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Full Text of HB4543  101st General Assembly

HB4543 101ST GENERAL ASSEMBLY

  
  

 


 
101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB4543

 

Introduced 2/5/2020, by Rep. Emanuel Chris Welch - Camille Y. Lilly - LaToya Greenwood - Frances Ann Hurley

 

SYNOPSIS AS INTRODUCED:
 
See Index

    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); reimbursements for inpatient general acute care services to non-publicly owned safety net hospitals, non-publicly owned critical access hospitals, hospital providers in high-need communities, and other facilities; the allocation of funds from the transitional access hospital pool; administrative rules for data collection and payment from the health disparities pay-for-collection pool; and other matters. Amends the Illinois Administrative Procedure Act. Provides that the Department of Healthcare and Family Services shall have emergency rulemaking authority to implement the provisions of the amendatory Act concerning assessments. 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.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4543LRB101 19021 KTG 68481 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. The General Assembly finds
5that, in order to improve equitable access to hospital services
6for all Illinoisans, the hospital provider assessment and
7associated payments to hospitals from the Hospital Provider
8Fund must be reoriented toward the support of hospitals that
9are located in areas with the greatest health needs and most
10adversely affected by health disparities.
 
11    Section 5. The Illinois Administrative Procedure Act is
12amended by adding Section 5-45.1 as follows:
 
13    (5 ILCS 100/5-45.1 new)
14    Sec. 5-45.1. Emergency rulemaking; Department of
15Healthcare and Family Services. To provide for the expeditious
16and timely implementation of changes made by this amendatory
17Act of the 101st General Assembly to Sections 5A-2, 5A-12.6,
185A-14, and 14-12 of the Illinois Public Aid Code, emergency
19rules may be adopted in accordance with Section 5-45 by the
20Department of Healthcare and Family Services. The adoption of
21emergency rules authorized by Section 5-45 and this Section is
22deemed to be necessary for the public interest, safety, and

 

 

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1welfare. This Section is repealed on January 1, 2026.
 
2    Section 10. The Emergency Medical Services (EMS) Systems
3Act is amended by changing Section 32.5 as follows:
 
4    (210 ILCS 50/32.5)
5    Sec. 32.5. Freestanding Emergency Center.
6    (a) The Department shall issue an annual Freestanding
7Emergency Center (FEC) license to any facility that has
8received a permit from the Health Facilities and Services
9Review Board to establish a Freestanding Emergency Center by
10January 1, 2015, and:
11        (1) is located: (A) in a municipality with a population
12    of 50,000 or fewer inhabitants; (B) within 50 miles of the
13    hospital that owns or controls the FEC; and (C) within 50
14    miles of the Resource Hospital affiliated with the FEC as
15    part of the EMS System;
16        (2) is wholly owned or controlled by an Associate or
17    Resource Hospital, but is not a part of the hospital's
18    physical plant;
19        (3) meets the standards for licensed FECs, adopted by
20    rule of the Department, including, but not limited to:
21            (A) facility design, specification, operation, and
22        maintenance standards;
23            (B) equipment standards; and
24            (C) the number and qualifications of emergency

 

 

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1        medical personnel and other staff, which must include
2        at least one board certified emergency physician
3        present at the FEC 24 hours per day.
4        (4) limits its participation in the EMS System strictly
5    to receiving a limited number of patients by ambulance: (A)
6    according to the FEC's 24-hour capabilities; (B) according
7    to protocols developed by the Resource Hospital within the
8    FEC's designated EMS System; and (C) as pre-approved by
9    both the EMS Medical Director and the Department;
10        (5) provides comprehensive emergency treatment
11    services, as defined in the rules adopted by the Department
12    pursuant to the Hospital Licensing Act, 24 hours per day,
13    on an outpatient basis;
14        (6) provides an ambulance and maintains on site
15    ambulance services staffed with paramedics 24 hours per
16    day;
17        (7) (blank);
18        (8) complies with all State and federal patient rights
19    provisions, including, but not limited to, the Emergency
20    Medical Treatment Act and the federal Emergency Medical
21    Treatment and Active Labor Act;
22        (9) maintains a communications system that is fully
23    integrated with its Resource Hospital within the FEC's
24    designated EMS System;
25        (10) reports to the Department any patient transfers
26    from the FEC to a hospital within 48 hours of the transfer

 

 

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1    plus any other data determined to be relevant by the
2    Department;
3        (11) submits to the Department, on a quarterly basis,
4    the FEC's morbidity and mortality rates for patients
5    treated at the FEC and other data determined to be relevant
6    by the Department;
7        (12) does not describe itself or hold itself out to the
8    general public as a full service hospital or hospital
9    emergency department in its advertising or marketing
10    activities;
11        (13) complies with any other rules adopted by the
12    Department under this Act that relate to FECs;
13        (14) passes the Department's site inspection for
14    compliance with the FEC requirements of this Act;
15        (15) submits a copy of the permit issued by the Health
16    Facilities and Services Review Board indicating that the
17    facility has complied with the Illinois Health Facilities
18    Planning Act with respect to the health services to be
19    provided at the facility;
20        (16) submits an application for designation as an FEC
21    in a manner and form prescribed by the Department by rule;
22    and
23        (17) pays the annual license fee as determined by the
24    Department by rule.
25    (a-5) Notwithstanding any other provision of this Section,
26the Department may issue an annual FEC license to a facility

