100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4099

 

Introduced , by Rep. Robert Rita

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5A-2  from Ch. 23, par. 5A-2
305 ILCS 5/5A-12.2
305 ILCS 5/5A-12.4
305 ILCS 5/5A-12.5
305 ILCS 5/14-12

    Amends the Illinois Public Aid Code. Provides that, subject to federal approval, for any redesign of certain hospital assessments and payments authorized under the Code, the volume data used to redesign the distribution of hospital payments shall include managed care organization denial payments or settlements between hospitals and managed care organizations. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4099LRB100 14594 KTG 29391 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5A-2, 5A-12.2, 5A-12.4, 5A-12.5, and 14-12 as
6follows:
 
7    (305 ILCS 5/5A-2)  (from Ch. 23, par. 5A-2)
8    (Section scheduled to be repealed on July 1, 2018)
9    Sec. 5A-2. Assessment.
10    (a)(1) Subject to Sections 5A-3 and 5A-10, for State fiscal
11years 2009 through 2018, an annual assessment on inpatient
12services is imposed on each hospital provider in an amount
13equal to $218.38 multiplied by the difference of the hospital's
14occupied bed days less the hospital's Medicare bed days,
15provided, however, that the amount of $218.38 shall be
16increased by a uniform percentage to generate an amount equal
17to 75% of the State share of the payments authorized under
18Section 5A-12.5, with such increase only taking effect upon the
19date that a State share for such payments is required under
20federal law. For the period of April through June 2015, the
21amount of $218.38 used to calculate the assessment under this
22paragraph shall, by emergency rule under subsection (s) of
23Section 5-45 of the Illinois Administrative Procedure Act, be

 

 

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1increased by a uniform percentage to generate $20,250,000 in
2the aggregate for that period from all hospitals subject to the
3annual assessment under this paragraph.
4    (2) In addition to any other assessments imposed under this
5Article, effective July 1, 2016 and semi-annually thereafter
6through June 2018, in addition to any federally required State
7share as authorized under paragraph (1), the amount of $218.38
8shall be increased by a uniform percentage to generate an
9amount equal to 75% of the ACA Assessment Adjustment, as
10defined in subsection (b-6) of this Section.
11    For State fiscal years 2009 through 2014 and after, a
12hospital's occupied bed days and Medicare bed days shall be
13determined using the most recent data available from each
14hospital's 2005 Medicare cost report as contained in the
15Healthcare Cost Report Information System file, for the quarter
16ending on December 31, 2006, without regard to any subsequent
17adjustments or changes to such data. If a hospital's 2005
18Medicare cost report is not contained in the Healthcare Cost
19Report Information System, then the Illinois Department may
20obtain the hospital provider's occupied bed days and Medicare
21bed days from any source available, including, but not limited
22to, records maintained by the hospital provider, which may be
23inspected at all times during business hours of the day by the
24Illinois Department or its duly authorized agents and
25employees.
26    (b) (Blank).

 

 

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1    (b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
2portion of State fiscal year 2012, beginning June 10, 2012
3through June 30, 2012, and for State fiscal years 2013 through
42018, an annual assessment on outpatient services is imposed on
5each hospital provider in an amount equal to .008766 multiplied
6by the hospital's outpatient gross revenue, provided, however,
7that the amount of .008766 shall be increased by a uniform
8percentage to generate an amount equal to 25% of the State
9share of the payments authorized under Section 5A-12.5, with
10such increase only taking effect upon the date that a State
11share for such payments is required under federal law. For the
12period beginning June 10, 2012 through June 30, 2012, the
13annual assessment on outpatient services shall be prorated by
14multiplying the assessment amount by a fraction, the numerator
15of which is 21 days and the denominator of which is 365 days.
16For the period of April through June 2015, the amount of
17.008766 used to calculate the assessment under this paragraph
18shall, by emergency rule under subsection (s) of Section 5-45
19of the Illinois Administrative Procedure Act, be increased by a
20uniform percentage to generate $6,750,000 in the aggregate for
21that period from all hospitals subject to the annual assessment
22under this paragraph.
23    (2) In addition to any other assessments imposed under this
24Article, effective July 1, 2016 and semi-annually thereafter
25through June 2018, in addition to any federally required State
26share as authorized under paragraph (1), the amount of .008766

 

 

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1shall be increased by a uniform percentage to generate an
2amount equal to 25% of the ACA Assessment Adjustment, as
3defined in subsection (b-6) of this Section.
4    For the portion of State fiscal year 2012, beginning June
510, 2012 through June 30, 2012, and State fiscal years 2013
6through 2018, a hospital's outpatient gross revenue shall be
7determined using the most recent data available from each
8hospital's 2009 Medicare cost report as contained in the
9Healthcare Cost Report Information System file, for the quarter
10ending on June 30, 2011, without regard to any subsequent
11adjustments or changes to such data. If a hospital's 2009
12Medicare cost report is not contained in the Healthcare Cost
13Report Information System, then the Department may obtain the
14hospital provider's outpatient gross revenue from any source
15available, including, but not limited to, records maintained by
16the hospital provider, which may be inspected at all times
17during business hours of the day by the Department or its duly
18authorized agents and employees.
19    (b-6)(1) As used in this Section, "ACA Assessment
20Adjustment" means:
21        (A) For the period of July 1, 2016 through December 31,
22    2016, the product of .19125 multiplied by the sum of the
23    fee-for-service payments to hospitals as authorized under
24    Section 5A-12.5 and the adjustments authorized under
25    subsection (t) of Section 5A-12.2 to managed care
26    organizations for hospital services due and payable in the

 

 

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1    month of April 2016 multiplied by 6.
2        (B) For the period of January 1, 2017 through June 30,
3    2017, the product of .19125 multiplied by the sum of the
4    fee-for-service payments to hospitals as authorized under
5    Section 5A-12.5 and the adjustments authorized under
6    subsection (t) of Section 5A-12.2 to managed care
7    organizations for hospital services due and payable in the
8    month of October 2016 multiplied by 6, except that the
9    amount calculated under this subparagraph (B) shall be
10    adjusted, either positively or negatively, to account for
11    the difference between the actual payments issued under
12    Section 5A-12.5 for the period beginning July 1, 2016
13    through December 31, 2016 and the estimated payments due
14    and payable in the month of April 2016 multiplied by 6 as
15    described in subparagraph (A).
16        (C) For the period of July 1, 2017 through December 31,
17    2017, the product of .19125 multiplied by the sum of the
18    fee-for-service payments to hospitals as authorized under
19    Section 5A-12.5 and the adjustments authorized under
20    subsection (t) of Section 5A-12.2 to managed care
21    organizations for hospital services due and payable in the
22    month of April 2017 multiplied by 6, except that the amount
23    calculated under this subparagraph (C) shall be adjusted,
24    either positively or negatively, to account for the
25    difference between the actual payments issued under
26    Section 5A-12.5 for the period beginning January 1, 2017

