101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB5280

 

Introduced , by Rep. Emanuel Chris Welch

 

SYNOPSIS AS INTRODUCED:
 
210 ILCS 50/32.5
305 ILCS 5/5A-2  from Ch. 23, par. 5A-2
305 ILCS 5/5A-12.6
305 ILCS 5/5A-14
305 ILCS 5/14-12

    Amends the Illinois Public Aid Code. Provides that for State Fiscal Years 2021 through 2024, an annual assessment on inpatient and outpatient services is imposed on each hospital provider, subject to other specified provisions. Contains provisions concerning a hospital's non-Medicaid gross revenue for State Fiscal Years 2021 and 2022. Contains provisions concerning the assignment of a pool allocation percentage for certain hospitals designated as a Level II trauma center; increased capitation payments to managed care organizations; the extension of certain assessments to July 1, 2022 (rather than July 1, 2020); the allocation of funds from the transitional access hospital pool; and other matters. Amends the Emergency Medical Services (EMS) Systems Act. Removes provisions requiring the Department of Public Health to issue a Freestanding Emergency Center license to a facility that has discontinued inpatient hospital services and meets other requirements. Effective immediately.


LRB101 19340 KTG 68811 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB5280LRB101 19340 KTG 68811 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 1. Legislative intent.
5    (1) Illinois must dedicate itself to eliminating
6inequities in its health care system. According to a well-known
72019 study from the New York University School of Medicine,
8residents of the Streeterville neighborhood of Chicago live 30
9years longer than residents of the Englewood neighborhood on
10average, the worst such disparity identified in the nation.
11    (2) In order to address disparities in health care access
12and outcomes, every community must have access to high quality
13and comprehensive health care services. This means investing in
14the health care delivery system in an equitable manner,
15emphasizing hospitals in areas of greatest health need and most
16adversely affected by health disparities.
17    (3) Safety net hospitals, which are most often located in
18low-income communities of color, need greater capacity, and
19expanded services. Instead, there is currently a crisis of
20hospital closures and service scale-backs throughout the most
21vulnerable communities in Illinois. In contrast, large
22academic medical centers and hospital systems have less need
23for public operational support. According to financial
24disclosures, many of these hospitals or systems hold billions

 

 

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1of dollars in financial investment accounts that could
2otherwise be used to improve care access and quality throughout
3the State.
4    (4) The Illinois hospital assessment, a roughly
5$3,500,000,000 program within the Illinois Medicaid program,
6should be used to ensure the stability, equity, and quality of
7our health care delivery system. This means directing
8additional Medicaid funding to hospitals in urgent need of
9public support. Currently, the assessment awards too much
10supplemental funding to wealthy hospitals and hospital systems
11and not enough to hospitals dependent on the Medicaid program.
12    (5) This Act of the 101st General Assembly amends the
13hospital provider assessment and associated payments to
14reorient them toward the support of hospitals in areas of
15greatest health need and most adversely affected by health
16disparities.
 
17    Section 10. The Emergency Medical Services (EMS) Systems
18Act is amended by changing Section 32.5 as follows:
 
19    (210 ILCS 50/32.5)
20    Sec. 32.5. Freestanding Emergency Center.
21    (a) The Department shall issue an annual Freestanding
22Emergency Center (FEC) license to any facility that has
23received a permit from the Health Facilities and Services
24Review Board to establish a Freestanding Emergency Center by

 

 

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1January 1, 2015, and:
2        (1) is located: (A) in a municipality with a population
3    of 50,000 or fewer inhabitants; (B) within 50 miles of the
4    hospital that owns or controls the FEC; and (C) within 50
5    miles of the Resource Hospital affiliated with the FEC as
6    part of the EMS System;
7        (2) is wholly owned or controlled by an Associate or
8    Resource Hospital, but is not a part of the hospital's
9    physical plant;
10        (3) meets the standards for licensed FECs, adopted by
11    rule of the Department, including, but not limited to:
12            (A) facility design, specification, operation, and
13        maintenance standards;
14            (B) equipment standards; and
15            (C) the number and qualifications of emergency
16        medical personnel and other staff, which must include
17        at least one board certified emergency physician
18        present at the FEC 24 hours per day.
19        (4) limits its participation in the EMS System strictly
20    to receiving a limited number of patients by ambulance: (A)
21    according to the FEC's 24-hour capabilities; (B) according
22    to protocols developed by the Resource Hospital within the
23    FEC's designated EMS System; and (C) as pre-approved by
24    both the EMS Medical Director and the Department;
25        (5) provides comprehensive emergency treatment
26    services, as defined in the rules adopted by the Department

 

 

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1    pursuant to the Hospital Licensing Act, 24 hours per day,
2    on an outpatient basis;
3        (6) provides an ambulance and maintains on site
4    ambulance services staffed with paramedics 24 hours per
5    day;
6        (7) (blank);
7        (8) complies with all State and federal patient rights
8    provisions, including, but not limited to, the Emergency
9    Medical Treatment Act and the federal Emergency Medical
10    Treatment and Active Labor Act;
11        (9) maintains a communications system that is fully
12    integrated with its Resource Hospital within the FEC's
13    designated EMS System;
14        (10) reports to the Department any patient transfers
15    from the FEC to a hospital within 48 hours of the transfer
16    plus any other data determined to be relevant by the
17    Department;
18        (11) submits to the Department, on a quarterly basis,
19    the FEC's morbidity and mortality rates for patients
20    treated at the FEC and other data determined to be relevant
21    by the Department;
22        (12) does not describe itself or hold itself out to the
23    general public as a full service hospital or hospital
24    emergency department in its advertising or marketing
25    activities;
26        (13) complies with any other rules adopted by the

 

 

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1    Department under this Act that relate to FECs;
2        (14) passes the Department's site inspection for
3    compliance with the FEC requirements of this Act;
4        (15) submits a copy of the permit issued by the Health
5    Facilities and Services Review Board indicating that the
6    facility has complied with the Illinois Health Facilities
7    Planning Act with respect to the health services to be
8    provided at the facility;
9        (16) submits an application for designation as an FEC
10    in a manner and form prescribed by the Department by rule;
11    and
12        (17) pays the annual license fee as determined by the
13    Department by rule.
14    (a-5) Notwithstanding any other provision of this Section,
15the Department may issue an annual FEC license to a facility
16that is located in a county that does not have a licensed
17general acute care hospital if the facility's application for a
18permit from the Illinois Health Facilities Planning Board has
19been deemed complete by the Department of Public Health by
20January 1, 2014 and if the facility complies with the
21requirements set forth in paragraphs (1) through (17) of
22subsection (a).
23    (a-10) Notwithstanding any other provision of this
24Section, the Department may issue an annual FEC license to a
25facility if the facility has, by January 1, 2014, filed a
26letter of intent to establish an FEC and if the facility

 

 

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1complies with the requirements set forth in paragraphs (1)
2through (17) of subsection (a).
3    (a-15) Notwithstanding any other provision of this
4Section, the Department shall issue an annual FEC license to a
5facility if the facility: (i) discontinues operation as a
6hospital within 180 days after December 4, 2015 (the effective
7date of Public Act 99-490) this amendatory Act of the 99th
8General Assembly with a Health Facilities and Services Review
9Board project number of E-017-15; (ii) has an application for a
10permit to establish an FEC from the Health Facilities and
11Services Review Board that is deemed complete by January 1,
122017; and (iii) complies with the requirements set forth in
13paragraphs (1) through (17) of subsection (a) of this Section.
14    (a-20) (Blank). Notwithstanding any other provision of
15this Section, the Department shall issue an annual FEC license
16to a facility if:
17        (1) the facility is a hospital that has discontinued
18    inpatient hospital services;
19        (2) the Department of Healthcare and Family Services
20    has certified the conversion to an FEC was approved by the
21    Hospital Transformation Review Committee as a project
22    subject to the hospital's transformation under subsection
23    (d-5) of Section 14-12 of the Illinois Public Aid Code;
24        (3) the facility complies with the requirements set
25    forth in paragraphs (1) through (17), provided however that
26    the FEC may be located in a municipality with a population

 

 

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1    greater than 50,000 inhabitants and shall not be subject to
2    the requirements of the Illinois Health Facilities
3    Planning Act that are applicable to the conversion to an
4    FEC if the Department of Healthcare and Family Service has
5    certified the conversion to an FEC was approved by the
6    Hospital Transformation Review Committee as a project
7    subject to the hospital's transformation under subsection
8    (d-5) of Section 14-12 of the Illinois Public Aid Code; and
9        (4) the facility is located at the same physical
10    location where the facility served as a hospital.
11    (b) The Department shall:
12        (1) annually inspect facilities of initial FEC
13    applicants and licensed FECs, and issue annual licenses to
14    or annually relicense FECs that satisfy the Department's
15    licensure requirements as set forth in subsection (a);
16        (2) suspend, revoke, refuse to issue, or refuse to
17    renew the license of any FEC, after notice and an
18    opportunity for a hearing, when the Department finds that
19    the FEC has failed to comply with the standards and
20    requirements of the Act or rules adopted by the Department
21    under the Act;
22        (3) issue an Emergency Suspension Order for any FEC
23    when the Director or his or her designee has determined
24    that the continued operation of the FEC poses an immediate
25    and serious danger to the public health, safety, and
26    welfare. An opportunity for a hearing shall be promptly

 

 

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1    initiated after an Emergency Suspension Order has been
2    issued; and
3        (4) adopt rules as needed to implement this Section.
4(Source: P.A. 99-490, eff. 12-4-15; 99-710, eff. 8-5-16;
5100-581, eff. 3-12-18; revised 7-23-19.)
 
6    Section 15. The Illinois Public Aid Code is amended by
7changing Sections 5A-2, 5A-12.6, 5A-14, and 14-12 as follows:
 
8    (305 ILCS 5/5A-2)  (from Ch. 23, par. 5A-2)
9    (Section scheduled to be repealed on July 1, 2020)
10    Sec. 5A-2. Assessment.
11    (a)(1) Subject to Sections 5A-3 and 5A-10, for State fiscal
12years 2009 through 2018, or as long as continued under Section
135A-16, an annual assessment on inpatient services is imposed on
14each hospital provider in an amount equal to $218.38 multiplied
15by the difference of the hospital's occupied bed days less the
16hospital's Medicare bed days, provided, however, that the
17amount of $218.38 shall be increased by a uniform percentage to
18generate an amount equal to 75% of the State share of the
19payments authorized under Section 5A-12.5, with such increase
20only taking effect upon the date that a State share for such
21payments is required under federal law. For the period of April
22through June 2015, the amount of $218.38 used to calculate the
23assessment under this paragraph shall, by emergency rule under
24subsection (s) of Section 5-45 of the Illinois Administrative

 

 

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1Procedure Act, be increased by a uniform percentage to generate
2$20,250,000 in the aggregate for that period from all hospitals
3subject to the annual 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, or as provided in Section 5A-16, in addition
7to any federally required State share as authorized under
8paragraph (1), the amount of $218.38 shall be increased by a
9uniform percentage to generate an amount equal to 75% of the
10ACA Assessment Adjustment, as defined in subsection (b-6) of
11this Section.
12    For State fiscal years 2009 through 2018, or as provided in
13Section 5A-16, a hospital's occupied bed days and Medicare bed
14days shall be determined using the most recent data available
15from each hospital's 2005 Medicare cost report as contained in
16the Healthcare Cost Report Information System file, for the
17quarter ending on December 31, 2006, without regard to any
18subsequent adjustments or changes to such data. If a hospital's
192005 Medicare cost report is not contained in the Healthcare
20Cost Report Information System, then the Illinois Department
21may obtain the hospital provider's occupied bed days and
22Medicare bed days from any source available, including, but not
23limited to, records maintained by the hospital provider, which
24may be inspected at all times during business hours of the day
25by the Illinois Department or its duly authorized agents and
26employees.

