 12, 2024
Date ___________________
Initialed _________________
Patient Identification Number __________________
PATIENT'S NAME
				  ________________________________________________________
LastFirstMiddle
				  Initial
In questions 1 through 4 below, please circle one number or
				  group of numbers:
1.
NUMBER OF PERSONS IN FAMILY
1
2
3
4
5
6 or more
2.
NUMBER OF CHILDREN
1
2
3
4
5 or more
3.
AGE OF OLDEST CHILD IN YEARS
0-5
6-15
16-17
18 and over
4.
AGE OF HEAD OF HOUSEHOLD
Under 35
35-54
55-64
65 and over
BUREAU OF LABOR STATISTICS (BLS) EQUIVALENCE
							 FACTOR=
__________
(see Table B)
Click here to view
				  image
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart F - EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM › Table C - List of Metropolitan Counties by SMSA Definition

Current through Register Vol. 48, No. 28, July 12, 2024
"SMSA" means Standard Metropolitan Statistical Area as
				  defined by the U.S. Office of Management and Budget (OMB).
Boone
Champaign
Clinton
Cook
DuPage
Henry
Kane
Kankakee
Lake
Macon
Madison
McHenry
McLean
Menard
Monroe
Peoria
Rock Island
Sangamon
St. Clair
Tazewell
Will
Winnebago
Woodford
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 149 - DIAGNOSIS RELATED GROUPING (DRG) PROSPECTIVE PAYMENT SYSTEM (PPS) › Section 149.10 - Applicability of Other Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1, 2014, the
				following provisions, in addition to those provisions specifically cited in
				this Part, shall apply to hospitals reimbursed under the Diagnosis Related
				Grouping Prospective Payment System (DRG PPS):
a) The general requirements applicable to all
			 hospital services, as described in General Provisions of 89 Ill. Adm. Code 148,
			 Subpart A.
b) Organ transplant
			 services, as described in 89 Ill. Adm. Code
			 148.82.
c) Hospital outpatient and hospital-based
			 clinic services, as described in 89 Ill. Adm. Code
			 148.140.
d) Payment for pre-operative days and patient
			 specific orders, as described in 89 Ill. Adm. Code
			 148.180.
e) Copayments, as described in 89 Ill. Adm.
			 Code
			 148.190.
f) Filing cost reports, as described in 89
			 Ill. Adm. Code
			 148.210.
g) Review procedure, as described in 89 Ill.
			 Adm. Code
			 148.310.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 149 - DIAGNOSIS RELATED GROUPING (DRG) PROSPECTIVE PAYMENT SYSTEM (PPS) › Section 149.25 - General Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				2014:
a) Basis of Payment
1) Payment on a Per Discharge Basis
A) Under the DRG PPS, hospitals are paid a
			 predetermined amount per discharge for inpatient hospital services furnished to
			 persons receiving coverage under the Medicaid Program.
B) The DRG prospective payment rate for each
			 discharge (as defined in subsection (b)) is determined according to the
			 methodology described in Sections
			 149.100
			 and
			 149.150,
			 as appropriate. An additional payment is made, in accordance with Section
			 149.105,
			 as appropriate. The rates paid shall be those in effect on the date of
			 admission.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 149 - DIAGNOSIS RELATED GROUPING (DRG) PROSPECTIVE PAYMENT SYSTEM (PPS) › Section 149.50 - Hospital Inpatient Services Subject to and Excluded from the DRG Prospective Payment System