 

 

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1    through June 30, 2017 and the estimated payments due and
2    payable in the month of October 2016 multiplied by 6 as
3    described in subparagraph (B).
4        (D) For the period of January 1, 2018 through June 30,
5    2018, the product of .19125 multiplied by the sum of the
6    fee-for-service payments to hospitals as authorized under
7    Section 5A-12.5 and the adjustments authorized under
8    subsection (t) of Section 5A-12.2 to managed care
9    organizations for hospital services due and payable in the
10    month of October 2017 multiplied by 6, except that:
11            (i) the amount calculated under this subparagraph
12        (D) shall be adjusted, either positively or
13        negatively, to account for the difference between the
14        actual payments issued under Section 5A-12.5 for the
15        period of July 1, 2017 through December 31, 2017 and
16        the estimated payments due and payable in the month of
17        April 2017 multiplied by 6 as described in subparagraph
18        (C); and
19            (ii) the amount calculated under this subparagraph
20        (D) shall be adjusted to include the product of .19125
21        multiplied by the sum of the fee-for-service payments,
22        if any, estimated to be paid to hospitals under
23        subsection (b) of Section 5A-12.5.
24    (2) The Department shall complete and apply a final
25reconciliation of the ACA Assessment Adjustment prior to June
2630, 2018 to account for:

 

 

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1        (A) any differences between the actual payments issued
2    or scheduled to be issued prior to June 30, 2018 as
3    authorized in Section 5A-12.5 for the period of January 1,
4    2018 through June 30, 2018 and the estimated payments due
5    and payable in the month of October 2017 multiplied by 6 as
6    described in subparagraph (D); and
7        (B) any difference between the estimated
8    fee-for-service payments under subsection (b) of Section
9    5A-12.5 and the amount of such payments that are actually
10    scheduled to be paid.
11    The Department shall notify hospitals of any additional
12amounts owed or reduction credits to be applied to the June
132018 ACA Assessment Adjustment. This is to be considered the
14final reconciliation for the ACA Assessment Adjustment.
15    (3) Notwithstanding any other provision of this Section, if
16for any reason the scheduled payments under subsection (b) of
17Section 5A-12.5 are not issued in full by the final day of the
18period authorized under subsection (b) of Section 5A-12.5,
19funds collected from each hospital pursuant to subparagraph (D)
20of paragraph (1) and pursuant to paragraph (2), attributable to
21the scheduled payments authorized under subsection (b) of
22Section 5A-12.5 that are not issued in full by the final day of
23the period attributable to each payment authorized under
24subsection (b) of Section 5A-12.5, shall be refunded.
25    (4) The increases authorized under paragraph (2) of
26subsection (a) and paragraph (2) of subsection (b-5) shall be

 

 

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1limited to the federally required State share of the total
2payments authorized under Section 5A-12.5 if the sum of such
3payments yields an annualized amount equal to or less than
4$450,000,000, or if the adjustments authorized under
5subsection (t) of Section 5A-12.2 are found not to be
6actuarially sound; however, this limitation shall not apply to
7the fee-for-service payments described in subsection (b) of
8Section 5A-12.5.
9    (c) (Blank).
10    (d) Notwithstanding any of the other provisions of this
11Section, the Department is authorized to adopt rules to reduce
12the rate of any annual assessment imposed under this Section,
13as authorized by Section 5-46.2 of the Illinois Administrative
14Procedure Act.
15    (e) Notwithstanding any other provision of this Section,
16any plan providing for an assessment on a hospital provider as
17a permissible tax under Title XIX of the federal Social
18Security Act and Medicaid-eligible payments to hospital
19providers from the revenues derived from that assessment shall
20be reviewed by the Illinois Department of Healthcare and Family
21Services, as the Single State Medicaid Agency required by
22federal law, to determine whether those assessments and
23hospital provider payments meet federal Medicaid standards. If
24the Department determines that the elements of the plan may
25meet federal Medicaid standards and a related State Medicaid
26Plan Amendment is prepared in a manner and form suitable for

 

 

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1submission, that State Plan Amendment shall be submitted in a
2timely manner for review by the Centers for Medicare and
3Medicaid Services of the United States Department of Health and
4Human Services and subject to approval by the Centers for
5Medicare and Medicaid Services of the United States Department
6of Health and Human Services. No such plan shall become
7effective without approval by the Illinois General Assembly by
8the enactment into law of related legislation. Notwithstanding
9any other provision of this Section, the Department is
10authorized to adopt rules to reduce the rate of any annual
11assessment imposed under this Section. Any such rules may be
12adopted by the Department under Section 5-50 of the Illinois
13Administrative Procedure Act.
14    (f) Subject to federal approval and notwithstanding any
15other provision of this Code, for any redesign of any
16assessments authorized under this Section, the volume data used
17to redesign the distribution of payments shall include managed
18care organization denial payments or settlements between
19hospitals and managed care organizations.
20(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14; 99-2,
21eff. 3-26-15; 99-516, eff. 6-30-16.)
 
22    (305 ILCS 5/5A-12.2)
23    (Section scheduled to be repealed on July 1, 2018)
24    Sec. 5A-12.2. Hospital access payments on or after July 1,
252008.

 

 

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1    (a) To preserve and improve access to hospital services,
2for hospital services rendered on or after July 1, 2008, the
3Illinois Department shall, except for hospitals described in
4subsection (b) of Section 5A-3, make payments to hospitals as
5set forth in this Section. These payments shall be paid in 12
6equal installments on or before the seventh State business day
7of each month, except that no payment shall be due within 100
8days after the later of the date of notification of federal
9approval of the payment methodologies required under this
10Section or any waiver required under 42 CFR 433.68, at which
11time the sum of amounts required under this Section prior to
12the date of notification is due and payable. Payments under
13this Section are not due and payable, however, until (i) the
14methodologies described in this Section are approved by the
15federal government in an appropriate State Plan amendment and
16(ii) the assessment imposed under this Article is determined to
17be a permissible tax under Title XIX of the Social Security
18Act.
19    (a-5) The Illinois Department may, when practicable,
20accelerate the schedule upon which payments authorized under
21this Section are made.
22    (b) Across-the-board inpatient adjustment.
23        (1) In addition to rates paid for inpatient hospital
24    services, the Department shall pay to each Illinois general
25    acute care hospital an amount equal to 40% of the total
26    base inpatient payments paid to the hospital for services

 

 