 

 

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1    (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
2fiscal years 2019 and 2020, an annual assessment on inpatient
3services is imposed on each hospital provider in an amount
4equal to $197.19 multiplied by the difference of the hospital's
5occupied bed days less the hospital's Medicare bed days;
6however, for State fiscal year 2021, the amount of $197.19
7shall be increased by a uniform percentage to generate an
8additional $6,250,000 in the aggregate for that period from all
9hospitals subject to the annual assessment under this
10paragraph. For State fiscal years 2019 and 2020, a hospital's
11occupied bed days and Medicare bed days shall be determined
12using the most recent data available from each hospital's 2015
13Medicare cost report as contained in the Healthcare Cost Report
14Information System file, for the quarter ending on March 31,
152017, without regard to any subsequent adjustments or changes
16to such data. If a hospital's 2015 Medicare cost report is not
17contained in the Healthcare Cost Report Information System,
18then the Illinois Department may obtain the hospital provider's
19occupied bed days and Medicare bed days from any source
20available, including, but not limited to, records maintained by
21the hospital provider, which may be inspected at all times
22during business hours of the day by the Illinois Department or
23its duly authorized agents and employees. Notwithstanding any
24other provision in this Article, for a hospital provider that
25did not have a 2015 Medicare cost report, but paid an
26assessment in State fiscal year 2018 on the basis of

 

 

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1hypothetical data, that assessment amount shall be used for
2State fiscal years 2019 and 2020; however, for State fiscal
3year 2021, the assessment amount shall be increased by the
4proportion that it represents of the total annual assessment
5that is generated from all hospitals in order to generate
6$6,250,000 in the aggregate for that period from all hospitals
7subject to the annual assessment under this paragraph.
8    Subject to Sections 5A-3 and 5A-10, for State fiscal years
92021 through 2024, an annual assessment on inpatient services
10is imposed on each hospital provider in an amount equal to
11$197.19 multiplied by the difference of the hospital's occupied
12bed days less the hospital's Medicare bed days, provided
13however, that the amount of $197.19 used to calculate the
14assessment under this paragraph shall, by rule, be adjusted by
15a uniform percentage to generate the same total annual
16assessment that was generated in State fiscal year 2020 from
17all hospitals subject to the annual assessment under this
18paragraph plus $6,250,000. For State fiscal years 2021 and
192022, a hospital's occupied bed days and Medicare bed days
20shall be determined using the most recent data available from
21each hospital's 2017 Medicare cost report as contained in the
22Healthcare Cost Report Information System file, for the quarter
23ending on March 31, 2019, without regard to any subsequent
24adjustments or changes to such data. For State fiscal years
252023 and 2024, a hospital's occupied bed days and Medicare bed
26days shall be determined using the most recent data available

 

 

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1from each hospital's 2019 Medicare cost report as contained in
2the Healthcare Cost Report Information System file, for the
3quarter ending on March 31, 2021, without regard to any
4subsequent adjustments or changes to such data.
5    (b) (Blank).
6    (b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
7portion of State fiscal year 2012, beginning June 10, 2012
8through June 30, 2012, and for State fiscal years 2013 through
92018, or as provided in Section 5A-16, an annual assessment on
10outpatient services is imposed on each hospital provider in an
11amount equal to .008766 multiplied by the hospital's outpatient
12gross revenue, provided, however, that the amount of .008766
13shall be increased by a uniform percentage to generate an
14amount equal to 25% of the State share of the payments
15authorized under Section 5A-12.5, with such increase only
16taking effect upon the date that a State share for such
17payments is required under federal law. For the period
18beginning June 10, 2012 through June 30, 2012, the annual
19assessment on outpatient services shall be prorated by
20multiplying the assessment amount by a fraction, the numerator
21of which is 21 days and the denominator of which is 365 days.
22For the period of April through June 2015, the amount of
23.008766 used to calculate the assessment under this paragraph
24shall, by emergency rule under subsection (s) of Section 5-45
25of the Illinois Administrative Procedure Act, be increased by a
26uniform percentage to generate $6,750,000 in the aggregate for

 

 

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1that period from all hospitals subject to the annual assessment
2under this paragraph.
3    (2) In addition to any other assessments imposed under this
4Article, effective July 1, 2016 and semi-annually thereafter
5through June 2018, in addition to any federally required State
6share as authorized under paragraph (1), the amount of .008766
7shall be increased by a uniform percentage to generate an
8amount equal to 25% of the ACA Assessment Adjustment, as
9defined in subsection (b-6) of this Section.
10    For the portion of State fiscal year 2012, beginning June
1110, 2012 through June 30, 2012, and State fiscal years 2013
12through 2018, or as provided in Section 5A-16, a hospital's
13outpatient gross revenue shall be determined using the most
14recent data available from each hospital's 2009 Medicare cost
15report as contained in the Healthcare Cost Report Information
16System file, for the quarter ending on June 30, 2011, without
17regard to any subsequent adjustments or changes to such data.
18If a hospital's 2009 Medicare cost report is not contained in
19the Healthcare Cost Report Information System, then the
20Department may obtain the hospital provider's outpatient gross
21revenue 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
24Department or its duly authorized agents and employees.
25    (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
26fiscal years 2019 and 2020, an annual assessment on outpatient

 

 

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1services is imposed on each hospital provider in an amount
2equal to .01358 multiplied by the hospital's outpatient gross
3revenue; however, for State fiscal year 2021, the amount of
4.01358 shall be increased by a uniform percentage to generate
5an additional $6,250,000 in the aggregate for that period from
6all hospitals subject to the annual assessment under this
7paragraph. For State fiscal years 2019 and 2020, a hospital's
8outpatient gross revenue shall be determined using the most
9recent data available from each hospital's 2015 Medicare cost
10report as contained in the Healthcare Cost Report Information
11System file, for the quarter ending on March 31, 2017, without
12regard to any subsequent adjustments or changes to such data.
13If a hospital's 2015 Medicare cost report is not contained in
14the Healthcare Cost Report Information System, then the
15Department may obtain the hospital provider's outpatient gross
16revenue from any source available, including, but not limited
17to, records maintained by the hospital provider, which may be
18inspected at all times during business hours of the day by the
19Department or its duly authorized agents and employees.
20Notwithstanding any other provision in this Article, for a
21hospital provider that did not have a 2015 Medicare cost
22report, but paid an assessment in State fiscal year 2018 on the
23basis of hypothetical data, that assessment amount shall be
24used for State fiscal years 2019 and 2020; however, for State
25fiscal year 2021, the assessment amount shall be increased by
26the proportion that it represents of the total annual

 

 

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1assessment that is generated from all hospitals in order to
2generate $6,250,000 in the aggregate for that period from all
3hospitals subject to the annual assessment under this
4paragraph.
5    Subject to Sections 5A-3 and 5A-10, for State fiscal years
62021 through 2024, an annual assessment on outpatient services
7is imposed on each hospital provider in an amount equal to
8.01358 multiplied by the hospital's outpatient gross revenue,
9provided however, that the amount of .01358 used to calculate
10the assessment under this paragraph shall, by rule, be adjusted
11by a uniform percentage to generate the same total annual
12assessment that was generated in State fiscal year 2020 from
13all hospitals subject to the annual assessment under this
14paragraph plus $6,250,000. For State fiscal years 2021 and
152022, a hospital's outpatient gross revenue shall be determined
16using the most recent data available from each hospital's 2017
17Medicare cost report as contained in the Healthcare Cost Report
18Information System file, for the quarter ending on March 31,
192019, without regard to any subsequent adjustments or changes
20to such data. For State fiscal years 2023 and 2024, a
21hospital's outpatient gross revenue shall be determined using
22the most recent data available from each hospital's 2019
23Medicare cost report as contained in the Healthcare Cost Report
24Information System file, for the quarter ending on March 31,
252021, without regard to any subsequent adjustments or changes
26to such data.

 

 

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

 

 

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

 

 

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1            (ii) the amount calculated under this subparagraph
2        (D) shall be adjusted to include the product of .19125
3        multiplied by the sum of the fee-for-service payments,
4        if any, estimated to be paid to hospitals under
5        subsection (b) of Section 5A-12.5.
6    (2) The Department shall complete and apply a final
7reconciliation of the ACA Assessment Adjustment prior to June
830, 2018 to account for:
9        (A) any differences between the actual payments issued
10    or scheduled to be issued prior to June 30, 2018 as
11    authorized in Section 5A-12.5 for the period of January 1,
12    2018 through June 30, 2018 and the estimated payments due
13    and payable in the month of October 2017 multiplied by 6 as
14    described in subparagraph (D); and
15        (B) any difference between the estimated
16    fee-for-service payments under subsection (b) of Section
17    5A-12.5 and the amount of such payments that are actually
18    scheduled to be paid.
19    The Department shall notify hospitals of any additional
20amounts owed or reduction credits to be applied to the June
212018 ACA Assessment Adjustment. This is to be considered the
22final reconciliation for the ACA Assessment Adjustment.
23    (3) Notwithstanding any other provision of this Section, if
24for any reason the scheduled payments under subsection (b) of
25Section 5A-12.5 are not issued in full by the final day of the
26period authorized under subsection (b) of Section 5A-12.5,

 

 