 

 

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1that is located in a county that does not have a licensed
2general acute care hospital if the facility's application for a
3permit from the Illinois Health Facilities Planning Board has
4been deemed complete by the Department of Public Health by
5January 1, 2014 and if the facility complies with the
6requirements set forth in paragraphs (1) through (17) of
7subsection (a).
8    (a-10) Notwithstanding any other provision of this
9Section, the Department may issue an annual FEC license to a
10facility if the facility has, by January 1, 2014, filed a
11letter of intent to establish an FEC and if the facility
12complies with the requirements set forth in paragraphs (1)
13through (17) of subsection (a).
14    (a-15) Notwithstanding any other provision of this
15Section, the Department shall issue an annual FEC license to a
16facility if the facility: (i) discontinues operation as a
17hospital within 180 days after December 4, 2015 (the effective
18date of Public Act 99-490) this amendatory Act of the 99th
19General Assembly with a Health Facilities and Services Review
20Board project number of E-017-15; (ii) has an application for a
21permit to establish an FEC from the Health Facilities and
22Services Review Board that is deemed complete by January 1,
232017; and (iii) complies with the requirements set forth in
24paragraphs (1) through (17) of subsection (a) of this Section.
25    (a-20) (Blank). Notwithstanding any other provision of
26this Section, the Department shall issue an annual FEC license

 

 

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1to a facility if:
2        (1) the facility is a hospital that has discontinued
3    inpatient hospital services;
4        (2) the Department of Healthcare and Family Services
5    has 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;
9        (3) the facility complies with the requirements set
10    forth in paragraphs (1) through (17), provided however that
11    the FEC may be located in a municipality with a population
12    greater than 50,000 inhabitants and shall not be subject to
13    the requirements of the Illinois Health Facilities
14    Planning Act that are applicable to the conversion to an
15    FEC if the Department of Healthcare and Family Service has
16    certified the conversion to an FEC was approved by the
17    Hospital Transformation Review Committee as a project
18    subject to the hospital's transformation under subsection
19    (d-5) of Section 14-12 of the Illinois Public Aid Code; and
20        (4) the facility is located at the same physical
21    location where the facility served as a hospital.
22    (b) The Department shall:
23        (1) annually inspect facilities of initial FEC
24    applicants and licensed FECs, and issue annual licenses to
25    or annually relicense FECs that satisfy the Department's
26    licensure requirements as set forth in subsection (a);

 

 

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1        (2) suspend, revoke, refuse to issue, or refuse to
2    renew the license of any FEC, after notice and an
3    opportunity for a hearing, when the Department finds that
4    the FEC has failed to comply with the standards and
5    requirements of the Act or rules adopted by the Department
6    under the Act;
7        (3) issue an Emergency Suspension Order for any FEC
8    when the Director or his or her designee has determined
9    that the continued operation of the FEC poses an immediate
10    and serious danger to the public health, safety, and
11    welfare. An opportunity for a hearing shall be promptly
12    initiated after an Emergency Suspension Order has been
13    issued; and
14        (4) adopt rules as needed to implement this Section.
15(Source: P.A. 99-490, eff. 12-4-15; 99-710, eff. 8-5-16;
16100-581, eff. 3-12-18; revised 7-23-19.)
 
17    Section 15. The Illinois Public Aid Code is amended by
18changing Sections 5A-2, 5A-12.6, 5A-13, 5A-14, and 14-12 as
19follows:
 
20    (305 ILCS 5/5A-2)  (from Ch. 23, par. 5A-2)
21    (Section scheduled to be repealed on July 1, 2020)
22    Sec. 5A-2. Assessment.
23    (a)(1) Subject to Sections 5A-3 and 5A-10, for State fiscal
24years 2009 through 2018, or as long as continued under Section

 

 

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15A-16, an annual assessment on inpatient services is imposed on
2each hospital provider in an amount equal to $218.38 multiplied
3by the difference of the hospital's occupied bed days less the
4hospital's Medicare bed days, provided, however, that the
5amount of $218.38 shall be increased by a uniform percentage to
6generate an amount equal to 75% of the State share of the
7payments authorized under Section 5A-12.5, with such increase
8only taking effect upon the date that a State share for such
9payments is required under federal law. For the period of April
10through June 2015, the amount of $218.38 used to calculate the
11assessment under this paragraph shall, by emergency rule under
12subsection (s) of Section 5-45 of the Illinois Administrative
13Procedure Act, be increased by a uniform percentage to generate
14$20,250,000 in the aggregate for that period from all hospitals
15subject to the annual assessment under this paragraph.
16    (2) In addition to any other assessments imposed under this
17Article, effective July 1, 2016 and semi-annually thereafter
18through June 2018, or as provided in Section 5A-16, in addition
19to any federally required State share as authorized under
20paragraph (1), the amount of $218.38 shall be increased by a
21uniform percentage to generate an amount equal to 75% of the
22ACA Assessment Adjustment, as defined in subsection (b-6) of
23this Section.
24    For State fiscal years 2009 through 2018, or as provided in
25Section 5A-16, 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 2005 Medicare cost report as contained in
2the Healthcare Cost Report Information System file, for the
3quarter ending on December 31, 2006, without regard to any
4subsequent adjustments or changes to such data. If a hospital's
52005 Medicare cost report is not contained in the Healthcare
6Cost Report Information System, then the Illinois Department
7may obtain the hospital provider's occupied bed days and
8Medicare bed days from any source available, including, but not
9limited to, records maintained by the hospital provider, which
10may be inspected at all times during business hours of the day
11by the Illinois Department or its duly authorized agents and
12employees.
13    (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
14fiscal years 2019 and 2020, an annual assessment on inpatient
15services is imposed on each hospital provider in an amount
16equal to $197.19 multiplied by the difference of the hospital's
17occupied bed days less the hospital's Medicare bed days;
18however, for State fiscal year 2021, the amount of $197.19
19shall be increased by a uniform percentage to generate an
20additional $6,250,000 in the aggregate for that period from all
21hospitals subject to the annual assessment under this
22paragraph. For State fiscal years 2019 and 2020, a hospital's
23occupied bed days and Medicare bed days shall be determined
24using the most recent data available from each hospital's 2015
25Medicare cost report as contained in the Healthcare Cost Report
26Information System file, for the quarter ending on March 31,