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1    provided in State fiscal year 2005.
2        (2) In addition to rates paid for inpatient hospital
3    services, the Department shall pay to each freestanding
4    Illinois specialty care hospital as defined in 89 Ill. Adm.
5    Code 149.50(c)(1), (2), or (4) an amount equal to 60% of
6    the total base inpatient payments paid to the hospital for
7    services provided in State fiscal year 2005.
8        (3) In addition to rates paid for inpatient hospital
9    services, the Department shall pay to each freestanding
10    Illinois rehabilitation or psychiatric hospital an amount
11    equal to $1,000 per Medicaid inpatient day multiplied by
12    the increase in the hospital's Medicaid inpatient
13    utilization ratio (determined using the positive
14    percentage change from the rate year 2005 Medicaid
15    inpatient utilization ratio to the rate year 2007 Medicaid
16    inpatient utilization ratio, as calculated by the
17    Department for the disproportionate share determination).
18        (4) In addition to rates paid for inpatient hospital
19    services, the Department shall pay to each Illinois
20    children's hospital an amount equal to 20% of the total
21    base inpatient payments paid to the hospital for services
22    provided in State fiscal year 2005 and an additional amount
23    equal to 20% of the base inpatient payments paid to the
24    hospital for psychiatric services provided in State fiscal
25    year 2005.
26        (5) In addition to rates paid for inpatient hospital

 

 

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1    services, the Department shall pay to each Illinois
2    hospital eligible for a pediatric inpatient adjustment
3    payment under 89 Ill. Adm. Code 148.298, as in effect for
4    State fiscal year 2007, a supplemental pediatric inpatient
5    adjustment payment equal to:
6            (i) For freestanding children's hospitals as
7        defined in 89 Ill. Adm. Code 149.50(c)(3)(A), 2.5
8        multiplied by the hospital's pediatric inpatient
9        adjustment payment required under 89 Ill. Adm. Code
10        148.298, as in effect for State fiscal year 2008.
11            (ii) For hospitals other than freestanding
12        children's hospitals as defined in 89 Ill. Adm. Code
13        149.50(c)(3)(B), 1.0 multiplied by the hospital's
14        pediatric inpatient adjustment payment required under
15        89 Ill. Adm. Code 148.298, as in effect for State
16        fiscal year 2008.
17    (c) Outpatient adjustment.
18        (1) In addition to the rates paid for outpatient
19    hospital services, the Department shall pay each Illinois
20    hospital an amount equal to 2.2 multiplied by the
21    hospital's ambulatory procedure listing payments for
22    categories 1, 2, 3, and 4, as defined in 89 Ill. Adm. Code
23    148.140(b), for State fiscal year 2005.
24        (2) In addition to the rates paid for outpatient
25    hospital services, the Department shall pay each Illinois
26    freestanding psychiatric hospital an amount equal to 3.25

 

 

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1    multiplied by the hospital's ambulatory procedure listing
2    payments for category 5b, as defined in 89 Ill. Adm. Code
3    148.140(b)(1)(E), for State fiscal year 2005.
4    (d) Medicaid high volume adjustment. In addition to rates
5paid for inpatient hospital services, the Department shall pay
6to each Illinois general acute care hospital that provided more
7than 20,500 Medicaid inpatient days of care in State fiscal
8year 2005 amounts as follows:
9        (1) For hospitals with a case mix index equal to or
10    greater than the 85th percentile of hospital case mix
11    indices, $350 for each Medicaid inpatient day of care
12    provided during that period; and
13        (2) For hospitals with a case mix index less than the
14    85th percentile of hospital case mix indices, $100 for each
15    Medicaid inpatient day of care provided during that period.
16    (e) Capital adjustment. In addition to rates paid for
17inpatient hospital services, the Department shall pay an
18additional payment to each Illinois general acute care hospital
19that has a Medicaid inpatient utilization rate of at least 10%
20(as calculated by the Department for the rate year 2007
21disproportionate share determination) amounts as follows:
22        (1) For each Illinois general acute care hospital that
23    has a Medicaid inpatient utilization rate of at least 10%
24    and less than 36.94% and whose capital cost is less than
25    the 60th percentile of the capital costs of all Illinois
26    hospitals, the amount of such payment shall equal the

 

 

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1    hospital's Medicaid inpatient days multiplied by the
2    difference between the capital costs at the 60th percentile
3    of the capital costs of all Illinois hospitals and the
4    hospital's capital costs.
5        (2) For each Illinois general acute care hospital that
6    has a Medicaid inpatient utilization rate of at least
7    36.94% and whose capital cost is less than the 75th
8    percentile of the capital costs of all Illinois hospitals,
9    the amount of such payment shall equal the hospital's
10    Medicaid inpatient days multiplied by the difference
11    between the capital costs at the 75th percentile of the
12    capital costs of all Illinois hospitals and the hospital's
13    capital costs.
14    (f) Obstetrical care adjustment.
15        (1) In addition to rates paid for inpatient hospital
16    services, the Department shall pay $1,500 for each Medicaid
17    obstetrical day of care provided in State fiscal year 2005
18    by each Illinois rural hospital that had a Medicaid
19    obstetrical percentage (Medicaid obstetrical days divided
20    by Medicaid inpatient days) greater than 15% for State
21    fiscal year 2005.
22        (2) In addition to rates paid for inpatient hospital
23    services, the Department shall pay $1,350 for each Medicaid
24    obstetrical day of care provided in State fiscal year 2005
25    by each Illinois general acute care hospital that was
26    designated a level III perinatal center as of December 31,

 

 

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1    2006, and that had a case mix index equal to or greater
2    than the 45th percentile of the case mix indices for all
3    level III perinatal centers.
4        (3) In addition to rates paid for inpatient hospital
5    services, the Department shall pay $900 for each Medicaid
6    obstetrical day of care provided in State fiscal year 2005
7    by each Illinois general acute care hospital that was
8    designated a level II or II+ perinatal center as of
9    December 31, 2006, and that had a case mix index equal to
10    or greater than the 35th percentile of the case mix indices
11    for all level II and II+ perinatal centers.
12    (g) Trauma adjustment.
13        (1) In addition to rates paid for inpatient hospital
14    services, the Department shall pay each Illinois general
15    acute care hospital designated as a trauma center as of
16    July 1, 2007, a payment equal to 3.75 multiplied by the
17    hospital's State fiscal year 2005 Medicaid capital
18    payments.
19        (2) In addition to rates paid for inpatient hospital
20    services, the Department shall pay $400 for each Medicaid
21    acute inpatient day of care provided in State fiscal year
22    2005 by each Illinois general acute care hospital that was
23    designated a level II trauma center, as defined in 89 Ill.
24    Adm. Code 148.295(a)(3) and 148.295(a)(4), as of July 1,
25    2007.
26        (3) In addition to rates paid for inpatient hospital

 

 