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1funds collected from each hospital pursuant to subparagraph (D)
2of paragraph (1) and pursuant to paragraph (2), attributable to
3the scheduled payments authorized under subsection (b) of
4Section 5A-12.5 that are not issued in full by the final day of
5the period attributable to each payment authorized under
6subsection (b) of Section 5A-12.5, shall be refunded.
7    (4) The increases authorized under paragraph (2) of
8subsection (a) and paragraph (2) of subsection (b-5) shall be
9limited to the federally required State share of the total
10payments authorized under Section 5A-12.5 if the sum of such
11payments yields an annualized amount equal to or less than
12$450,000,000, or if the adjustments authorized under
13subsection (t) of Section 5A-12.2 are found not to be
14actuarially sound; however, this limitation shall not apply to
15the fee-for-service payments described in subsection (b) of
16Section 5A-12.5.
17    (c) (Blank).
18    (c-5)(1) Subject to Sections 5A-3 and 5A-10, for State
19Fiscal Years 2021 through 2024, an annual assessment on
20inpatient and outpatient services is imposed on each hospital
21provider. The assessment shall be as described in paragraph (2)
22of this subsection.
23    (2)(A) The "total assessment" shall be equal to the sum of
24the following 2 numbers:
25        (i) The total annual assessment on inpatient services
26    that was generated in State fiscal year 2020 from all

 

 

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1    hospitals subject to the annual assessment under this
2    paragraph plus $6,250,000.
3        (ii) The total annual assessment on inpatient services
4    that was generated in State fiscal year 2020 from all
5    hospitals subject to the annual assessment under this
6    paragraph plus $6,250,000.
7    (B) The assessment imposed on each hospital provider shall
8be equal to a rate multiplied by the sum of their non-Medicaid
9inpatient gross revenue and non-Medicaid outpatient gross
10revenue. The Department shall determine the rate so that it is
11uniform for all hospital providers subject to the assessment
12and the funds generated by the assessment are equivalent to the
13total assessment.
14    For State Fiscal Years 2021 and 2022, a hospital's
15non-Medicaid gross revenue shall be determined using the most
16recent data available from each hospital's 2017 Medicare cost
17report as contained in the Healthcare Cost Report Information
18System file, for the quarter ending on March 31, 2019, without
19regard to any subsequent adjustments or changes to such data.
20For State Fiscal Years 2023 and 2024, a hospital's non-Medicaid
21gross revenue shall be determined using the most recent data
22available from each hospital's 2019 Medicare cost report as
23contained in the Healthcare Cost Report Information System
24file, for the quarter ending on March 31, 2021, without regard
25to any subsequent adjustments or changes to such data. If a
26hospital's Medicare cost report is not contained in the

 

 

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1Healthcare Cost Report Information System or the hospital's
2Medicare cost report contains insufficient information to
3determine gross non-Medicaid inpatient or outpatient revenue,
4then the Department may obtain the hospital provider's gross
5non-Medicaid revenue from any source available, including, but
6not limited to, records maintained by the hospital provider,
7which may be inspected at all times during business hours of
8the day by the Department or its duly authorized agents and
9employees. The Department may also set any additional reporting
10requirements for Medicare cost reports as deemed necessary to
11determine non-Medicaid gross revenue inpatient and outpatient
12revenue for future fiscal years.
13    (d) Notwithstanding any of the other provisions of this
14Section, the Department is authorized to adopt rules to reduce
15the rate of any annual assessment imposed under this Section,
16as authorized by Section 5-46.2 of the Illinois Administrative
17Procedure Act.
18    (e) Notwithstanding any other provision of this Section,
19any plan providing for an assessment on a hospital provider as
20a permissible tax under Title XIX of the federal Social
21Security Act and Medicaid-eligible payments to hospital
22providers from the revenues derived from that assessment shall
23be reviewed by the Illinois Department of Healthcare and Family
24Services, as the Single State Medicaid Agency required by
25federal law, to determine whether those assessments and
26hospital provider payments meet federal Medicaid standards. If

 

 

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1the Department determines that the elements of the plan may
2meet federal Medicaid standards and a related State Medicaid
3Plan Amendment is prepared in a manner and form suitable for
4submission, that State Plan Amendment shall be submitted in a
5timely manner for review by the Centers for Medicare and
6Medicaid Services of the United States Department of Health and
7Human Services and subject to approval by the Centers for
8Medicare and Medicaid Services of the United States Department
9of Health and Human Services. No such plan shall become
10effective without approval by the Illinois General Assembly by
11the enactment into law of related legislation. Notwithstanding
12any other provision of this Section, the Department is
13authorized to adopt rules to reduce the rate of any annual
14assessment imposed under this Section. Any such rules may be
15adopted by the Department under Section 5-50 of the Illinois
16Administrative Procedure Act.
17(Source: P.A. 100-581, eff. 3-12-18; 101-10, eff. 6-5-19.)
 
18    (305 ILCS 5/5A-12.6)
19    (Section scheduled to be repealed on July 1, 2020)
20    Sec. 5A-12.6. Continuation of hospital access payments on
21or after July 1, 2018.
22    (a) To preserve and improve access to hospital services,
23for hospital services rendered on or after July 1, 2018 the
24Department shall, except for hospitals described in subsection
25(b) of Section 5A-3, make payments to hospitals as set forth in

 

 

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1this Section. Payments under this Section are not due and
2payable, however, until (i) the methodologies described in this
3Section are approved by the federal government in an
4appropriate State Plan amendment and (ii) the assessment
5imposed under this Article is determined to be a permissible
6tax under Title XIX of the Social Security Act. In determining
7the hospital access payments authorized under subsections (f)
8through (n) of this Section, unless otherwise specified, only
9Illinois hospitals shall be eligible for a payment and total
10Medicaid utilization statistics shall be used to determine the
11payment amount. In determining the hospital access payments
12authorized under subsection (d) and subsections (f) through (l)
13of this Section, if a hospital ceases to receive payments from
14the pool, the payments for all hospitals continuing to receive
15payments from such pool shall be uniformly adjusted to fully
16expend the aggregate amount of the pool, with such adjustment
17being effective on the first day of the second month following
18the date the hospital ceases to receive payments from such
19pool.
20    (b) Phase in of funds to claims-based payments and updates.
21To ensure access to hospital services, the Department may only
22use funds financed by the assessment authorized under Section
235A-2 to increase claims-based payment rates, including
24applicable policy add-on payments or adjusters, in accordance
25with this subsection. Starting in State Fiscal Year 2021, to To
26increase the claims-based payment rates up to the amounts

 

 

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1specified in this subsection, the Department shall, by rule,
2reduce to zero any of the hospital access payments authorized
3in subsections (d) through (l) that it finds do not serve the
4purposes of ensuring equitable access to hospital services for
5recipients under the Medical Assistance Program by supporting
6hospitals in areas of greatest health need and areas most
7adversely affected by health disparities. Following this, the
8remaining hospital access payments authorized in the hospital
9access payments authorized in subsection (d) and subsections
10(g) through (l) of this Section shall be uniformly reduced.
11        (1) For State fiscal years 2019 and 2020, up to
12    $635,000,000 of the total spending financed from the
13    assessment authorized under Section 5A-2 that is intended
14    to pay for hospital services and the hospital supplemental
15    access payments authorized under subsections (d) and (f) of
16    Section 14-12 for payment in State fiscal year 2018 may be
17    used to increase claims-based hospital payment rates as
18    specified under Section 14-12.
19        (2) For State fiscal years 2021 and 2022, up to
20    $1,696,000,000 $1,164,000,000 of the total spending
21    financed from the assessment authorized under Section 5A-2
22    that is intended to pay for hospital services and the
23    hospital supplemental access payments authorized under
24    subsections (d) and (f) of Section 14-12 for payment in
25    State Fiscal Year 2018 may be used to increase claims-based
26    hospital payment rates as specified under Section 14-12.

 

 

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1        (3) (Blank). For State fiscal years 2023, up to
2    $1,397,000,000 of the total spending financed from the
3    assessment authorized under Section 5A-2 that is intended
4    to pay for hospital services and the hospital supplemental
5    access payments authorized under subsections (d) and (f) of
6    Section 14-12 for payment in State Fiscal Year 2018 may be
7    used to increase claims-based hospital payment rates as
8    specified under Section 14-12.
9        (4) (Blank). For State fiscal years 2024, up to
10    $1,663,000,000 of the total spending financed from the
11    assessment authorized under Section 5A-2 that is intended
12    to pay for hospital services and the hospital supplemental
13    access payments authorized under subsections (d) and (f) of
14    Section 14-12 for payment in State Fiscal Year 2018 may be
15    used to increase claims-based hospital payment rates as
16    specified under Section 14-12.
17        (5) Beginning in State fiscal year 2021, and at least
18    every 24 months thereafter, the Department shall, by rule,
19    update the hospital access payments authorized under this
20    Section to take into account the amount of funds being used
21    to increase claims-based hospital payment rates under
22    Section 14-12 and to apply the most recently available data
23    and information, including data from the most recent base
24    year and qualifying criteria which shall correlate to the
25    updated base year data, to determine a hospital's
26    eligibility for each payment and the amount of the payment

 

 

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1    authorized under this Section. Any updates of the hospital
2    access payment methodologies shall not result in any
3    diminishment of the aggregate amount of hospital access
4    payment expenditures, except for reductions attributable
5    to the use of such funds to increase claims-based hospital
6    payment rates as authorized by this Section. Nothing in
7    this Section shall be construed as precluding variations in
8    the amount of any individual hospital's access payments.
9    The Department shall publish the proposed rules to update
10    the hospital access payments at least 90 days before their
11    proposed effective date. The proposed rules shall not be
12    adopted using emergency rulemaking authority. The
13    Department shall notify each hospital, in writing, of the
14    impact of these updates on the hospital at least 30
15    calendar days prior to their effective date.
16    For purposes of this subsection, "health disparities"
17means preventable differences in the burden of disease, injury,
18violence, or opportunities to achieve optimal health that are
19experienced by socially disadvantaged populations.
20    (c) The hospital access payments authorized under
21subsections (d) through (n) of this Section shall be paid in 12
22equal installments on or before the seventh State business day
23of each month, except that no payment shall be due within 100
24days after the later of the date of notification of federal
25approval of the payment methodologies required under this
26Section or any waiver required under 42 CFR 433.68, at which

 

 

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1time the sum of amounts required under this Section prior to
2the date of notification is due and payable. Payments under
3this Section are not due and payable, however, until (i) the
4methodologies described in this Section are approved by the
5federal government in an appropriate State Plan amendment and
6(ii) the assessment imposed under this Article is determined to
7be a permissible tax under Title XIX of the Social Security
8Act. The Department may, when practicable, accelerate the
9schedule upon which payments authorized under this Section are
10made.
11    (d) Rate increase-based adjustment.
12        (1) From the funds financed by the assessment
13    authorized under Section 5A-2, individual funding pools by
14    category of service shall be established, for Inpatient
15    General Acute Care services in the amount of $268,051,572,
16    Inpatient Rehab Care services in the amount of $24,500,610,
17    Inpatient Psychiatric Care service in the amount of
18    $94,617,812, and Outpatient Care Services in the amount of
19    $328,828,641.
20        (2) Each Illinois hospital and other hospitals
21    authorized under this subsection, except for long-term
22    acute care hospitals and public hospitals, shall be
23    assigned a pool allocation percentage for each category of
24    service that is equal to the ratio of the hospital's
25    estimated FY2019 claims-based payments including all
26    applicable FY2019 policy adjusters, multiplied by the

 

 

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1    applicable service credit factor for the hospital, divided
2    by the total of the FY2019 claims-based payments including
3    all FY2019 policy adjusters for each category of service
4    adjusted by each hospital's applicable service credit
5    factor for all qualified hospitals. For each category of
6    service, a hospital shall receive a supplemental payment
7    equal to its pool allocation percentage multiplied by the
8    total pool amount.
9        (3) Effective July 1, 2018, for purposes of determining
10    for State fiscal years 2019 and 2020 the hospitals eligible
11    for the payments authorized under this subsection, the
12    Department shall include children's hospitals located in
13    St. Louis that are designated a Level III perinatal center
14    by the Department of Public Health and also designated a
15    Level I pediatric trauma center by the Department of Public
16    Health as of December 1, 2017.
17        (4) As used in this subsection, "service credit factor"
18    is determined based on a hospital's Rate Year 2017 Medicaid
19    inpatient utilization rate ("MIUR") rounded to the nearest
20    whole percentage, as follows:
21            (A) Tier 1: A hospital with a MIUR equal to or
22        greater than 60% shall have a service credit factor of
23        200%.
24            (B) Tier 2: A hospital with a MIUR equal to or
25        greater than 33% but less than 60% shall have a service
26        credit factor of 100%.