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				2014:
a) Inpatient Services Subject to
			 Submission for DRG Grouping. All hospital inpatient services provided to
			 enrollees of the Medical Assistance programs, without regard to balance due or
			 expected reimbursement methodology to be applied by the Department, must be
			 documented on a claim and submitted to the Department. The Department shall
			 process and group all hospital inpatient claims through the DRG
			 grouper.
b) Excluded from DRG PPS
			 reimbursements are:
1) Psychiatric services
			 provided by:
A) A psychiatric hospital, as
			 described in 89 Ill. Adm. Code
			 148.25(d)(1).
B) A distinct part psychiatric unit, as
			 described in 89 Ill. Adm. Code
			 148.25(c)(1).
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 149 - DIAGNOSIS RELATED GROUPING (DRG) PROSPECTIVE PAYMENT SYSTEM (PPS) › Section 149.75 - Conditions for Payment Under the DRG Prospective Payment System

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				2014:
a) General Requirements
1) A hospital must meet the conditions of
			 this Section to receive payment under the DRG PPS for inpatient hospital
			 services furnished to persons receiving coverage under the Medicaid
			 Program.
2) If a hospital fails to
			 comply fully with these conditions with respect to inpatient hospital services
			 furnished to one or more Medical Assistance clients, the Department may, as
			 appropriate:
A) Withhold Medicaid payments
			 (in full or in part) to the hospital until the hospital provides adequate
			 assurances of compliance; or
B)
			 Terminate the hospital's Provider Agreement pursuant to 89 Ill. Adm. Code
			 140.16.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 149 - DIAGNOSIS RELATED GROUPING (DRG) PROSPECTIVE PAYMENT SYSTEM (PPS) › Section 149.100 - Methodology for Determining DRG PPS Payment Rates

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				2014:
a) Inpatient hospital services
			 that are not excluded from the DRG PPS pursuant to Section
			 149.50(b)
			 shall be reimbursed as determined in this Section.
b) Total DRG PPS Payment. Under the DRG PPS,
			 services to inpatients who are:
1) Discharges
			 shall be paid pursuant to subsection (c).
2) Transfers shall be paid pursuant to
			 subsection (g).
3) The total
			 payment for an inpatient stay will equal the sum of the payment determined in
			 subsection (c) or (g), as applicable, and any applicable adjustments to payment
			 specified in 89 Ill. Adm. Code
			 148.290.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 149 - DIAGNOSIS RELATED GROUPING (DRG) PROSPECTIVE PAYMENT SYSTEM (PPS) › Section 149.105 - Payment For Outlier Cases

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				2014:
a) Outlier adjustment
			 determination. Except as provided in subsection (b), the Department may provide
			 for additional payment, approximating a hospital's marginal cost of covered
			 inpatient hospital services beyond thresholds specified by the Department. To
			 qualify for the payment, the claim must meet the following criteria:
1) The services on the claim must be
			 reimbursable under the DRG PPS.
2)
			 The DRG grouper must be able to assign the claim to a DRG.
3) The estimated claim cost for a claim
			 exceeds the claim outlier threshold for the DRG to which the claim has been
			 assigned.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 150 - ELECTRONIC HEALTH INFORMATION TECHNOLOGY › Subpart A - GENERAL PROVISIONS › Section 150.5 - Incorporation by Reference

Current through Register Vol. 48, No. 28, July 12, 2024
a) Any
				rules or regulations of an agency of the United States or of a nationally
				recognized organization or association that are incorporated by reference in
				this Part are incorporated as of the date specified and do not include any
				later amendments or editions.
b) To
				the extent that they are not inconsistent with this Part, the provisions of 42
				CFR 495(2011) are incorporated in this Part.
Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 150 - ELECTRONIC HEALTH INFORMATION TECHNOLOGY › Subpart A - GENERAL PROVISIONS › Section 150.15 - Applicability

Current through Register Vol. 48, No. 28, July 12, 2024
a) Should any rule,
				subdivision, clause, phrase or provision of this Part be held unconstitutional
				or invalid for any reason whatsoever, those holdings shall not affect the
				validity of the remaining portions of this Part.
b) This Part shall be operative only to the
				extent that it does not conflict with any federal law or regulation governing
				federal grants for the funding of, or reimbursement of public expenditures for,
				the development and use of health information technology.