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1    services, the Department shall pay $235 for each Illinois
2    Medicaid acute inpatient day of care provided in State
3    fiscal year 2005 by each level I pediatric trauma center
4    located outside of Illinois that had more than 8,000
5    Illinois Medicaid inpatient days in State fiscal year 2005.
6    (h) Supplemental tertiary care adjustment. In addition to
7rates paid for inpatient services, the Department shall pay to
8each Illinois hospital eligible for tertiary care adjustment
9payments under 89 Ill. Adm. Code 148.296, as in effect for
10State fiscal year 2007, a supplemental tertiary care adjustment
11payment equal to the tertiary care adjustment payment required
12under 89 Ill. Adm. Code 148.296, as in effect for State fiscal
13year 2007.
14    (i) Crossover adjustment. In addition to rates paid for
15inpatient services, the Department shall pay each Illinois
16general acute care hospital that had a ratio of crossover days
17to total inpatient days for medical assistance programs
18administered by the Department (utilizing information from
192005 paid claims) greater than 50%, and a case mix index
20greater than the 65th percentile of case mix indices for all
21Illinois hospitals, a rate of $1,125 for each Medicaid
22inpatient day including crossover days.
23    (j) Magnet hospital adjustment. In addition to rates paid
24for inpatient hospital services, the Department shall pay to
25each Illinois general acute care hospital and each Illinois
26freestanding children's hospital that, as of February 1, 2008,

 

 

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1was recognized as a Magnet hospital by the American Nurses
2Credentialing Center and that had a case mix index greater than
3the 75th percentile of case mix indices for all Illinois
4hospitals amounts as follows:
5        (1) For hospitals located in a county whose eligibility
6    growth factor is greater than the mean, $450 multiplied by
7    the eligibility growth factor for the county in which the
8    hospital is located for each Medicaid inpatient day of care
9    provided by the hospital during State fiscal year 2005.
10        (2) For hospitals located in a county whose eligibility
11    growth factor is less than or equal to the mean, $225
12    multiplied by the eligibility growth factor for the county
13    in which the hospital is located for each Medicaid
14    inpatient day of care provided by the hospital during State
15    fiscal year 2005.
16    For purposes of this subsection, "eligibility growth
17factor" means the percentage by which the number of Medicaid
18recipients in the county increased from State fiscal year 1998
19to State fiscal year 2005.
20    (k) For purposes of this Section, a hospital that is
21enrolled to provide Medicaid services during State fiscal year
222005 shall have its utilization and associated reimbursements
23annualized prior to the payment calculations being performed
24under this Section.
25    (l) For purposes of this Section, the terms "Medicaid
26days", "ambulatory procedure listing services", and

 

 

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1"ambulatory procedure listing payments" do not include any
2days, charges, or services for which Medicare or a managed care
3organization reimbursed on a capitated basis was liable for
4payment, except where explicitly stated otherwise in this
5Section.
6    (m) For purposes of this Section, in determining the
7percentile ranking of an Illinois hospital's case mix index or
8capital costs, hospitals described in subsection (b) of Section
95A-3 shall be excluded from the ranking.
10    (n) Definitions. Unless the context requires otherwise or
11unless provided otherwise in this Section, the terms used in
12this Section for qualifying criteria and payment calculations
13shall have the same meanings as those terms have been given in
14the Illinois Department's administrative rules as in effect on
15March 1, 2008. Other terms shall be defined by the Illinois
16Department by rule.
17    As used in this Section, unless the context requires
18otherwise:
19    "Base inpatient payments" means, for a given hospital, the
20sum of base payments for inpatient services made on a per diem
21or per admission (DRG) basis, excluding those portions of per
22admission payments that are classified as capital payments.
23Disproportionate share hospital adjustment payments, Medicaid
24Percentage Adjustments, Medicaid High Volume Adjustments, and
25outlier payments, as defined by rule by the Department as of
26January 1, 2008, are not base payments.

 

 

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1    "Capital costs" means, for a given hospital, the total
2capital costs determined using the most recent 2005 Medicare
3cost report as contained in the Healthcare Cost Report
4Information System file, for the quarter ending on December 31,
52006, divided by the total inpatient days from the same cost
6report to calculate a capital cost per day. The resulting
7capital cost per day is inflated to the midpoint of State
8fiscal year 2009 utilizing the national hospital market price
9proxies (DRI) hospital cost index. If a hospital's 2005
10Medicare cost report is not contained in the Healthcare Cost
11Report Information System, the Department may obtain the data
12necessary to compute the hospital's capital costs from any
13source available, including, but not limited to, records
14maintained by the hospital provider, which may be inspected at
15all times during business hours of the day by the Illinois
16Department or its duly authorized agents and employees.
17    "Case mix index" means, for a given hospital, the sum of
18the DRG relative weighting factors in effect on January 1,
192005, for all general acute care admissions for State fiscal
20year 2005, excluding Medicare crossover admissions and
21transplant admissions reimbursed under 89 Ill. Adm. Code
22148.82, divided by the total number of general acute care
23admissions for State fiscal year 2005, excluding Medicare
24crossover admissions and transplant admissions reimbursed
25under 89 Ill. Adm. Code 148.82.
26    "Medicaid inpatient day" means, for a given hospital, the

 

 

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1sum of days of inpatient hospital days provided to recipients
2of medical assistance under Title XIX of the federal Social
3Security Act, excluding days for individuals eligible for
4Medicare under Title XVIII of that Act (Medicaid/Medicare
5crossover days), as tabulated from the Department's paid claims
6data for admissions occurring during State fiscal year 2005
7that was adjudicated by the Department through March 23, 2007.
8    "Medicaid obstetrical day" means, for a given hospital, the
9sum of days of inpatient hospital days grouped by the
10Department to DRGs of 370 through 375 provided to recipients of
11medical assistance under Title XIX of the federal Social
12Security Act, excluding days for individuals eligible for
13Medicare under Title XVIII of that Act (Medicaid/Medicare
14crossover days), as tabulated from the Department's paid claims
15data for admissions occurring during State fiscal year 2005
16that was adjudicated by the Department through March 23, 2007.
17    "Outpatient ambulatory procedure listing payments" means,
18for a given hospital, the sum of payments for ambulatory
19procedure listing services, as described in 89 Ill. Adm. Code
20148.140(b), provided to recipients of medical assistance under
21Title XIX of the federal Social Security Act, excluding
22payments for individuals eligible for Medicare under Title
23XVIII of the Act (Medicaid/Medicare crossover days), as
24tabulated from the Department's paid claims data for services
25occurring in State fiscal year 2005 that were adjudicated by
26the Department through March 23, 2007.