 

 

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1            (C) Tier 3: A hospital with a MIUR equal to or
2        greater than 20% but less than 33% shall have a service
3        credit factor of 50%.
4            (D) Tier 4: A hospital with a MIUR less than 20%
5        shall have a service credit factor of 10%.
6    (e) Graduate medical education.
7        (1) The calculation of graduate medical education
8    payments shall be based on the hospital's Medicare cost
9    report ending in Calendar Year 2015, as reported in
10    Medicare cost reports released on October 19, 2016 with
11    data through September 30, 2016. An Illinois hospital
12    reporting intern and resident cost on its Medicare cost
13    report shall be eligible for graduate medical education
14    payments.
15        (2) Each hospital's annualized Medicaid Intern
16    Resident Cost is calculated using annualized intern and
17    resident total costs obtained from Worksheet B Part I,
18    Column 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
19    96-98, and 105-112 multiplied by the percentage that the
20    hospital's Medicaid days (Worksheet S3 Part I, Column 7,
21    Lines 14 and 16-18) comprise of the hospital's total days
22    (Worksheet S3 Part I, Column 8, Lines 14 and 16-18).
23        (3) An annualized Medicaid indirect medical education
24    (IME) payment is calculated for each hospital using its IME
25    payments (Worksheet E Part A, Line 29, Col 1) multiplied by
26    the percentage that its Medicaid days (Worksheet S3 Part I,

 

 

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1    Column 7, Lines 14 and 16-18) comprise of its Medicare days
2    (Worksheet S3 Part I, Column 6, Lines 14 and 16-18).
3        (4) For each hospital, its annualized Medicaid Intern
4    Resident Cost and its annualized Medicaid IME payment are
5    summed and multiplied by 33% to determine the hospital's
6    final graduate medical education payment.
7    (f) Alzheimer's treatment access payment. Each Illinois
8academic medical center or teaching hospital, as defined in
9Section 5-5e.2 of this Code, that is identified as the primary
10hospital affiliate of one of the Regional Alzheimer's Disease
11Assistance Centers, as designated by the Alzheimer's Disease
12Assistance Act and identified in the Department of Public
13Health's Alzheimer's Disease State Plan dated December 2016,
14shall be paid an Alzheimer's treatment access payment equal to
15the product of $10,000,000 multiplied by a fraction, the
16numerator of which is the qualifying hospital's Fiscal Year
172015 total admissions and the denominator of which is the
18Fiscal Year 2015 total admissions for all hospitals eligible
19for the payment.
20    (g) Safety-net hospital, private critical access hospital,
21and outpatient high volume access payment.
22        (1) Each safety-net hospital, as defined in Section
23    5-5e.1 of this Code, for Rate Year 2017 that is not
24    publicly owned shall be paid an outpatient high volume
25    access payment equal to $40,000,000 multiplied by a
26    fraction, the numerator of which is the hospital's Fiscal

 

 

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1    Year 2015 outpatient services and the denominator of which
2    is the Fiscal Year 2015 outpatient services for all
3    hospitals eligible under this paragraph for this payment.
4        (2) Each critical access hospital that is not publicly
5    owned shall be paid an outpatient high volume access
6    payment equal to $55,000,000 multiplied by a fraction, the
7    numerator of which is the hospital's Fiscal Year 2015
8    outpatient services and the denominator of which is the
9    Fiscal Year 2015 outpatient services for all hospitals
10    eligible under this paragraph for this payment.
11        (3) Each tier 1 hospital that is not publicly owned
12    shall be paid an outpatient high volume access payment
13    equal to $25,000,000 multiplied by a fraction, the
14    numerator of which is the hospital's Fiscal Year 2015
15    outpatient services and the denominator of which is the
16    Fiscal Year 2015 outpatient services for all hospitals
17    eligible under this paragraph for this payment. A tier 1
18    outpatient high volume hospital means one of the following:
19    (i) a non-publicly owned hospital, excluding a safety net
20    hospital as defined in Section 5-5e.1 of this Code for Rate
21    Year 2017, with total outpatient services, equal to or
22    greater than the regional mean plus one standard deviation
23    for all hospitals in the region but less than the mean plus
24    1.5 standard deviation; (ii) an Illinois non-publicly
25    owned hospital with total outpatient service units equal to
26    or greater than the statewide mean plus one standard

 

 

HB5280- 32 -LRB101 19340 KTG 68811 b

1    deviation; or (iii) a non-publicly owned safety net
2    hospital as defined in Section 5-5e.1 of this Code for Rate
3    Year 2017, with total outpatient services, equal to or
4    greater than the regional mean plus one standard deviation
5    for all hospitals in the region.
6        (4) Each tier 2 hospital that is not publicly owned
7    shall be paid an outpatient high volume access payment
8    equal to $25,000,000 multiplied by a fraction, the
9    numerator of which is the hospital's Fiscal Year 2015
10    outpatient services and the denominator of which is the
11    Fiscal Year 2015 outpatient services for all hospitals
12    eligible under this paragraph for this payment. A tier 2
13    outpatient high volume hospital means a non-publicly owned
14    hospital, excluding a safety-net hospital as defined in
15    Section 5-5e.1 of this Code for Rate Year 2017, with total
16    outpatient services equal to or greater than the regional
17    mean plus 1.5 standard deviations for all hospitals in the
18    region but less than the mean plus 2 standard deviations.
19        (5) Each tier 3 hospital that is not publicly owned
20    shall be paid an outpatient high volume access payment
21    equal to $58,000,000 multiplied by a fraction, the
22    numerator of which is the hospital's Fiscal Year 2015
23    outpatient services and the denominator of which is the
24    Fiscal Year 2015 outpatient services for all hospitals
25    eligible under this paragraph for this payment. A tier 3
26    outpatient high volume hospital means a non-publicly owned

 

 

HB5280- 33 -LRB101 19340 KTG 68811 b

1    hospital, excluding a safety-net hospital as defined in
2    Section 5-5e.1 of this Code for Rate Year 2017, with total
3    outpatient services equal to or greater than the regional
4    mean plus 2 standard deviations for all hospitals in the
5    region.
6    (h) Medicaid dependent or high volume hospital access
7payment.
8        (1) To qualify for a Medicaid dependent hospital access
9    payment, a hospital shall meet one of the following
10    criteria:
11            (A) Be a non-publicly owned general acute care
12        hospital that is a safety-net hospital, as defined in
13        Section 5-5e.1 of this Code, for Rate Year 2017.
14            (B) Be a pediatric hospital that is a safety net
15        hospital, as defined in Section 5-5e.1 of this Code,
16        for Rate Year 2017 and have a Medicaid inpatient
17        utilization rate equal to or greater than 50%.
18            (C) Be a general acute care hospital with a
19        Medicaid inpatient utilization rate equal to or
20        greater than 50% in Rate Year 2017.
21        (2) The Medicaid dependent hospital access payment
22    shall be determined as follows:
23            (A) Each tier 1 hospital shall be paid a Medicaid
24        dependent hospital access payment equal to $23,000,000
25        multiplied by a fraction, the numerator of which is the
26        hospital's Fiscal Year 2015 total days and the

 

 

HB5280- 34 -LRB101 19340 KTG 68811 b

1        denominator of which is the Fiscal Year 2015 total days
2        for all hospitals eligible under this subparagraph for
3        this payment. A tier 1 Medicaid dependent hospital
4        means a qualifying hospital with a Rate Year 2017
5        Medicaid inpatient utilization rate equal to or
6        greater than the statewide mean but less than the
7        statewide mean plus 0.5 standard deviation.
8            (B) Each tier 2 hospital shall be paid a Medicaid
9        dependent hospital access payment equal to $15,000,000
10        multiplied by a fraction, the numerator of which is the
11        hospital's Fiscal Year 2015 total days and the
12        denominator of which is the Fiscal Year 2015 total days
13        for all hospitals eligible under this subparagraph for
14        this payment. A tier 2 Medicaid dependent hospital
15        means a qualifying hospital with a Rate Year 2017
16        Medicaid inpatient utilization rate equal to or
17        greater than the statewide mean plus 0.5 standard
18        deviations but less than the statewide mean plus one
19        standard deviation.
20            (C) Each tier 3 hospital shall be paid a Medicaid
21        dependent hospital access payment equal to $15,000,000
22        multiplied by a fraction, the numerator of which is the
23        hospital's Fiscal Year 2015 total days and the
24        denominator of which is the Fiscal Year 2015 total days
25        for all hospitals eligible under this subparagraph for
26        this payment. A tier 3 Medicaid dependent hospital

 

 

HB5280- 35 -LRB101 19340 KTG 68811 b

1        means a qualifying hospital with a Rate Year 2017
2        Medicaid inpatient utilization rate equal to or
3        greater than the statewide mean plus one standard
4        deviation but less than the statewide mean plus 1.5
5        standard deviations.
6            (D) Each tier 4 hospital shall be paid a Medicaid
7        dependent hospital access payment equal to $53,000,000
8        multiplied by a fraction, the numerator of which is the
9        hospital's Fiscal Year 2015 total days and the
10        denominator of which is the Fiscal Year 2015 total days
11        for all hospitals eligible under this subparagraph for
12        this payment. A tier 4 Medicaid dependent hospital
13        means a qualifying hospital with a Rate Year 2017
14        Medicaid inpatient utilization rate equal to or
15        greater than the statewide mean plus 1.5 standard
16        deviations but less than the statewide mean plus 2
17        standard deviations.
18            (E) Each tier 5 hospital shall be paid a Medicaid
19        dependent hospital access payment equal to $75,000,000
20        multiplied by a fraction, the numerator of which is the
21        hospital's Fiscal Year 2015 total days and the
22        denominator of which is the Fiscal Year 2015 total days
23        for all hospitals eligible under this subparagraph for
24        this payment. A tier 5 Medicaid dependent hospital
25        means a qualifying hospital with a Rate Year 2017
26        Medicaid inpatient utilization rate equal to or