 

 

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12017, without regard to any subsequent adjustments or changes
2to such data. If a hospital's 2015 Medicare cost report is not
3contained in the Healthcare Cost Report Information System,
4then the Illinois Department may obtain the hospital provider's
5occupied bed days and Medicare bed days from any source
6available, including, but not limited to, records maintained by
7the hospital provider, which may be inspected at all times
8during business hours of the day by the Illinois Department or
9its duly authorized agents and employees. Notwithstanding any
10other provision in this Article, for a hospital provider that
11did not have a 2015 Medicare cost report, but paid an
12assessment in State fiscal year 2018 on the basis of
13hypothetical data, that assessment amount shall be used for
14State fiscal years 2019 and 2020; however, for State fiscal
15year 2021, the assessment amount shall be increased by the
16proportion that it represents of the total annual assessment
17that is generated from all hospitals in order to generate
18$6,250,000 in the aggregate for that period from all hospitals
19subject to the annual assessment under this paragraph.
20    Subject to Sections 5A-3 and 5A-10, for State fiscal years
212021 through 2024, an annual assessment on inpatient services
22is imposed on each hospital provider in an amount equal to
23$197.19 multiplied by the difference of the hospital's occupied
24bed days less the hospital's Medicare bed days, provided
25however, that the amount of $197.19 used to calculate the
26assessment under this paragraph shall, by rule, be adjusted by

 

 

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1a uniform percentage to generate the same total annual
2assessment that was generated in State fiscal year 2020 from
3all hospitals subject to the annual assessment under this
4paragraph plus $6,250,000. For State fiscal years 2021 and
52022, a hospital's occupied bed days and Medicare bed days
6shall be determined using the most recent data available from
7each hospital's 2017 Medicare cost report as contained in the
8Healthcare Cost Report Information System file, for the quarter
9ending on March 31, 2019, without regard to any subsequent
10adjustments or changes to such data. For State fiscal years
112023 and 2024, a hospital's occupied bed days and Medicare bed
12days shall be determined using the most recent data available
13from each hospital's 2019 Medicare cost report as contained in
14the Healthcare Cost Report Information System file, for the
15quarter ending on March 31, 2021, without regard to any
16subsequent adjustments or changes to such data.
17    (b) (Blank).
18    (b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
19portion of State fiscal year 2012, beginning June 10, 2012
20through June 30, 2012, and for State fiscal years 2013 through
212018, or as provided in Section 5A-16, an annual assessment on
22outpatient services is imposed on each hospital provider in an
23amount equal to .008766 multiplied by the hospital's outpatient
24gross revenue, provided, however, that the amount of .008766
25shall be increased by a uniform percentage to generate an
26amount equal to 25% of the State share of the payments

 

 

HB4543- 12 -LRB101 19021 KTG 68481 b

1authorized under Section 5A-12.5, with such increase only
2taking effect upon the date that a State share for such
3payments is required under federal law. For the period
4beginning June 10, 2012 through June 30, 2012, the annual
5assessment on outpatient services shall be prorated by
6multiplying the assessment amount by a fraction, the numerator
7of which is 21 days and the denominator of which is 365 days.
8For the period of April through June 2015, the amount of
9.008766 used to calculate the assessment under this paragraph
10shall, by emergency rule under subsection (s) of Section 5-45
11of the Illinois Administrative Procedure Act, be increased by a
12uniform percentage to generate $6,750,000 in the aggregate for
13that period from all hospitals subject to the annual assessment
14under this paragraph.
15    (2) In addition to any other assessments imposed under this
16Article, effective July 1, 2016 and semi-annually thereafter
17through June 2018, in addition to any federally required State
18share as authorized under paragraph (1), the amount of .008766
19shall be increased by a uniform percentage to generate an
20amount equal to 25% of the ACA Assessment Adjustment, as
21defined in subsection (b-6) of this Section.
22    For the portion of State fiscal year 2012, beginning June
2310, 2012 through June 30, 2012, and State fiscal years 2013
24through 2018, or as provided in Section 5A-16, a hospital's
25outpatient gross revenue shall be determined using the most
26recent data available from each hospital's 2009 Medicare cost