 

 

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1    (o) The Department may adjust payments made under this
2Section 5A-12.2 to comply with federal law or regulations
3regarding hospital-specific payment limitations on
4government-owned or government-operated hospitals.
5    (p) Notwithstanding any of the other provisions of this
6Section, the Department is authorized to adopt rules that
7change the hospital access improvement payments specified in
8this Section, but only to the extent necessary to conform to
9any federally approved amendment to the Title XIX State plan.
10Any such rules shall be adopted by the Department as authorized
11by Section 5-50 of the Illinois Administrative Procedure Act.
12Notwithstanding any other provision of law, any changes
13implemented as a result of this subsection (p) shall be given
14retroactive effect so that they shall be deemed to have taken
15effect as of the effective date of this Section.
16    (q) (Blank).
17    (r) On and after July 1, 2012, the Department shall reduce
18any rate of reimbursement for services or other payments or
19alter any methodologies authorized by this Code to reduce any
20rate of reimbursement for services or other payments in
21accordance with Section 5-5e.
22    (s) On or after January 1, 2016, and no less than annually
23thereafter, the Department shall increase capitation payments
24to capitated managed care organizations (MCOs) to equal the
25aggregate reduction of payments made in this Section and in
26Section 5A-12.4 by a uniform percentage on a regional basis to

 

 

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1preserve access to hospital services for recipients under the
2Illinois Medical Assistance Program. The aggregate amount of
3all increased capitation payments to all MCOs for a fiscal year
4shall be the amount needed to avoid reduction in payments
5authorized under Section 5A-15. Payments to MCOs under this
6Section shall be consistent with actuarial certification and
7shall be published by the Department each year. Each MCO shall
8only expend the increased capitation payments it receives under
9this Section to support the availability of hospital services
10and to ensure access to hospital services, with such
11expenditures being made within 15 calendar days from when the
12MCO receives the increased capitation payment. The Department
13shall make available, on a monthly basis, a report of the
14capitation payments that are made to each MCO pursuant to this
15subsection, including the number of enrollees for which such
16payment is made, the per enrollee amount of the payment, and
17any adjustments that have been made. Payments made under this
18subsection shall be guaranteed by a surety bond obtained by the
19MCO in an amount established by the Department to approximate
20one month's liability of payments authorized under this
21subsection. The Department may advance the payments guaranteed
22by the surety bond. Payments to MCOs that would be paid
23consistent with actuarial certification and enrollment in the
24absence of the increased capitation payments under this Section
25shall not be reduced as a consequence of payments made under
26this subsection.

 

 

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1    As used in this subsection, "MCO" means an entity which
2contracts with the Department to provide services where payment
3for medical services is made on a capitated basis.
4    (t) On or after July 1, 2014, the Department may increase
5capitation payments to capitated managed care organizations
6(MCOs) to equal the aggregate reduction of payments made in
7Section 5A-12.5 to preserve access to hospital services for
8recipients under the Illinois Medical Assistance Program.
9Effective January 1, 2016, the Department shall increase
10capitation payments to MCOs to include the payments authorized
11under Section 5A-12.5 to preserve access to hospital services
12for recipients under the Illinois Medical Assistance Program by
13ensuring that the reimbursement provided for Affordable Care
14Act adults enrolled in a MCO is equivalent to the reimbursement
15provided for Affordable Care Act adults enrolled in a
16fee-for-service program. Payments to MCOs under this Section
17shall be consistent with actuarial certification and federal
18approval (which may be retrospectively determined) and shall be
19published by the Department each year. Each MCO shall only
20expend the increased capitation payments it receives under this
21Section to support the availability of hospital services and to
22ensure access to hospital services, with such expenditures
23being made within 15 calendar days from when the MCO receives
24the increased capitation payment. Payments made under this
25subsection may be guaranteed by a surety bond obtained by the
26MCO in an amount established by the Department to approximate

 

 

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1one month's liability of payments authorized under this
2subsection. The Department may advance the payments to
3hospitals under this subsection, in the event the MCO fails to
4make such payments. The Department shall make available, on a
5monthly basis, a report of the capitation payments that are
6made to each MCO pursuant to this subsection, including the
7number of enrollees for which such payment is made, the per
8enrollee amount of the payment, and any adjustments that have
9been made. Payments to MCOs that would be paid consistent with
10actuarial certification and enrollment in the absence of the
11increased capitation payments under this subsection shall not
12be reduced as a consequence of payments made under this
13subsection.
14    As used in this subsection, "MCO" means an entity which
15contracts with the Department to provide services where payment
16for medical services is made on a capitated basis.
17    (u) Subject to federal approval and notwithstanding any
18other provision of this Code, for any redesign of any payments
19authorized under this Section, the volume data used to redesign
20the distribution of payments shall include managed care
21organization denial payments or settlements between hospitals
22and managed care organizations.
23(Source: P.A. 98-651, eff. 6-16-14; 99-516, eff. 6-30-16.)
 
24    (305 ILCS 5/5A-12.4)
25    (Section scheduled to be repealed on July 1, 2018)

 

 

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1    Sec. 5A-12.4. Hospital access improvement payments on or
2after June 10, 2012.
3    (a) Hospital access improvement payments. To preserve and
4improve access to hospital services, for hospital and physician
5services rendered on or after June 10, 2012, the Illinois
6Department shall, except for hospitals described in subsection
7(b) of Section 5A-3, make payments to hospitals as set forth in
8this Section. These payments shall be paid in 12 equal
9installments on or before the 7th State business day of each
10month, except that no payment shall be due within 100 days
11after the later of the date of notification of federal approval
12of the payment methodologies required under this Section or any
13waiver required under 42 CFR 433.68, at which time the sum of
14amounts required under this Section prior to the date of
15notification is due and payable. Payments under this Section
16are not due and payable, however, until (i) the methodologies
17described in this Section are approved by the federal
18government in an appropriate State Plan amendment and (ii) the
19assessment imposed under subsection (b-5) of Section 5A-2 of
20this Article is determined to be a permissible tax under Title
21XIX of the Social Security Act. The Illinois Department shall
22take all actions necessary to implement the payments under this
23Section effective June 10, 2012, including but not limited to
24providing public notice pursuant to federal requirements, the
25filing of a State Plan amendment, and the adoption of
26administrative rules. For State fiscal year 2013, payments

 

 

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1under this Section shall be increased by 21/365ths. The funding
2source for these additional payments shall be from the
3increased assessment under subsection (b-5) of Section 5A-2
4that was received from hospital providers under Section 5A-4
5for the portion of State fiscal year 2012 beginning June 10,
62012 through June 30, 2012.
7    (a-5) Accelerated schedule. The Illinois Department may,
8when practicable, accelerate the schedule upon which payments
9authorized under this Section are made.
10    (b) Magnet and perinatal hospital adjustment. In addition
11to rates paid for inpatient hospital services, the Department
12shall pay to each Illinois general acute care hospital that, as
13of August 25, 2011, was recognized as a Magnet hospital by the
14American Nurses Credentialing Center and that, as of September
1514, 2011, was designated as a level III perinatal center
16amounts as follows:
17        (1) For hospitals with a case mix index equal to or
18    greater than the 80th percentile of case mix indices for
19    all Illinois hospitals, $470 for each Medicaid general
20    acute care inpatient day of care provided by the hospital
21    during State fiscal year 2009.
22        (2) For all other hospitals, $170 for each Medicaid
23    general acute care inpatient day of care provided by the
24    hospital during State fiscal year 2009.
25    (c) Trauma level II adjustment. In addition to rates paid
26for inpatient hospital services, the Department shall pay to

 

 