 

 

HB5280- 36 -LRB101 19340 KTG 68811 b

1        greater than the statewide mean plus 2 standard
2        deviations.
3        (3) Each Medicaid high volume hospital shall be paid a
4    Medicaid high volume access payment equal to $300,000,000
5    multiplied by a fraction, the numerator of which is the
6    hospital's Fiscal Year 2015 total admissions and the
7    denominator of which is the Fiscal Year 2015 total
8    admissions for all hospitals eligible under this paragraph
9    for this payment. A Medicaid high volume hospital means the
10    Illinois general acute care hospitals with the highest
11    number of Fiscal Year 2015 total admissions that when
12    ranked in descending order from the highest Fiscal Year
13    2015 total admissions to the lowest Fiscal Year 2015 total
14    admissions, in the aggregate, sum to at least 50% of the
15    total admissions for all such hospitals in Fiscal Year
16    2015; however, any hospital which has qualified as a
17    Medicaid dependent hospital shall not also be considered a
18    Medicaid high volume hospital.
19    (i) Perinatal care access payment.
20        (1) Each Illinois non-publicly owned hospital
21    designated a Level II or II+ perinatal center by the
22    Department of Public Health as of December 1, 2017 shall be
23    assigned a pool allocation percentage equal to a fraction,
24    the numerator of which is the hospital's Fiscal Year 2015
25    total admissions multiplied by the hospital's Medicaid
26    utilization factor and the denominator of which is the sum

 

 

HB5280- 37 -LRB101 19340 KTG 68811 b

1    of Fiscal Year 2015 admissions multiplied by Medicaid
2    utilization factor for all hospitals authorized for
3    payment under this paragraph. Each qualifying hospital
4    shall be paid an access payment equal to $200,000,000
5    multiplied by its pool allocation percentage. a fraction,
6    the numerator of which is the hospital's Fiscal Year 2015
7    total admissions and the denominator of which is the Fiscal
8    Year 2015 total admissions for all hospitals eligible under
9    this paragraph for this payment.
10        (2) Each Illinois non-publicly owned hospital
11    designated a Level III perinatal center by the Department
12    of Public Health as of December 1, 2017 shall be paid an
13    access payment equal to $100,000,000 multiplied by a
14    fraction, the numerator of which is the hospital's Fiscal
15    Year 2015 total admissions and the denominator of which is
16    the Fiscal Year 2015 total admissions for all hospitals
17    eligible under this paragraph for this payment.
18        (3) As used in this subsection, "Medicaid utilization
19    factor" is equal to the square of the sum of 0.5 and the
20    hospital's rate year 2017 Medicaid inpatient utilization
21    rate.
22    (j) Trauma care access payment.
23        (1) Each Illinois non-publicly owned hospital
24    designated a Level I trauma center by the Department of
25    Public Health as of December 1, 2017 shall be paid an
26    access payment equal to $160,000,000 multiplied by a

 

 

HB5280- 38 -LRB101 19340 KTG 68811 b

1    fraction, the numerator of which is the hospital's Fiscal
2    Year 2015 total admissions and the denominator of which is
3    the Fiscal Year 2015 total admissions for all hospitals
4    eligible under this paragraph for this payment.
5        (2) Each Illinois non-publicly owned hospital
6    designated a Level II trauma center by the Department of
7    Public Health as of December 1, 2017 shall be assigned a
8    pool allocation percentage equal to a fraction, the
9    numerator of which is the hospital's Fiscal Year 2015 total
10    admissions multiplied by the hospital's Medicaid
11    utilization factor and the denominator of which is the sum
12    of Fiscal Year 2015 admissions multiplied by the Medicaid
13    utilization factor for all hospitals authorized for
14    payment under this paragraph. Each qualifying hospital
15    shall be paid an access payment equal to $200,000,000
16    multiplied by its pool allocation percentage. a fraction,
17    the numerator of which is the hospital's Fiscal Year 2015
18    total admissions and the denominator of which is the Fiscal
19    Year 2015 total admissions for all hospitals eligible under
20    this paragraph for this payment.
21        (3) As used in this subsection, "Medicaid utilization
22    factor" is equal to the square of the sum of 0.5 and the
23    hospital's rate year 2017 Medicaid inpatient utilization
24    rate.
25    (k) Perinatal and trauma center access payment.
26        (1) Each Illinois non-publicly owned hospital

 

 

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1    designated a Level III perinatal center and a Level I or II
2    trauma center by the Department of Public Health as of
3    December 1, 2017, and that has a Rate Year 2017 Medicaid
4    inpatient utilization rate equal to or greater than 20% and
5    a calendar year 2015 occupancy ratio equal to or greater
6    than 50%, shall be paid an access payment equal to
7    $160,000,000 multiplied by a fraction, the numerator of
8    which is the hospital's Fiscal Year 2015 total admissions
9    and the denominator of which is the Fiscal Year 2015 total
10    admissions for all hospitals eligible under this paragraph
11    for this payment.
12        (2) Each Illinois non-publicly owned hospital
13    designated a Level II or II+ perinatal center and a Level I
14    or II trauma center by the Department of Public Health as
15    of December 1, 2017, and that has a Rate Year 2017 Medicaid
16    inpatient utilization rate equal to or greater than 20% and
17    a calendar year 2015 occupancy ratio equal to or greater
18    than 50%, shall be paid an access payment equal to
19    $200,000,000 multiplied by a fraction, the numerator of
20    which is the hospital's Fiscal Year 2015 total admissions
21    and the denominator of which is the Fiscal Year 2015 total
22    admissions for all hospitals eligible under this paragraph
23    for this payment.
24    (l) Long-term acute care access payment. Each Illinois
25non-publicly owned long-term acute care hospital that has a
26Rate Year 2017 Medicaid inpatient utilization rate equal to or

 

 

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1greater than 25% and a calendar year 2015 occupancy ratio equal
2to or greater than 60% shall be paid an access payment equal to
3$19,000,000 multiplied by a fraction, the numerator of which is
4the hospital's Fiscal Year 2015 general acute care admissions
5and the denominator of which is the Fiscal Year 2015 general
6acute care admissions for all hospitals eligible under this
7subsection for this payment.
8    (m) Small public hospital access payment.
9        (1) As used in this subsection, "small public hospital"
10    means any Illinois publicly owned hospital which is not a
11    "large public hospital" as described in 89 Ill. Adm. Code
12    148.25(a).
13        (2) Each small public hospital shall be paid an
14    inpatient access payment equal to $2,825,000 multiplied by
15    a fraction, the numerator of which is the hospital's Fiscal
16    Year 2015 total days and the denominator of which is the
17    Fiscal Year 2015 total days for all hospitals under this
18    paragraph for this payment.
19        (3) Each small public hospital shall be paid an
20    outpatient access payment equal to $24,000,000 multiplied
21    by a fraction, the numerator of which is the hospital's
22    Fiscal Year 2015 outpatient services and the denominator of
23    which is the Fiscal Year 2015 outpatient services for all
24    hospitals eligible under this paragraph for this payment.
25    (n) Psychiatric care access payment. In addition to rates
26paid for inpatient psychiatric services, the Illinois

 

 

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1Department shall, by rule, establish an access payment for
2inpatient hospital psychiatric services that shall, in the
3aggregate, spend approximately $61,141,188 annually. In
4consultation with the hospital community, the Department may,
5by rule, incorporate the funds used for this access payment to
6increase the payment rates for inpatient psychiatric services,
7except that such changes shall not take effect before July 1,
82019. Upon incorporation into the claims payment rates, this
9access payment shall be repealed. Beginning July 1, 2018, for
10purposes of determining for State fiscal years 2019 and 2020
11the hospitals eligible for the payments authorized under this
12subsection, the Department shall include out-of-state
13hospitals that are designated a Level I pediatric trauma center
14or a Level I trauma center by the Department of Public Health
15as of December 1, 2017.
16    (o) For purposes of this Section, a hospital that is
17enrolled to provide Medicaid services during State fiscal year
182015 shall have its utilization and associated reimbursements
19annualized prior to the payment calculations being performed
20under this Section.
21    (p) Definitions. As used in this Section, unless the
22context requires otherwise:
23    "General acute care admissions" means, for a given
24hospital, the sum of inpatient hospital admissions provided to
25recipients of medical assistance under Title XIX of the Social
26Security Act for general acute care, excluding admissions for

 

 

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1individuals eligible for Medicare under Title XVIII of the
2Social Security Act (Medicaid/Medicare crossover admissions),
3as tabulated from the Department's paid claims data for general
4acute care admissions occurring during State fiscal year 2015
5that was adjudicated by the Department through October 28,
62016.
7    "Occupancy ratio" is determined utilizing the IDPH
8Hospital Profile CY15 - Facility Utilization Data - Source 2015
9Annual Hospital Questionnaire. Utilizes all beds and days
10including observation days but excludes Long Term Care and
11Swing bed and their associated beds and days.
12    "Outpatient services" means, for a given hospital, the sum
13of the number of outpatient encounters identified as unique
14services provided to recipients of medical assistance under
15Title XIX of the Social Security Act for general acute care,
16psychiatric care, and rehabilitation care, excluding
17outpatient services for individuals eligible for Medicare
18under Title XVIII of the Social Security Act (Medicaid/Medicare
19crossover services), as tabulated from the Department's paid
20claims data for outpatient services occurring during State
21fiscal year 2015 that was adjudicated by the Department through
22October 28, 2016.
23    "Total days" means, for a given hospital, the sum of
24inpatient hospital days provided to recipients of medical
25assistance under Title XIX of the Social Security Act for
26general acute care, psychiatric care, and rehabilitation care,

 

 

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1excluding days for individuals eligible for Medicare under
2Title XVIII of the Social Security Act (Medicaid/Medicare
3crossover days), as tabulated from the Department's paid claims
4data for total days occurring during State fiscal year 2015
5that was adjudicated by the Department through October 28,
62016.
7    "Total admissions" means, for a given hospital, the sum of
8inpatient hospital admissions provided to recipients of
9medical assistance under Title XIX of the Social Security Act
10for general acute care, psychiatric care, and rehabilitation
11care, excluding admissions for individuals eligible for
12Medicare under Title XVIII of that Act (Medicaid/Medicare
13crossover admissions), as tabulated from the Department's paid
14claims data for admissions occurring during State fiscal year
152015 that was adjudicated by the Department through October 28,
162016.
17    (q) Notwithstanding any of the other provisions of this
18Section, the Department is authorized to adopt rules that
19change the hospital access payments specified in this Section,
20but only to the extent necessary to conform to any federally
21approved amendment to the Title XIX State Plan. Any such rules
22shall be adopted by the Department as authorized by Section
235-50 of the Illinois Administrative Procedure Act.
24Notwithstanding any other provision of law, any changes
25implemented as a result of this subsection (q) shall be given
26retroactive effect so that they shall be deemed to have taken