 

 

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1report as contained in the Healthcare Cost Report Information
2System file, for the quarter ending on June 30, 2011, without
3regard to any subsequent adjustments or changes to such data.
4If a hospital's 2009 Medicare cost report is not contained in
5the Healthcare Cost Report Information System, then the
6Department may obtain the hospital provider's outpatient gross
7revenue from any source available, including, but not limited
8to, records maintained by the hospital provider, which may be
9inspected at all times during business hours of the day by the
10Department or its duly authorized agents and employees.
11    (3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
12fiscal years 2019 and 2020, an annual assessment on outpatient
13services is imposed on each hospital provider in an amount
14equal to .01358 multiplied by the hospital's outpatient gross
15revenue; however, for State fiscal year 2021, the amount of
16.01358 shall be increased by a uniform percentage to generate
17an additional $6,250,000 in the aggregate for that period from
18all hospitals subject to the annual assessment under this
19paragraph. For State fiscal years 2019 and 2020, a hospital's
20outpatient gross revenue shall be determined using the most
21recent data available from each hospital's 2015 Medicare cost
22report as contained in the Healthcare Cost Report Information
23System file, for the quarter ending on March 31, 2017, without
24regard to any subsequent adjustments or changes to such data.
25If a hospital's 2015 Medicare cost report is not contained in
26the Healthcare Cost Report Information System, then the

 

 

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1Department may obtain the hospital provider's outpatient gross
2revenue from any source available, including, but not limited
3to, records maintained by the hospital provider, which may be
4inspected at all times during business hours of the day by the
5Department or its duly authorized agents and employees.
6Notwithstanding any other provision in this Article, for a
7hospital provider that did not have a 2015 Medicare cost
8report, but paid an assessment in State fiscal year 2018 on the
9basis of hypothetical data, that assessment amount shall be
10used for State fiscal years 2019 and 2020; however, for State
11fiscal year 2021, the assessment amount shall be increased by
12the proportion that it represents of the total annual
13assessment that is generated from all hospitals in order to
14generate $6,250,000 in the aggregate for that period from all
15hospitals subject to the annual assessment under this
16paragraph.
17    Subject to Sections 5A-3 and 5A-10, for State fiscal years
182021 through 2024, an annual assessment on outpatient services
19is imposed on each hospital provider in an amount equal to
20.01358 multiplied by the hospital's outpatient gross revenue,
21provided however, that the amount of .01358 used to calculate
22the assessment under this paragraph shall, by rule, be adjusted
23by a uniform percentage to generate the same total annual
24assessment that was generated in State fiscal year 2020 from
25all hospitals subject to the annual assessment under this
26paragraph plus $6,250,000. For State fiscal years 2021 and

 

 

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12022, a hospital's outpatient gross revenue shall be determined
2using the most recent data available from each hospital's 2017
3Medicare cost report as contained in the Healthcare Cost Report
4Information System file, for the quarter ending on March 31,
52019, without regard to any subsequent adjustments or changes
6to such data. For State fiscal years 2023 and 2024, a
7hospital's outpatient gross revenue shall be determined using
8the most recent data available from each hospital's 2019
9Medicare cost report as contained in the Healthcare Cost Report
10Information System file, for the quarter ending on March 31,
112021, without regard to any subsequent adjustments or changes
12to such data.
13    (b-6)(1) As used in this Section, "ACA Assessment
14Adjustment" means:
15        (A) For the period of July 1, 2016 through December 31,
16    2016, the product of .19125 multiplied by the sum of the
17    fee-for-service payments to hospitals as authorized under
18    Section 5A-12.5 and the adjustments authorized under
19    subsection (t) of Section 5A-12.2 to managed care
20    organizations for hospital services due and payable in the
21    month of April 2016 multiplied by 6.
22        (B) For the period of January 1, 2017 through June 30,
23    2017, the product of .19125 multiplied by the sum of the
24    fee-for-service payments to hospitals as authorized under
25    Section 5A-12.5 and the adjustments authorized under
26    subsection (t) of Section 5A-12.2 to managed care

 

 