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1each Illinois general acute care hospital that, as of July 1,
22011, was designated as a level II trauma center amounts as
3follows:
4        (1) For hospitals with a case mix index equal to or
5    greater than the 50th percentile of case mix indices for
6    all Illinois hospitals, $470 for each Medicaid general
7    acute care inpatient day of care provided by the hospital
8    during State fiscal year 2009.
9        (2) For all other hospitals, $170 for each Medicaid
10    general acute care inpatient day of care provided by the
11    hospital during State fiscal year 2009.
12        (3) For the purposes of this adjustment, hospitals
13    located in the same city that alternate their trauma center
14    designation as defined in 89 Ill. Adm. Code 148.295(a)(2)
15    shall have the adjustment provided under this Section
16    divided between the 2 hospitals.
17    (d) Dual-eligible adjustment. In addition to rates paid for
18inpatient services, the Department shall pay each Illinois
19general acute care hospital that had a ratio of crossover days
20to total inpatient days for programs under Title XIX of the
21Social Security Act administered by the Department (utilizing
22information from 2009 paid claims) greater than 50%, and a case
23mix index equal to or greater than the 75th percentile of case
24mix indices for all Illinois hospitals, a rate of $400 for each
25Medicaid inpatient day during State fiscal year 2009 including
26crossover days.

 

 

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1    (e) Medicaid volume adjustment. In addition to rates paid
2for inpatient hospital services, the Department shall pay to
3each Illinois general acute care hospital that provided more
4than 10,000 Medicaid inpatient days of care in State fiscal
5year 2009, has a Medicaid inpatient utilization rate of at
6least 29.05% as calculated by the Department for the Rate Year
72011 Disproportionate Share determination, and is not eligible
8for Medicaid Percentage Adjustment payments in rate year 2011
9an amount equal to $135 for each Medicaid inpatient day of care
10provided during State fiscal year 2009.
11    (f) Outpatient service adjustment. In addition to the rates
12paid for outpatient hospital services, the Department shall pay
13each Illinois hospital an amount at least equal to $100
14multiplied by the hospital's outpatient ambulatory procedure
15listing services (excluding categories 3B and 3C) and by the
16hospital's end stage renal disease treatment services provided
17for State fiscal year 2009.
18    (g) Ambulatory service adjustment.
19        (1) In addition to the rates paid for outpatient
20    hospital services provided in the emergency department,
21    the Department shall pay each Illinois hospital an amount
22    equal to $105 multiplied by the hospital's outpatient
23    ambulatory procedure listing services for categories 3A,
24    3B, and 3C for State fiscal year 2009.
25        (2) In addition to the rates paid for outpatient
26    hospital services, the Department shall pay each Illinois

 

 

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1    freestanding psychiatric hospital an amount equal to $200
2    multiplied by the hospital's ambulatory procedure listing
3    services for category 5A for State fiscal year 2009.
4    (h) Specialty hospital adjustment. In addition to the rates
5paid for outpatient hospital services, the Department shall pay
6each Illinois long term acute care hospital and each Illinois
7hospital devoted exclusively to the treatment of cancer, an
8amount equal to $700 multiplied by the hospital's outpatient
9ambulatory procedure listing services and by the hospital's end
10stage renal disease treatment services (including services
11provided to individuals eligible for both Medicaid and
12Medicare) provided for State fiscal year 2009.
13    (h-1) ER Safety Net Payments. In addition to rates paid for
14outpatient services, the Department shall pay to each Illinois
15general acute care hospital with an emergency room ratio equal
16to or greater than 55%, that is not eligible for Medicaid
17percentage adjustments payments in rate year 2011, with a case
18mix index equal to or greater than the 20th percentile, and
19that is not designated as a trauma center by the Illinois
20Department of Public Health on July 1, 2011, as follows:
21        (1) Each hospital with an emergency room ratio equal to
22    or greater than 74% shall receive a rate of $225 for each
23    outpatient ambulatory procedure listing and end-stage
24    renal disease treatment service provided for State fiscal
25    year 2009.
26        (2) For all other hospitals, $65 shall be paid for each

 

 

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1    outpatient ambulatory procedure listing and end-stage
2    renal disease treatment service provided for State fiscal
3    year 2009.
4    (i) Physician supplemental adjustment. In addition to the
5rates paid for physician services, the Department shall make an
6adjustment payment for services provided by physicians as
7follows:
8        (1) Physician services eligible for the adjustment
9    payment are those provided by physicians employed by or who
10    have a contract to provide services to patients of the
11    following hospitals: (i) Illinois general acute care
12    hospitals that provided at least 17,000 Medicaid inpatient
13    days of care in State fiscal year 2009 and are eligible for
14    Medicaid Percentage Adjustment Payments in rate year 2011;
15    and (ii) Illinois freestanding children's hospitals, as
16    defined in 89 Ill. Adm. Code 149.50(c)(3)(A).
17        (2) The amount of the adjustment for each eligible
18    hospital under this subsection (i) shall be determined by
19    rule by the Department to spend a total pool of at least
20    $6,960,000 annually. This pool shall be allocated among the
21    eligible hospitals based on the difference between the
22    upper payment limit for what could have been paid under
23    Medicaid for physician services provided during State
24    fiscal year 2009 by physicians employed by or who had a
25    contract with the hospital and the amount that was paid
26    under Medicaid for such services, provided however, that in

 

 

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1    no event shall physicians at any individual hospital
2    collectively receive an annual, aggregate adjustment in
3    excess of $435,000, except that any amount that is not
4    distributed to a hospital because of the upper payment
5    limit shall be reallocated among the remaining eligible
6    hospitals that are below the upper payment limitation, on a
7    proportionate basis.
8    (i-5) For any children's hospital which did not charge for
9its services during the base period, the Department shall use
10data supplied by the hospital to determine payments using
11similar methodologies for freestanding children's hospitals
12under this Section or Section 5A-12.2.
13    (j) For purposes of this Section, a hospital that is
14enrolled to provide Medicaid services during State fiscal year
152009 shall have its utilization and associated reimbursements
16annualized prior to the payment calculations being performed
17under this Section.
18    (k) For purposes of this Section, the terms "Medicaid
19days", "ambulatory procedure listing services", and
20"ambulatory procedure listing payments" do not include any
21days, charges, or services for which Medicare or a managed care
22organization reimbursed on a capitated basis was liable for
23payment, except where explicitly stated otherwise in this
24Section.
25    (l) Definitions. Unless the context requires otherwise or
26unless provided otherwise in this Section, the terms used in

 

 