 

 

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1effect as of the effective date of this amendatory Act of the
2100th General Assembly.
3    (r)(1) On or after July 1, 2018, and no less than annually
4thereafter, the Department shall calculate increased increase
5capitation payments to capitated managed care organizations
6(MCOs) to equal the aggregate reduction of payments made in
7this Section to preserve access to hospital services for
8recipients under the Medical Assistance Program. The
9calculated aggregate amount of all increased capitation
10payments to all MCOs for a fiscal year shall at least be the
11amount needed to avoid reduction in payments authorized under
12Section 5A-15.
13    (2) On or after July 1, 2018, and no less than annually
14thereafter until the changes described in paragraph (3) are
15implemented, the Department shall increase capitation payments
16to MCOs by the amount calculated under paragraph (1). Payments
17to MCOs under this Section shall be consistent with actuarial
18certification and shall be published by the Department each
19year. Managed care organizations and hospitals (including
20through their representative organizations), shall develop and
21implement methodologies and rates for payments that will
22preserve and improve access to hospital services for recipients
23in furtherance of the State's public policy to ensure equal
24access to covered services to recipients under the Medical
25Assistance Program. The Department shall make available, on a
26monthly basis, a report of the capitation payments that are

 

 

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1made to each MCO, including the number of enrollees for which
2such payment is made, the per enrollee amount of the payment,
3and any adjustments that have been made. Payments to MCOs that
4would be paid consistent with actuarial certification and
5enrollment in the absence of the increased capitation payments
6under this Section shall not be reduced as a consequence of
7payments made under this subsection.
8    (3) Following the effective date of this amendatory Act of
9the 101st General Assembly, contracts between the Department
10and MCOs for subsequent plan years shall require MCOs to pass
11through the payment amounts in accordance with this Section
12reduced and added up to the aggregate amount calculated under
13paragraph (1), in conformance with 42 CFR 438.6. Each MCO shall
14submit to the Department and the Department shall make
15available, on a quarterly basis, a report of each payment to a
16hospital in accordance with this paragraph.
17    (4) As used in this subsection, "MCO" means an entity which
18contracts with the Department to provide services where payment
19for medical services is made on a capitated basis.
20(Source: P.A. 100-581, eff. 3-12-18.)
 
21    (305 ILCS 5/5A-14)
22    Sec. 5A-14. Repeal of assessments and disbursements.
23    (a) Section 5A-2 is repealed on July 1, 2022 2020.
24    (b) Section 5A-12 is repealed on July 1, 2005.
25    (c) Section 5A-12.1 is repealed on July 1, 2008.

 

 

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1    (d) Section 5A-12.2 and Section 5A-12.4 are repealed on
2July 1, 2018, subject to Section 5A-16.
3    (e) Section 5A-12.3 is repealed on July 1, 2011.
4    (f) Section 5A-12.6 is repealed on July 1, 2022 2020.
5(Source: P.A. 100-581, eff. 3-12-18.)
 
6    (305 ILCS 5/14-12)
7    Sec. 14-12. Hospital rate reform payment system. The
8hospital payment system pursuant to Section 14-11 of this
9Article shall be as follows:
10    (a) Inpatient hospital services. Effective for discharges
11on and after July 1, 2014, reimbursement for inpatient general
12acute care services shall utilize the All Patient Refined
13Diagnosis Related Grouping (APR-DRG) software, version 30,
14distributed by 3MTM Health Information System.
15        (1) The Department shall establish Medicaid weighting
16    factors to be used in the reimbursement system established
17    under this subsection. Initial weighting factors shall be
18    the weighting factors as published by 3M Health Information
19    System, associated with Version 30.0 adjusted for the
20    Illinois experience.
21        (2) The Department shall establish a
22    statewide-standardized amount to be used in the inpatient
23    reimbursement system. The Department shall publish these
24    amounts on its website no later than 10 calendar days prior
25    to their effective date.

 

 

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1        (3) In addition to the statewide-standardized amount,
2    the Department shall develop adjusters to adjust the rate
3    of reimbursement for critical Medicaid providers or
4    services for trauma, transplantation services, perinatal
5    care, and Graduate Medical Education (GME).
6        (4) The Department shall develop add-on payments to
7    account for exceptionally costly inpatient stays,
8    consistent with Medicare outlier principles. Outlier fixed
9    loss thresholds may be updated to control for excessive
10    growth in outlier payments no more frequently than on an
11    annual basis, but at least triennially. Upon updating the
12    fixed loss thresholds, the Department shall be required to
13    update base rates within 12 months.
14        (5) The Department shall define those hospitals or
15    distinct parts of hospitals that shall be exempt from the
16    APR-DRG reimbursement system established under this
17    Section. The Department shall publish these hospitals'
18    inpatient rates on its website no later than 10 calendar
19    days prior to their effective date.
20        (6) Beginning July 1, 2014 and ending on June 30, 2024,
21    in addition to the statewide-standardized amount, the
22    Department shall develop an adjustor to adjust the rate of
23    reimbursement for safety-net hospitals defined in Section
24    5-5e.1 of this Code excluding pediatric hospitals.
25        (7) Beginning July 1, 2014 and ending on June 30, 2020,
26    or upon implementation of inpatient psychiatric rate

 

 

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1    increases as described in subsection (n) of Section
2    5A-12.6, in addition to the statewide-standardized amount,
3    the Department shall develop an adjustor to adjust the rate
4    of reimbursement for Illinois freestanding inpatient
5    psychiatric hospitals that are not designated as
6    children's hospitals by the Department but are primarily
7    treating patients under the age of 21.
8        (7.5) (Blank). Beginning July 1, 2020, the
9    reimbursement for inpatient psychiatric services shall be
10    so that base claims projected reimbursement is increased by
11    an amount equal to the funds allocated in paragraph (2) of
12    subsection (b) of Section 5A-12.6, less the amount
13    allocated under paragraphs (8) and (9) of this subsection
14    and paragraphs (3) and (4) of subsection (b) multiplied by
15    13%. Beginning July 1, 2022, the reimbursement for
16    inpatient psychiatric services shall be so that base claims
17    projected reimbursement is increased by an amount equal to
18    the funds allocated in paragraph (3) of subsection (b) of
19    Section 5A-12.6, less the amount allocated under
20    paragraphs (8) and (9) of this subsection and paragraphs
21    (3) and (4) of subsection (b) multiplied by 13%. Beginning
22    July 1, 2024, the reimbursement for inpatient psychiatric
23    services shall be so that base claims projected
24    reimbursement is increased by an amount equal to the funds
25    allocated in paragraph (4) of subsection (b) of Section
26    5A-12.6, less the amount allocated under paragraphs (8) and

 

 

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1    (9) of this subsection and paragraphs (3) and (4) of
2    subsection (b) multiplied by 13%.
3        (8) Beginning July 1, 2018, in addition to the
4    statewide-standardized amount, the Department shall adjust
5    the rate of reimbursement for hospitals designated by the
6    Department of Public Health as a Perinatal Level II or II+
7    center by applying the same adjustor that is applied to
8    Perinatal and Obstetrical care cases for Perinatal Level
9    III centers, as of December 31, 2017.
10        (9) Beginning July 1, 2018, in addition to the
11    statewide-standardized amount, the Department shall apply
12    the same adjustor that is applied to trauma cases as of
13    December 31, 2017 to inpatient claims to treat patients
14    with burns, including, but not limited to, APR-DRGs 841,
15    842, 843, and 844.
16        (10) Beginning July 1, 2018, the
17    statewide-standardized amount for inpatient general acute
18    care services shall be uniformly increased so that base
19    claims projected reimbursement is increased by an amount
20    equal to the funds allocated in paragraph (1) of subsection
21    (b) of Section 5A-12.6, less the amount allocated under
22    paragraphs (8)and (9) of this subsection and paragraphs (3)
23    and (4) of subsection (b) multiplied by 40%. Beginning July
24    1, 2020, the statewide-standardized amount for inpatient
25    general acute care services shall be uniformly increased so
26    that base claims projected reimbursement is increased by an

 

 

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1    amount equal to the funds allocated in paragraph (2) of
2    subsection (b) of Section 5A-12.6, less the amount
3    allocated under paragraphs (8), (9), (12), and (13) and (9)
4    of this subsection and paragraphs (3) and (4) of subsection
5    (b) multiplied by 40%. Beginning July 1, 2022, the
6    statewide-standardized amount for inpatient general acute
7    care services shall be uniformly increased so that base
8    claims projected reimbursement is increased by an amount
9    equal to the funds allocated in paragraph (3) of subsection
10    (b) of Section 5A-12.6, less the amount allocated under
11    paragraphs (8) and (9) of this subsection and paragraphs
12    (3) and (4) of subsection (b) multiplied by 40%. Beginning
13    July 1, 2023 the statewide-standardized amount for
14    inpatient general acute care services shall be uniformly
15    increased so that base claims projected reimbursement is
16    increased by an amount equal to the funds allocated in
17    paragraph (4) of subsection (b) of Section 5A-12.6, less
18    the amount allocated under paragraphs (8) and (9) of this
19    subsection and paragraphs (3) and (4) of subsection (b)
20    multiplied by 40%.
21        (11) Beginning July 1, 2018, the reimbursement for
22    inpatient rehabilitation services shall be increased by
23    the addition of a $96 per day add-on.
24        Beginning July 1, 2020, the reimbursement for
25    inpatient rehabilitation services shall be uniformly
26    increased so that the $96 per day add-on is increased by an

 

 

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1    amount equal to the funds allocated in paragraph (2) of
2    subsection (b) of Section 5A-12.6, less the amount
3    allocated under paragraphs (8) and (9) of this subsection
4    and paragraphs (3) and (4) of subsection (b) multiplied by
5    0.9%.
6        Beginning July 1, 2022, the reimbursement for
7    inpatient rehabilitation services shall be uniformly
8    increased so that the $96 per day add-on as adjusted by the
9    July 1, 2020 increase, is increased by an amount equal to
10    the funds allocated in paragraph (3) of subsection (b) of
11    Section 5A-12.6, less the amount allocated under
12    paragraphs (8) and (9) of this subsection and paragraphs
13    (3) and (4) of subsection (b) multiplied by 0.9%.
14        Beginning July 1, 2023, the reimbursement for
15    inpatient rehabilitation services shall be uniformly
16    increased so that the $96 per day add-on as adjusted by the
17    July 1, 2022 increase, is increased by an amount equal to
18    the funds allocated in paragraph (4) of subsection (b) of
19    Section 5A-12.6, less the amount allocated under
20    paragraphs (8) and (9) of this subsection and paragraphs
21    (3) and (4) of subsection (b) multiplied by 0.9%.
22        (12) By July 1, 2020, the Department shall, by rule,
23    put in place reimbursement increases for inpatient
24    services targeted to serve the purposes of ensuring
25    equitable access to hospital services for recipients under
26    the Medical Assistance Program by supporting hospitals in