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1    organizations for hospital services due and payable in the
2    month of October 2016 multiplied by 6, except that the
3    amount calculated under this subparagraph (B) shall be
4    adjusted, either positively or negatively, to account for
5    the difference between the actual payments issued under
6    Section 5A-12.5 for the period beginning July 1, 2016
7    through December 31, 2016 and the estimated payments due
8    and payable in the month of April 2016 multiplied by 6 as
9    described in subparagraph (A).
10        (C) For the period of July 1, 2017 through December 31,
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 April 2017 multiplied by 6, except that the amount
17    calculated under this subparagraph (C) shall be adjusted,
18    either positively or negatively, to account for the
19    difference between the actual payments issued under
20    Section 5A-12.5 for the period beginning January 1, 2017
21    through June 30, 2017 and the estimated payments due and
22    payable in the month of October 2016 multiplied by 6 as
23    described in subparagraph (B).
24        (D) For the period of January 1, 2018 through June 30,
25    2018, 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 October 2017 multiplied by 6, except that:
5            (i) the amount calculated under this subparagraph
6        (D) shall be adjusted, either positively or
7        negatively, to account for the difference between the
8        actual payments issued under Section 5A-12.5 for the
9        period of July 1, 2017 through December 31, 2017 and
10        the estimated payments due and payable in the month of
11        April 2017 multiplied by 6 as described in subparagraph
12        (C); and
13            (ii) the amount calculated under this subparagraph
14        (D) shall be adjusted to include the product of .19125
15        multiplied by the sum of the fee-for-service payments,
16        if any, estimated to be paid to hospitals under
17        subsection (b) of Section 5A-12.5.
18    (2) The Department shall complete and apply a final
19reconciliation of the ACA Assessment Adjustment prior to June
2030, 2018 to account for:
21        (A) any differences between the actual payments issued
22    or scheduled to be issued prior to June 30, 2018 as
23    authorized in Section 5A-12.5 for the period of January 1,
24    2018 through June 30, 2018 and the estimated payments due
25    and payable in the month of October 2017 multiplied by 6 as
26    described in subparagraph (D); and

 

 

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1        (B) any difference between the estimated
2    fee-for-service payments under subsection (b) of Section
3    5A-12.5 and the amount of such payments that are actually
4    scheduled to be paid.
5    The Department shall notify hospitals of any additional
6amounts owed or reduction credits to be applied to the June
72018 ACA Assessment Adjustment. This is to be considered the
8final reconciliation for the ACA Assessment Adjustment.
9    (3) Notwithstanding any other provision of this Section, if
10for any reason the scheduled payments under subsection (b) of
11Section 5A-12.5 are not issued in full by the final day of the
12period authorized under subsection (b) of Section 5A-12.5,
13funds collected from each hospital pursuant to subparagraph (D)
14of paragraph (1) and pursuant to paragraph (2), attributable to
15the scheduled payments authorized under subsection (b) of
16Section 5A-12.5 that are not issued in full by the final day of
17the period attributable to each payment authorized under
18subsection (b) of Section 5A-12.5, shall be refunded.
19    (4) The increases authorized under paragraph (2) of
20subsection (a) and paragraph (2) of subsection (b-5) shall be
21limited to the federally required State share of the total
22payments authorized under Section 5A-12.5 if the sum of such
23payments yields an annualized amount equal to or less than
24$450,000,000, or if the adjustments authorized under
25subsection (t) of Section 5A-12.2 are found not to be
26actuarially sound; however, this limitation shall not apply to

 

 

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1the fee-for-service payments described in subsection (b) of
2Section 5A-12.5.
3    (c) (Blank).
4    (c-5)(1) Subject to Sections 5A-3 and 5A-10, for State
5Fiscal Years 2021 through 2024, an annual assessment on
6inpatient and outpatient services is imposed on each hospital
7provider. The assessment shall be as described in paragraph (2)
8of this subsection.
9    (2)(A) The "total assessment" shall be equal to the sum of
10the following 2 numbers:
11    (B) The assessment imposed on each hospital provider shall
12be equal to a rate multiplied by the sum of their non-Medicaid
13inpatient gross revenue and non-Medicaid outpatient gross
14revenue. The Department shall determine the rate so that it is
15uniform for all hospital providers subject to the assessment
16and the funds generated by the assessment are equivalent to the
17total assessment.
18    For State Fiscal Years 2021 and 2022, a hospital's
19non-Medicaid gross revenue shall be determined using the most
20recent data available from each hospital's 2017 Medicare cost
21report as contained in the Healthcare Cost Report Information
22System file, for the quarter ending on March 31, 2019, without
23regard to any subsequent adjustments or changes to such data.
24For State Fiscal Years 2023 and 2024, a hospital's non-Medicaid
25gross revenue shall be determined using the most recent data
26available from each hospital's 2019 Medicare cost report as

 

 

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1contained in the Healthcare Cost Report Information System
2file, for the quarter ending on March 31, 2021, without regard
3to any subsequent adjustments or changes to such data. If a
4hospital's Medicare cost report is not contained in the
5Healthcare Cost Report Information System or the hospital's
6Medicare cost report contains insufficient information to
7determine gross non-Medicaid inpatient or outpatient revenue,
8then the Department may obtain the hospital provider's gross
9non-Medicaid revenue from any source available, including, but
10not limited to, records maintained by the hospital provider,
11which may be inspected at all times during business hours of
12the day by the Department or its duly authorized agents and
13employees. The Department may also set any additional reporting
14requirements for Medicare cost reports as deemed necessary to
15determine non-Medicaid gross revenue inpatient and outpatient
16revenue for future fiscal years.
17    (d) Notwithstanding any of the other provisions of this
18Section, the Department is authorized to adopt rules to reduce
19the rate of any annual assessment imposed under this Section,
20as authorized by Section 5-46.2 of the Illinois Administrative
21Procedure Act.
22    (e) Notwithstanding any other provision of this Section,
23any plan providing for an assessment on a hospital provider as
24a permissible tax under Title XIX of the federal Social
25Security Act and Medicaid-eligible payments to hospital
26providers from the revenues derived from that assessment shall

 

 

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

 

 