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1this Section for qualifying criteria and payment calculations
2shall have the same meanings as those terms have been given in
3the Illinois Department's administrative rules as in effect on
4October 1, 2011. Other terms shall be defined by the Illinois
5Department by rule.
6    As used in this Section, unless the context requires
7otherwise:
8    "Case mix index" means, for a given hospital, the sum of
9the per admission (DRG) relative weighting factors in effect on
10January 1, 2005, for all general acute care admissions for
11State fiscal year 2009, excluding Medicare crossover
12admissions and transplant admissions reimbursed under 89 Ill.
13Adm. Code 148.82, divided by the total number of general acute
14care admissions for State fiscal year 2009, excluding Medicare
15crossover admissions and transplant admissions reimbursed
16under 89 Ill. Adm. Code 148.82.
17    "Emergency room ratio" means, for a given hospital, a
18fraction, the denominator of which is the number of the
19hospital's outpatient ambulatory procedure listing and
20end-stage renal disease treatment services provided for State
21fiscal year 2009 and the numerator of which is the hospital's
22outpatient ambulatory procedure listing services for
23categories 3A, 3B, and 3C for State fiscal year 2009.
24    "Medicaid inpatient day" means, for a given hospital, the
25sum of days of inpatient hospital days provided to recipients
26of medical assistance under Title XIX of the federal Social

 

 

HB4099- 33 -LRB100 14594 KTG 29391 b

1Security Act, excluding days for individuals eligible for
2Medicare under Title XVIII of that Act (Medicaid/Medicare
3crossover days), as tabulated from the Department's paid claims
4data for admissions occurring during State fiscal year 2009
5that was adjudicated by the Department through June 30, 2010.
6    "Outpatient ambulatory procedure listing services" means,
7for a given hospital, ambulatory procedure listing services, as
8described in 89 Ill. Adm. Code 148.140(b), provided to
9recipients of medical assistance under Title XIX of the federal
10Social Security Act, excluding services for individuals
11eligible for Medicare under Title XVIII of the Act
12(Medicaid/Medicare crossover days), as tabulated from the
13Department's paid claims data for services occurring in State
14fiscal year 2009 that were adjudicated by the Department
15through September 2, 2010.
16    "Outpatient end-stage renal disease treatment services"
17means, for a given hospital, the services, as described in 89
18Ill. Adm. Code 148.140(c), provided to recipients of medical
19assistance under Title XIX of the federal Social Security Act,
20excluding payments for individuals eligible for Medicare under
21Title XVIII of the Act (Medicaid/Medicare crossover days), as
22tabulated from the Department's paid claims data for services
23occurring in State fiscal year 2009 that were adjudicated by
24the Department through September 2, 2010.
25    (m) The Department may adjust payments made under this
26Section 5A-12.4 to comply with federal law or regulations

 

 

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1regarding hospital-specific payment limitations on
2government-owned or government-operated hospitals.
3    (n) Notwithstanding any of the other provisions of this
4Section, the Department is authorized to adopt rules that
5change the hospital access improvement payments specified in
6this Section, but only to the extent necessary to conform to
7any federally approved amendment to the Title XIX State plan.
8Any such rules shall be adopted by the Department as authorized
9by Section 5-50 of the Illinois Administrative Procedure Act.
10Notwithstanding any other provision of law, any changes
11implemented as a result of this subsection (n) shall be given
12retroactive effect so that they shall be deemed to have taken
13effect as of the effective date of this Section.
14    (o) The Department of Healthcare and Family Services must
15submit a State Medicaid Plan Amendment to the Centers for
16Medicare and Medicaid Services to implement the payments under
17this Section.
18    (p) Subject to federal approval and notwithstanding any
19other provision of this Code, for any redesign of any payments
20authorized under this Section, the volume data used to redesign
21the distribution of payments shall include managed care
22organization denial payments or settlements between hospitals
23and managed care organizations.
24(Source: P.A. 97-688, eff. 6-14-12; 98-104, eff. 7-22-13;
2598-463, eff. 8-16-13; 98-756, eff. 7-16-14.)
 

 

 

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1    (305 ILCS 5/5A-12.5)
2    Sec. 5A-12.5. Affordable Care Act adults; hospital access
3payments.
4    (a) The Department shall, subject to federal approval,
5mirror the Medical Assistance hospital reimbursement
6methodology for Affordable Care Act adults who are enrolled
7under a fee-for-service or capitated managed care program,
8including hospital access payments as defined in Section
95A-12.2 of this Article and hospital access improvement
10payments as defined in Section 5A-12.4 of this Article, in
11compliance with the equivalent rate provisions of the
12Affordable Care Act.
13    (b) If the fee-for-service payments authorized under this
14Section are deemed to be increases to payments for a prior
15period, the Department shall seek federal approval to issue
16such increases for the payments made through the period ending
17on June 30, 2018, even if such increases are paid out during an
18extended payment period beyond such date. Payment of such
19increases beyond such date is subject to federal approval.
20    (b-5) Subject to federal approval and notwithstanding any
21other provision of this Code, for any redesign of any payments
22authorized under this Section, the volume data used to redesign
23the distribution of payments shall include managed care
24organization denial payments or settlements between hospitals
25and managed care organizations.
26    (c) As used in this Section, "Affordable Care Act" is the

 

 

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1collective term for the Patient Protection and Affordable Care
2Act (Pub. L. 111-148) and the Health Care and Education
3Reconciliation Act of 2010 (Pub. L. 111-152).
4(Source: P.A. 98-651, eff. 6-16-14; 99-516, eff. 6-30-16.)
 
5    (305 ILCS 5/14-12)
6    Sec. 14-12. Hospital rate reform payment system. The
7hospital payment system pursuant to Section 14-11 of this
8Article shall be as follows:
9    (a) Inpatient hospital services. Effective for discharges
10on and after July 1, 2014, reimbursement for inpatient general
11acute care services shall utilize the All Patient Refined
12Diagnosis Related Grouping (APR-DRG) software, version 30,
13distributed by 3MTM Health Information System.
14        (1) The Department shall establish Medicaid weighting
15    factors to be used in the reimbursement system established
16    under this subsection. Initial weighting factors shall be
17    the weighting factors as published by 3M Health Information
18    System, associated with Version 30.0 adjusted for the
19    Illinois experience.
20        (2) The Department shall establish a
21    statewide-standardized amount to be used in the inpatient
22    reimbursement system. The Department shall publish these
23    amounts on its website no later than 10 calendar days prior
24    to their effective date.
25        (3) In addition to the statewide-standardized amount,

 

 

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1    the Department shall develop adjusters to adjust the rate
2    of reimbursement for critical Medicaid providers or
3    services for trauma, transplantation services, perinatal
4    care, and Graduate Medical Education (GME).
5        (4) The Department shall develop add-on payments to
6    account for exceptionally costly inpatient stays,
7    consistent with Medicare outlier principles. Outlier fixed
8    loss thresholds may be updated to control for excessive
9    growth in outlier payments no more frequently than on an
10    annual basis, but at least triennially. Upon updating the
11    fixed loss thresholds, the Department shall be required to
12    update base rates within 12 months.
13        (5) The Department shall define those hospitals or
14    distinct parts of hospitals that shall be exempt from the
15    APR-DRG reimbursement system established under this
16    Section. The Department shall publish these hospitals'
17    inpatient rates on its website no later than 10 calendar
18    days prior to their effective date.
19        (6) Beginning July 1, 2014 and ending on June 30, 2018,
20    in addition to the statewide-standardized amount, the
21    Department shall develop an adjustor to adjust the rate of
22    reimbursement for safety-net hospitals defined in Section
23    5-5e.1 of this Code excluding pediatric hospitals.
24        (7) Beginning July 1, 2014 and ending on June 30, 2018,
25    in addition to the statewide-standardized amount, the
26    Department shall develop an adjustor to adjust the rate of