 

 

HB5280- 52 -LRB101 19340 KTG 68811 b

1    areas of greatest health need and areas most adversely
2    affected by health disparities. To achieve these purposes,
3    the Department shall identify classes of hospitals to which
4    uniform amount rate increases shall be directed. The amount
5    shall be set so that base claims projected reimbursement is
6    increased by an amount equal to $1,000,000,000 of the funds
7    allocated in paragraph (2) of subsection (b) of Section
8    5A-12.6.
9        (13) Beginning July 1, 2020, the reimbursement for
10    inpatient psychiatric services to non-publicly owned
11    general acute care hospitals shall be increased by a
12    uniform dollar amount so that base claims projected
13    reimbursement is increased by an amount equal to
14    $61,000,000 of the funds allocated in paragraph (2) of
15    subsection (b) of Section 5A-12.6.
16    For purposes of this subsection, "health disparities"
17means preventable differences in the burden of disease, injury,
18violence, or opportunities to achieve optimal health that are
19experienced by socially disadvantaged populations.
20    (b) Outpatient hospital services. Effective for dates of
21service on and after July 1, 2014, reimbursement for outpatient
22services shall utilize the Enhanced Ambulatory Procedure
23Grouping (EAPG) software, version 3.7 distributed by 3MTM
24Health Information System.
25        (1) The Department shall establish Medicaid weighting
26    factors to be used in the reimbursement system established

 

 

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1    under this subsection. The initial weighting factors shall
2    be the weighting factors as published by 3M Health
3    Information System, associated with Version 3.7.
4        (2) The Department shall establish service specific
5    statewide-standardized amounts to be used in the
6    reimbursement system.
7            (A) The initial statewide standardized amounts,
8        with the labor portion adjusted by the Calendar Year
9        2013 Medicare Outpatient Prospective Payment System
10        wage index with reclassifications, shall be published
11        by the Department on its website no later than 10
12        calendar days prior to their effective date.
13            (B) The Department shall establish adjustments to
14        the statewide-standardized amounts for each Critical
15        Access Hospital, as designated by the Department of
16        Public Health in accordance with 42 CFR 485, Subpart F.
17        For outpatient services provided on or before June 30,
18        2018, the EAPG standardized amounts are determined
19        separately for each critical access hospital such that
20        simulated EAPG payments using outpatient base period
21        paid claim data plus payments under Section 5A-12.4 of
22        this Code net of the associated tax costs are equal to
23        the estimated costs of outpatient base period claims
24        data with a rate year cost inflation factor applied.
25        (3) In addition to the statewide-standardized amounts,
26    the Department shall develop adjusters to adjust the rate

 

 

HB5280- 54 -LRB101 19340 KTG 68811 b

1    of reimbursement for critical Medicaid hospital outpatient
2    providers or services, including outpatient high volume or
3    safety-net hospitals. Beginning July 1, 2018, the
4    outpatient high volume adjustor shall be increased to
5    increase annual expenditures associated with this adjustor
6    by $79,200,000, based on the State Fiscal Year 2015 base
7    year data and this adjustor shall apply to public
8    hospitals, except for large public hospitals, as defined
9    under 89 Ill. Adm. Code 148.25(a).
10        (4) Beginning July 1, 2018, in addition to the
11    statewide standardized amounts, the Department shall make
12    an add-on payment for outpatient expensive devices and
13    drugs. This add-on payment shall at least apply to claim
14    lines that: (i) are assigned with one of the following
15    EAPGs: 490, 1001 to 1020, and coded with one of the
16    following revenue codes: 0274 to 0276, 0278; or (ii) are
17    assigned with one of the following EAPGs: 430 to 441, 443,
18    444, 460 to 465, 495, 496, 1090. The add-on payment shall
19    be calculated as follows: the claim line's covered charges
20    multiplied by the hospital's total acute cost to charge
21    ratio, less the claim line's EAPG payment plus $1,000,
22    multiplied by 0.8.
23        (5) Beginning July 1, 2018, the statewide-standardized
24    amounts for outpatient services shall be increased by a
25    uniform percentage so that base claims projected
26    reimbursement is increased by an amount equal to no less

 

 

HB5280- 55 -LRB101 19340 KTG 68811 b

1    than the funds allocated in paragraph (1) of subsection (b)
2    of Section 5A-12.6, less the amount allocated under
3    paragraphs (8)and (9) of subsection (a) and paragraphs (3)
4    and (4) of this subsection multiplied by 46%. Beginning
5    July 1, 2020, the statewide-standardized amounts for
6    outpatient services shall be increased by a uniform
7    percentage so that base claims projected reimbursement is
8    increased by an amount equal to no less than the funds
9    allocated in paragraph (2) of subsection (b) of Section
10    5A-12.6, less the amount allocated under paragraphs (8),
11    (9), (12), and (13) and (9) of subsection (a) and
12    paragraphs (3) and (4) of this subsection multiplied by
13    46%. Beginning July 1, 2022, the statewide-standardized
14    amounts for outpatient services shall be increased by a
15    uniform percentage so that base claims projected
16    reimbursement is increased by an amount equal to the funds
17    allocated in paragraph (3) of subsection (b) of Section
18    5A-12.6, less the amount allocated under paragraphs (8) and
19    (9) of subsection (a) and paragraphs (3) and (4) of this
20    subsection multiplied by 46%. Beginning July 1, 2023, the
21    statewide-standardized amounts for outpatient services
22    shall be increased by a uniform percentage so that base
23    claims projected reimbursement is increased by an amount
24    equal to no less than the funds allocated in paragraph (4)
25    of subsection (b) of Section 5A-12.6, less the amount
26    allocated under paragraphs (8) and (9) of subsection (a)

 

 

HB5280- 56 -LRB101 19340 KTG 68811 b

1    and paragraphs (3) and (4) of this subsection multiplied by
2    46%.
3        (6) Effective for dates of service on or after July 1,
4    2018, the Department shall establish adjustments to the
5    statewide-standardized amounts for each Critical Access
6    Hospital, as designated by the Department of Public Health
7    in accordance with 42 CFR 485, Subpart F, such that each
8    Critical Access Hospital's standardized amount for
9    outpatient services shall be increased by the applicable
10    uniform percentage determined pursuant to paragraph (5) of
11    this subsection. It is the intent of the General Assembly
12    that the adjustments required under this paragraph (6) by
13    Public Act 100-1181 this amendatory Act of the 100th
14    General Assembly shall be applied retroactively to claims
15    for dates of service provided on or after July 1, 2018.
16        (7) Effective for dates of service on or after March 8,
17    2019 (the effective date of Public Act 100-1181) this
18    amendatory Act of the 100th General Assembly, the
19    Department shall recalculate and implement an updated
20    statewide-standardized amount for outpatient services
21    provided by hospitals that are not Critical Access
22    Hospitals to reflect the applicable uniform percentage
23    determined pursuant to paragraph (5).
24            (1) Any recalculation to the
25        statewide-standardized amounts for outpatient services
26        provided by hospitals that are not Critical Access

 

 

HB5280- 57 -LRB101 19340 KTG 68811 b

1        Hospitals shall be the amount necessary to achieve the
2        increase in the statewide-standardized amounts for
3        outpatient services increased by a uniform percentage,
4        so that base claims projected reimbursement is
5        increased by an amount equal to no less than the funds
6        allocated in paragraph (1) of subsection (b) of Section
7        5A-12.6, less the amount allocated under paragraphs
8        (8), (9), (12), and (13) and (9) of subsection (a) and
9        paragraphs (3) and (4) of this subsection, for all
10        hospitals that are not Critical Access Hospitals,
11        multiplied by 46%.
12            (2) It is the intent of the General Assembly that
13        the recalculations required under this paragraph (7)
14        by Public Act 100-1181 this amendatory Act of the 100th
15        General Assembly shall be applied prospectively to
16        claims for dates of service provided on or after March
17        8, 2019 (the effective date of Public Act 100-1181)
18        this amendatory Act of the 100th General Assembly and
19        that no recoupment or repayment by the Department or an
20        MCO of payments attributable to recalculation under
21        this paragraph (7), issued to the hospital for dates of
22        service on or after July 1, 2018 and before March 8,
23        2019 (the effective date of Public Act 100-1181) this
24        amendatory Act of the 100th General Assembly, shall be
25        permitted.
26        (8) The Department shall ensure that all necessary

 

 

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1    adjustments to the managed care organization capitation
2    base rates necessitated by the adjustments under
3    subparagraph (6) or (7) of this subsection are completed
4    and applied retroactively in accordance with Section
5    5-30.8 of this Code within 90 days of March 8, 2019 (the
6    effective date of Public Act 100-1181) this amendatory Act
7    of the 100th General Assembly.
8    (c) In consultation with the hospital community, the
9Department is authorized to replace 89 Ill. Admin. Code 152.150
10as published in 38 Ill. Reg. 4980 through 4986 within 12 months
11of June 16, 2014 (the effective date of Public Act 98-651). If
12the Department does not replace these rules within 12 months of
13June 16, 2014 (the effective date of Public Act 98-651), the
14rules in effect for 152.150 as published in 38 Ill. Reg. 4980
15through 4986 shall remain in effect until modified by rule by
16the Department. Nothing in this subsection shall be construed
17to mandate that the Department file a replacement rule.
18    (d) Transition period. There shall be a transition period
19to the reimbursement systems authorized under this Section that
20shall begin on the effective date of these systems and continue
21until June 30, 2018, unless extended by rule by the Department.
22To help provide an orderly and predictable transition to the
23new reimbursement systems and to preserve and enhance access to
24the hospital services during this transition, the Department
25shall allocate a transitional hospital access pool of at least
26$290,000,000 annually so that transitional hospital access

 

 

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1payments are made to hospitals.
2        (1) After the transition period, the Department may
3    begin incorporating the transitional hospital access pool
4    into the base rate structure; however, the transitional
5    hospital access payments in effect on June 30, 2018 shall
6    continue to be paid, if continued under Section 5A-16.
7        (2) After the transition period, if the Department
8    reduces payments from the transitional hospital access
9    pool, it shall increase base rates, develop new adjustors,
10    adjust current adjustors, develop new hospital access
11    payments based on updated information, or any combination
12    thereof by an amount equal to the decreases proposed in the
13    transitional hospital access pool payments, ensuring that
14    the entire transitional hospital access pool amount shall
15    continue to be used for hospital payments.
16    (d-5) Hospital transformation program. The Department, in
17conjunction with the Hospital Transformation Review Committee
18created under subsection (d-5), shall develop a hospital
19transformation program to provide financial assistance to
20hospitals in areas of greatest health need and areas most
21adversely affected by health disparities that require such
22assistance to transform or expand in transforming their
23services and care models to better meet align with the needs of
24the communities they serve. The payments authorized in this
25Section shall be subject to approval by the federal government.
26        (1) Phase 1. In State fiscal years 2019 through 2020,