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1    (a) To preserve and improve access to hospital services,
2for hospital services rendered on or after July 1, 2018 the
3Department shall, except for hospitals described in subsection
4(b) of Section 5A-3, make payments to hospitals as set forth in
5this Section. Payments under this Section are not due and
6payable, however, until (i) the methodologies described in this
7Section are approved by the federal government in an
8appropriate State Plan amendment and (ii) the assessment
9imposed under this Article is determined to be a permissible
10tax under Title XIX of the Social Security Act. In determining
11the hospital access payments authorized under subsections (f)
12through (n) of this Section, unless otherwise specified, only
13Illinois hospitals shall be eligible for a payment and total
14Medicaid utilization statistics shall be used to determine the
15payment amount. In determining the hospital access payments
16authorized under subsection (d) and subsections (f) through (l)
17of this Section, if a hospital ceases to receive payments from
18the pool, the payments for all hospitals continuing to receive
19payments from such pool shall be uniformly adjusted to fully
20expend the aggregate amount of the pool, with such adjustment
21being effective on the first day of the second month following
22the date the hospital ceases to receive payments from such
23pool.
24    (b) Phase in of funds to claims-based payments and updates.
25To ensure access to hospital services, the Department may only
26use funds financed by the assessment authorized under Section

 

 

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15A-2 to increase claims-based payment rates, including
2applicable policy add-on payments or adjusters, in accordance
3with this subsection. Starting in State Fiscal Year 2021, to To
4increase the claims-based payment rates up to the amounts
5specified in this subsection, the hospital access payments
6authorized in paragraphs (3) through (5) of subsection (g),
7paragraph (3) of subsection (h), paragraph (2) of subsection
8(i), paragraph (1) of subsection (j), subsection (k), and
9subsection (n) of this Section shall be reduced to zero.
10Following this, the remaining hospital access payments
11authorized in subsection (d) and subsections (g) through (l) of
12this Section shall be uniformly reduced.
13        (1) For State fiscal years 2019 and 2020, up to
14    $635,000,000 of the total spending financed from the
15    assessment authorized under Section 5A-2 that is intended
16    to pay for hospital services and the hospital supplemental
17    access payments authorized under subsections (d) and (f) of
18    Section 14-12 for payment in State fiscal year 2018 may be
19    used to increase claims-based hospital payment rates as
20    specified under Section 14-12.
21        (2) For State fiscal years 2021 and 2022, up to
22    $1,696,000,000 $1,164,000,000 of the total spending
23    financed from the assessment authorized under Section 5A-2
24    that is intended to pay for hospital services and the
25    hospital supplemental access payments authorized under
26    subsections (d) and (f) of Section 14-12 for payment in

 

 

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

 

 

HB4543- 25 -LRB101 19021 KTG 68481 b

1    updated base year data, to determine a hospital's
2    eligibility for each payment and the amount of the payment
3    authorized under this Section. Any updates of the hospital
4    access payment methodologies shall not result in any
5    diminishment of the aggregate amount of hospital access
6    payment expenditures, except for reductions attributable
7    to the use of such funds to increase claims-based hospital
8    payment rates as authorized by this Section. Nothing in
9    this Section shall be construed as precluding variations in
10    the amount of any individual hospital's access payments.
11    The Department shall publish the proposed rules to update
12    the hospital access payments at least 90 days before their
13    proposed effective date. The proposed rules shall not be
14    adopted using emergency rulemaking authority. The
15    Department shall notify each hospital, in writing, of the
16    impact of these updates on the hospital at least 30
17    calendar days prior to their effective date.
18    (c) The hospital access payments authorized under
19subsections (d) through (n) of this Section shall be paid in 12
20equal installments on or before the seventh State business day
21of each month, except that no payment shall be due within 100
22days after the later of the date of notification of federal
23approval of the payment methodologies required under this
24Section or any waiver required under 42 CFR 433.68, at which
25time the sum of amounts required under this Section prior to
26the date of notification is due and payable. Payments under

 

 

HB4543- 26 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 27 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 28 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 29 -LRB101 19021 KTG 68481 b

1        (4) For each hospital, its annualized Medicaid Intern
2    Resident Cost and its annualized Medicaid IME payment are
3    summed and multiplied by 33% to determine the hospital's
4    final graduate medical education payment.
5    (f) Alzheimer's treatment access payment. Each Illinois
6academic medical center or teaching hospital, as defined in
7Section 5-5e.2 of this Code, that is identified as the primary
8hospital affiliate of one of the Regional Alzheimer's Disease
9Assistance Centers, as designated by the Alzheimer's Disease
10Assistance Act and identified in the Department of Public
11Health's Alzheimer's Disease State Plan dated December 2016,
12shall be paid an Alzheimer's treatment access payment equal to
13the product of $10,000,000 multiplied by a fraction, the
14numerator of which is the qualifying hospital's Fiscal Year
152015 total admissions and the denominator of which is the
16Fiscal Year 2015 total admissions for all hospitals eligible
17for the payment.
18    (g) Safety-net hospital, private critical access hospital,
19and outpatient high volume access payment.
20        (1) Each safety-net hospital, as defined in Section
21    5-5e.1 of this Code, for Rate Year 2017 that is not
22    publicly owned shall be paid an outpatient high volume
23    access payment equal to $40,000,000 multiplied by a
24    fraction, the numerator of which is the hospital's Fiscal
25    Year 2015 outpatient services and the denominator of which
26    is the Fiscal Year 2015 outpatient services for all