 

 

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1    reimbursement for Illinois freestanding inpatient
2    psychiatric hospitals that are not designated as
3    children's hospitals by the Department but are primarily
4    treating patients under the age of 21.
5    (b) Outpatient hospital services. Effective for dates of
6service on and after July 1, 2014, reimbursement for outpatient
7services shall utilize the Enhanced Ambulatory Procedure
8Grouping (E-APG) software, version 3.7 distributed by 3MTM
9Health Information System.
10        (1) The Department shall establish Medicaid weighting
11    factors to be used in the reimbursement system established
12    under this subsection. The initial weighting factors shall
13    be the weighting factors as published by 3M Health
14    Information System, associated with Version 3.7.
15        (2) The Department shall establish service specific
16    statewide-standardized amounts to be used in the
17    reimbursement system.
18            (A) The initial statewide standardized amounts,
19        with the labor portion adjusted by the Calendar Year
20        2013 Medicare Outpatient Prospective Payment System
21        wage index with reclassifications, shall be published
22        by the Department on its website no later than 10
23        calendar days prior to their effective date.
24            (B) The Department shall establish adjustments to
25        the statewide-standardized amounts for each Critical
26        Access Hospital, as designated by the Department of

 

 

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1        Public Health in accordance with 42 CFR 485, Subpart F.
2        The EAPG standardized amounts are determined
3        separately for each critical access hospital such that
4        simulated EAPG payments using outpatient base period
5        paid claim data plus payments under Section 5A-12.4 of
6        this Code net of the associated tax costs are equal to
7        the estimated costs of outpatient base period claims
8        data with a rate year cost inflation factor applied.
9        (3) In addition to the statewide-standardized amounts,
10    the Department shall develop adjusters to adjust the rate
11    of reimbursement for critical Medicaid hospital outpatient
12    providers or services, including outpatient high volume or
13    safety-net hospitals.
14    (c) In consultation with the hospital community, the
15Department is authorized to replace 89 Ill. Admin. Code 152.150
16as published in 38 Ill. Reg. 4980 through 4986 within 12 months
17of the effective date of this amendatory Act of the 98th
18General Assembly. If the Department does not replace these
19rules within 12 months of the effective date of this amendatory
20Act of the 98th General Assembly, the rules in effect for
21152.150 as published in 38 Ill. Reg. 4980 through 4986 shall
22remain in effect until modified by rule by the Department.
23Nothing in this subsection shall be construed to mandate that
24the Department file a replacement rule.
25    (d) Transition period. There shall be a transition period
26to the reimbursement systems authorized under this Section that

 

 

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1shall begin on the effective date of these systems and continue
2until June 30, 2018, unless extended by rule by the Department.
3To help provide an orderly and predictable transition to the
4new reimbursement systems and to preserve and enhance access to
5the hospital services during this transition, the Department
6shall allocate a transitional hospital access pool of at least
7$290,000,000 annually so that transitional hospital access
8payments are made to hospitals.
9        (1) After the transition period, the Department may
10    begin incorporating the transitional hospital access pool
11    into the base rate structure.
12        (2) After the transition period, if the Department
13    reduces payments from the transitional hospital access
14    pool, it shall increase base rates, develop new adjustors,
15    adjust current adjustors, develop new hospital access
16    payments based on updated information, or any combination
17    thereof by an amount equal to the decreases proposed in the
18    transitional hospital access pool payments, ensuring that
19    the entire transitional hospital access pool amount shall
20    continue to be used for hospital payments.
21    Subject to federal approval and notwithstanding any other
22provision of this Code, for any redesign of transitional
23hospital access payments authorized under this Section, the
24volume data used to redesign the distribution of payments shall
25include managed care organization denial payments or
26settlements between hospitals and managed care organizations.

 

 

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1    (e) Beginning 36 months after initial implementation, the
2Department shall update the reimbursement components in
3subsections (a) and (b), including standardized amounts and
4weighting factors, and at least triennially and no more
5frequently than annually thereafter. The Department shall
6publish these updates on its website no later than 30 calendar
7days prior to their effective date.
8    (f) Continuation of supplemental payments. Any
9supplemental payments authorized under Illinois Administrative
10Code 148 effective January 1, 2014 and that continue during the
11period of July 1, 2014 through December 31, 2014 shall remain
12in effect as long as the assessment imposed by Section 5A-2 is
13in effect.
14    (g) Notwithstanding subsections (a) through (f) of this
15Section and notwithstanding the changes authorized under
16Section 5-5b.1, any updates to the system shall not result in
17any diminishment of the overall effective rates of
18reimbursement as of the implementation date of the new system
19(July 1, 2014). These updates shall not preclude variations in
20any individual component of the system or hospital rate
21variations. Nothing in this Section shall prohibit the
22Department from increasing the rates of reimbursement or
23developing payments to ensure access to hospital services.
24Nothing in this Section shall be construed to guarantee a
25minimum amount of spending in the aggregate or per hospital as
26spending may be impacted by factors including but not limited

 

 

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1to the number of individuals in the medical assistance program
2and the severity of illness of the individuals.
3    (h) The Department shall have the authority to modify by
4rulemaking any changes to the rates or methodologies in this
5Section as required by the federal government to obtain federal
6financial participation for expenditures made under this
7Section.
8    (i) Except for subsections (g) and (h) of this Section, the
9Department shall, pursuant to subsection (c) of Section 5-40 of
10the Illinois Administrative Procedure Act, provide for
11presentation at the June 2014 hearing of the Joint Committee on
12Administrative Rules (JCAR) additional written notice to JCAR
13of the following rules in order to commence the second notice
14period for the following rules: rules published in the Illinois
15Register, rule dated February 21, 2014 at 38 Ill. Reg. 4559
16(Medical Payment), 4628 (Specialized Health Care Delivery
17Systems), 4640 (Hospital Services), 4932 (Diagnostic Related
18Grouping (DRG) Prospective Payment System (PPS)), and 4977
19(Hospital Reimbursement Changes), and published in the
20Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
21(Specialized Health Care Delivery Systems) and 6505 (Hospital
22Services).
23(Source: P.A. 98-651, eff. 6-16-14; 99-2, eff. 3-26-15.)
 
24    Section 99. Effective date. This Act takes effect upon
25becoming law.