 

 

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1    the Department shall allocate funds from the transitional
2    access hospital pool to create a hospital transformation
3    pool of at least $262,906,870 annually and make hospital
4    transformation payments to hospitals. Subject to Section
5    5A-16, in State fiscal years 2019 and 2020, an Illinois
6    hospital that received either a transitional hospital
7    access payment under subsection (d) or a supplemental
8    payment under subsection (f) of this Section in State
9    fiscal year 2018, shall receive a hospital transformation
10    payment as follows:
11            (A) If the hospital's Rate Year 2017 Medicaid
12        inpatient utilization rate is equal to or greater than
13        45%, the hospital transformation payment shall be
14        equal to 100% of the sum of its transitional hospital
15        access payment authorized under subsection (d) and any
16        supplemental payment authorized under subsection (f).
17            (B) If the hospital's Rate Year 2017 Medicaid
18        inpatient utilization rate is equal to or greater than
19        25% but less than 45%, the hospital transformation
20        payment shall be equal to 75% of the sum of its
21        transitional hospital access payment authorized under
22        subsection (d) and any supplemental payment authorized
23        under subsection (f).
24            (C) If the hospital's Rate Year 2017 Medicaid
25        inpatient utilization rate is less than 25%, the
26        hospital transformation payment shall be equal to 50%

 

 

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1        of the sum of its transitional hospital access payment
2        authorized under subsection (d) and any supplemental
3        payment authorized under subsection (f).
4        (2) Phase 2. In State Fiscal Year 2021, the Department
5    shall allocate the funds from the transitional access
6    hospital pool in the same manner as for Phase 1 as
7    described in paragraph (1). In addition, during State
8    Fiscal Year 2021 the Department shall prepare and make
9    available to hospitals data on health disparities for their
10    use in planning improvements by which they can address
11    negative impacts of health disparities in communities they
12    serve. In addition, during State Fiscal Year 2021, the
13    Department, in conjunction with the Hospital
14    Transformation Review Committee, shall complete a
15    stakeholder process to determine the priorities of the
16    hospital transformation program, including at a minimum
17    the following:
18            (A) The Department, in conjunction with the
19        Hospital Transformation Review Committee, shall
20        provide an opportunity for public input and formal
21        mechanism for stakeholder participation in identifying
22        priority delivery system reform and improvement
23        purposes for the transformation program based on
24        community health needs.
25            (B) The Department, in conjunction with the
26        Hospital Transformation Review Committee, shall

 

 

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1        conduct no fewer than 6 hearings for this purpose. No
2        fewer than 2 of these hearings shall be held in the
3        City of Chicago, and at least one additional hearing
4        shall be held in another location in Cook County.
5            (C) The Department shall publish a report with the
6        results of this process on its website.
7        (3) Phase 3. During State fiscal years 2021 and 2022
8    and thereafter, the Department shall allocate funds from
9    the transitional access hospital pool to create a hospital
10    transformation pool annually and make hospital
11    transformation payments from the hospital transformation
12    pool to hospitals participating in the transformation
13    program. Hospitals in areas of greatest health need and
14    areas most adversely affected by health disparities that
15    require assistance to transform or expand their services to
16    better meet the needs of communities they serve, as defined
17    in rules adopted in accordance with subparagraph (B) of
18    paragraph 4, Any hospital may seek transformation funding
19    in Phase 3, however, priority shall be given to
20    Disproportionate Share Hospitals and Critical Access
21    Hospitals 2. Any hospital that seeks transformation
22    funding in Phase 3 2 to update or repurpose the hospital's
23    physical structure to transition to a new delivery model,
24    must submit to the Department in writing a transformation
25    plan, based on the Department's guidelines, that describes
26    the changes or service expansions it seeks to make and

 

 

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1    selects process and outcome measures, from a set developed
2    by the Department, the hospital will meet through the
3    course of the transformation project; a timeline for the
4    transformation plan; as well as financial information
5    sufficient to allow the Department to determine whether the
6    changes or service expansions could occur but for
7    transformation program funding. desired delivery model
8    with projections of patient volumes by service lines and
9    projected revenues, expenses, and net income that
10    correspond to the new delivery model. In Phase 3 2, subject
11    to the approval of rules, the Department may use the
12    hospital transformation pool to increase base rates,
13    develop new adjustors, or adjust current adjustors, or
14    develop new access payments in order to support and
15    incentivize hospitals pursuing to pursue such
16    transformation. In developing such methodologies, the
17    Department shall ensure that the entire hospital
18    transformation pool continues to be expended to ensure
19    access to hospital services. The Department annually shall
20    allocate to the hospital transformation pool funds from the
21    transitional access hospital pool as set forth in paragraph
22    (1) plus $150,000,000 from the Hospital Provider Fund. or
23    to support organizations that had received hospital
24    transformation payments under this Section.
25            (A) Any hospital participating in the hospital
26        transformation program shall provide an opportunity

 

 

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1        for public input by local community groups, hospital
2        workers, and healthcare professionals and assist in
3        facilitating discussions about any transformations or
4        changes to the hospital.
5            (A-5) Any hospital that seeks to commit
6        transformation funding to capital spending shall
7        submit to the Department in writing a transformation
8        plan, based on the Department's guidelines, that
9        describes the proposed changes to the hospital's
10        physical facilities with projections of patient
11        volumes by service lines and projected revenues,
12        expenses, and net income.
13            (B) As provided in paragraph (9) of Section 3 of
14        the Illinois Health Facilities Planning Act, any
15        hospital seeking to expand services through
16        participating in the transformation program may be
17        excluded from the requirements of the Illinois Health
18        Facilities Planning Act for those projects related to
19        the hospital's transformation. To be eligible, the
20        hospital must submit to the Health Facilities and
21        Services Review Board certification from the
22        Department, approved by the Hospital Transformation
23        Review Committee, that the project is a part of the
24        hospital's transformation.
25            (C) (Blank). As provided in subsection (a-20) of
26        Section 32.5 of the Emergency Medical Services (EMS)

 

 

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1        Systems Act, a hospital that received hospital
2        transformation payments under this Section may convert
3        to a freestanding emergency center. To be eligible for
4        such a conversion, the hospital must submit to the
5        Department of Public Health certification from the
6        Department, approved by the Hospital Transformation
7        Review Committee, that the project is a part of the
8        hospital's transformation.
9        (4) By March 1, 2021 (3) By April 1, 2019 March 12,
10    2018 (Public Act 100-581) the Department, in conjunction
11    with the Hospital Transformation Review Committee, shall
12    develop and file as an administrative rule with the
13    Secretary of State the goals, objectives, policies,
14    standards, payment models, process and outcome measures,
15    or criteria to be applied in Phase 3 2 of the program to
16    allocate the hospital transformation funds. The goals,
17    objectives, and policies to be considered may include, but
18    are not limited to, reducing health disparities; achieving
19    unmet needs of a community that a hospital serves such as
20    behavioral health services, outpatient services, or drug
21    rehabilitation services; attaining certain quality or
22    patient safety benchmarks for health care services; or
23    improving the coordination, effectiveness, and efficiency
24    of care delivery. Notwithstanding any other provision of
25    law, any rule adopted in accordance with this subsection
26    (d-5) may be submitted to the Joint Committee on

 

 

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1    Administrative Rules for approval only if the rule has
2    first been approved by 9 of the 14 members of the Hospital
3    Transformation Review Committee.
4        (5) (4) Hospital Transformation Review Committee.
5    There is created the Hospital Transformation Review
6    Committee. The Committee shall consist of 14 members. No
7    later than 30 days after March 12, 2018 (the effective date
8    of Public Act 100-581), the 4 legislative leaders shall
9    each appoint 3 members; the Governor shall appoint the
10    Director of Healthcare and Family Services, or his or her
11    designee, as a member; and the Director of Healthcare and
12    Family Services shall appoint one member. Any vacancy shall
13    be filled by the applicable appointing authority within 15
14    calendar days. The members of the Committee shall select a
15    Chair and a Vice-Chair from among its members, provided
16    that the Chair and Vice-Chair cannot be appointed by the
17    same appointing authority and must be from different
18    political parties. The Chair shall have the authority to
19    establish a meeting schedule and convene meetings of the
20    Committee, and the Vice-Chair shall have the authority to
21    convene meetings in the absence of the Chair. The Committee
22    may establish its own rules with respect to meeting
23    schedule, notice of meetings, and the disclosure of
24    documents; however, the Committee shall not have the power
25    to subpoena individuals or documents and any rules must be
26    approved by 9 of the 14 members. The Committee shall

 

 

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1    perform the functions described in this Section and advise
2    and consult with the Director in the administration of this
3    Section. In addition to reviewing and approving the
4    policies, procedures, and rules for the hospital
5    transformation program, the Committee shall consider and
6    make recommendations related to qualifying criteria and
7    payment methodologies related to safety-net hospitals and
8    children's hospitals. Members of the Committee appointed
9    by the legislative leaders shall be subject to the
10    jurisdiction of the Legislative Ethics Commission, not the
11    Executive Ethics Commission, and all requests under the
12    Freedom of Information Act shall be directed to the
13    applicable Freedom of Information officer for the General
14    Assembly. The Department shall provide operational support
15    to the Committee as necessary. The Committee is dissolved
16    on April 1, 2019.
17        (6) Definitions. As used in this subsection:
18        "Managed care organization" or "MCO" means an entity
19    which contracts with the Department to provide services
20    where payment for medical services is made on a capitated
21    basis.
22        "Health disparities" mean preventable differences in
23    the burden of disease, injury, violence, or opportunities
24    to achieve optimal health that are experienced by socially
25    disadvantaged populations.
26    

 

 

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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
13that is in effect on December 31, 2017 remains in 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    (j) Out-of-state hospitals. Beginning July 1, 2018, for
24purposes of determining for State fiscal years 2019 and 2020
25the hospitals eligible for the payments authorized under
26subsections (a) and (b) of this Section, the Department shall

 

 

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1include out-of-state hospitals that are designated a Level I
2pediatric trauma center or a Level I trauma center by the
3Department of Public Health as of December 1, 2017.
4    (k) The Department shall notify each hospital and managed
5care organization, in writing, of the impact of the updates
6under this Section at least 30 calendar days prior to their
7effective date.
8(Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19;
9101-81, eff. 7-12-19; revised 7-29-19.)
 
10    Section 99. Effective date. This Act takes effect upon
11becoming law.