 

 

HB4543- 30 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 31 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 32 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 33 -LRB101 19021 KTG 68481 b

1        this payment. A tier 1 Medicaid dependent hospital
2        means a qualifying hospital with a Rate Year 2017
3        Medicaid inpatient utilization rate equal to or
4        greater than the statewide mean but less than the
5        statewide mean plus 0.5 standard deviation.
6            (B) Each tier 2 hospital shall be paid a Medicaid
7        dependent hospital access payment equal to $15,000,000
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 2 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 0.5 standard
16        deviations but less than the statewide mean plus one
17        standard deviation.
18            (C) Each tier 3 hospital shall be paid a Medicaid
19        dependent hospital access payment equal to $15,000,000
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 3 Medicaid dependent hospital
25        means a qualifying hospital with a Rate Year 2017
26        Medicaid inpatient utilization rate equal to or

 

 

HB4543- 34 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 35 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 36 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 37 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 38 -LRB101 19021 KTG 68481 b

1    December 1, 2017, and that has a Rate Year 2017 Medicaid
2    inpatient utilization rate equal to or greater than 20% and
3    a calendar year 2015 occupancy ratio equal to or greater
4    than 50%, shall be paid an access payment equal to
5    $160,000,000 multiplied by a fraction, the numerator of
6    which is the hospital's Fiscal Year 2015 total admissions
7    and the denominator of which is the Fiscal Year 2015 total
8    admissions for all hospitals eligible under this paragraph
9    for this payment.
10        (2) Each Illinois non-publicly owned hospital
11    designated a Level II or II+ perinatal center and a Level I
12    or II trauma center by the Department of Public Health as
13    of December 1, 2017, and that has a Rate Year 2017 Medicaid
14    inpatient utilization rate equal to or greater than 20% and
15    a calendar year 2015 occupancy ratio equal to or greater
16    than 50%, shall be paid an access payment equal to
17    $200,000,000 multiplied by a fraction, the numerator of
18    which is the hospital's Fiscal Year 2015 total admissions
19    and the denominator of which is the Fiscal Year 2015 total
20    admissions for all hospitals eligible under this paragraph
21    for this payment.
22    (l) Long-term acute care access payment. Each Illinois
23non-publicly owned long-term acute care hospital that has a
24Rate Year 2017 Medicaid inpatient utilization rate equal to or
25greater than 25% and a calendar year 2015 occupancy ratio equal
26to or greater than 60% shall be paid an access payment equal to

 

 

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

 

 

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1aggregate, spend approximately $61,141,188 annually. In
2consultation with the hospital community, the Department may,
3by rule, incorporate the funds used for this access payment to
4increase the payment rates for inpatient psychiatric services,
5except that such changes shall not take effect before July 1,
62019. Upon incorporation into the claims payment rates, this
7access payment shall be repealed. Beginning July 1, 2018, for
8purposes of determining for State fiscal years 2019 and 2020
9the hospitals eligible for the payments authorized under this
10subsection, the Department shall include out-of-state
11hospitals that are designated a Level I pediatric trauma center
12or a Level I trauma center by the Department of Public Health
13as of December 1, 2017.
14    (o) For purposes of this Section, a hospital that is
15enrolled to provide Medicaid services during State fiscal year
162015 shall have its utilization and associated reimbursements
17annualized prior to the payment calculations being performed
18under this Section.
19    (p) Definitions. As used in this Section, unless the
20context requires otherwise:
21    "General acute care admissions" means, for a given
22hospital, the sum of inpatient hospital admissions provided to
23recipients of medical assistance under Title XIX of the Social
24Security Act for general acute care, excluding admissions for
25individuals eligible for Medicare under Title XVIII of the
26Social Security Act (Medicaid/Medicare crossover admissions),

 

 

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1as tabulated from the Department's paid claims data for general
2acute care admissions occurring during State fiscal year 2015
3that was adjudicated by the Department through October 28,
42016.
5    "Occupancy ratio" is determined utilizing the IDPH
6Hospital Profile CY15 - Facility Utilization Data - Source 2015
7Annual Hospital Questionnaire. Utilizes all beds and days
8including observation days but excludes Long Term Care and
9Swing bed and their associated beds and days.
10    "Outpatient services" means, for a given hospital, the sum
11of the number of outpatient encounters identified as unique
12services provided to recipients of medical assistance under
13Title XIX of the Social Security Act for general acute care,
14psychiatric care, and rehabilitation care, excluding
15outpatient services for individuals eligible for Medicare
16under Title XVIII of the Social Security Act (Medicaid/Medicare
17crossover services), as tabulated from the Department's paid
18claims data for outpatient services occurring during State
19fiscal year 2015 that was adjudicated by the Department through
20October 28, 2016.
21    "Total days" means, for a given hospital, the sum of
22inpatient hospital days provided to recipients of medical
23assistance under Title XIX of the Social Security Act for
24general acute care, psychiatric care, and rehabilitation care,
25excluding days for individuals eligible for Medicare under
26Title XVIII of the Social Security Act (Medicaid/Medicare

 

 

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1crossover days), as tabulated from the Department's paid claims
2data for total days occurring during State fiscal year 2015
3that was adjudicated by the Department through October 28,
42016.
5    "Total admissions" means, for a given hospital, the sum of
6inpatient hospital admissions provided to recipients of
7medical assistance under Title XIX of the Social Security Act
8for general acute care, psychiatric care, and rehabilitation
9care, excluding admissions for individuals eligible for
10Medicare under Title XVIII of that Act (Medicaid/Medicare
11crossover admissions), as tabulated from the Department's paid
12claims data for admissions occurring during State fiscal year
132015 that was adjudicated by the Department through October 28,
142016.
15    (q) Notwithstanding any of the other provisions of this
16Section, the Department is authorized to adopt rules that
17change the hospital access payments specified in this Section,
18but only to the extent necessary to conform to any federally
19approved amendment to the Title XIX State Plan. Any such rules
20shall be adopted by the Department as authorized by Section
215-50 of the Illinois Administrative Procedure Act.
22Notwithstanding any other provision of law, any changes
23implemented as a result of this subsection (q) shall be given
24retroactive effect so that they shall be deemed to have taken
25effect as of the effective date of this amendatory Act of the
26100th General Assembly.

 

 

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

 

 

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1and any adjustments that have been made. Following the
2effective date of this amendatory Act of the 101st General
3Assembly, each MCO shall expend at least an amount equivalent
4to the increased capitation payments it receives under this
5Section to support the availability of hospital services and to
6ensure access to hospital services in furtherance of the
7State's public policy. Each MCO shall submit to the Department
8and the Department shall make available, on a monthly basis, a
9report of each payment to a hospital in accordance with
10methodologies and rates to preserve and improve access to
11hospital services. Payments to MCOs that would be paid
12consistent with actuarial certification and enrollment in the
13absence of the increased capitation payments under this Section
14shall not be reduced as a consequence of payments made under
15this subsection.
16    (3) Following the effective date of this amendatory Act of
17the 101st General Assembly, contracts between the Department
18and MCOs for subsequent plan years shall require MCOs to pass
19through the payment amounts in accordance with this Section
20reduced and added up to the aggregate amount calculated under
21paragraph (1), in conformance with 42 CFR 438.6. Each MCO shall
22submit to the Department and the Department shall make
23available, on a quarterly basis, a report of each payment to a
24hospital in accordance with this paragraph.
25    (4) As used in this subsection, "MCO" means an entity which
26contracts with the Department to provide services where payment

 

 

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1for medical services is made on a capitated basis.
2(Source: P.A. 100-581, eff. 3-12-18.)
 
3    (305 ILCS 5/5A-13)
4    Sec. 5A-13. Emergency rulemaking.
5    (a) The Department of Healthcare and Family Services
6(formerly Department of Public Aid) may adopt rules necessary
7to implement this amendatory Act of the 94th General Assembly
8through the use of emergency rulemaking in accordance with
9Section 5-45 of the Illinois Administrative Procedure Act. For
10purposes of that Act, the General Assembly finds that the
11adoption of rules to implement this amendatory Act of the 94th
12General Assembly is deemed an emergency and necessary for the
13public interest, safety, and welfare.
14    (b) The Department of Healthcare and Family Services may
15adopt rules necessary to implement this amendatory Act of the
1697th General Assembly through the use of emergency rulemaking
17in accordance with Section 5-45 of the Illinois Administrative
18Procedure Act. For purposes of that Act, the General Assembly
19finds that the adoption of rules to implement this amendatory
20Act of the 97th General Assembly is deemed an emergency and
21necessary for the public interest, safety, and welfare.
22    (c) The Department of Healthcare and Family Services may
23adopt rules necessary to initially implement the changes to
24Articles 5, 5A, 12, and 14 of this Code under this amendatory
25Act of the 100th General Assembly through the use of emergency

 

 

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1rulemaking in accordance with subsection (aa) of Section 5-45
2of the Illinois Administrative Procedure Act. For purposes of
3that Act, the General Assembly finds that the adoption of rules
4to implement the changes to Articles 5, 5A, 12, and 14 of this
5Code under this amendatory Act of the 100th General Assembly is
6deemed an emergency and necessary for the public interest,
7safety, and welfare. The 24-month limitation on the adoption of
8emergency rules does not apply to rules adopted to initially
9implement the changes to Articles 5, 5A, 12, and 14 of this
10Code under this amendatory Act of the 100th General Assembly.
11For purposes of this subsection, "initially" means any
12emergency rules necessary to immediately implement the changes
13authorized to Articles 5, 5A, 12, and 14 of this Code under
14this amendatory Act of the 100th General Assembly; however,
15emergency rulemaking authority shall not be used to make
16changes that could otherwise be made following the process
17established in the Illinois Administrative Procedure Act.
18    (d) The Department of Healthcare and Family Services may on
19a one-time-only basis adopt rules necessary to initially
20implement the changes to Articles 5A and 14 of this Code under
21this amendatory Act of the 100th General Assembly through the
22use of emergency rulemaking in accordance with subsection (ee)
23of Section 5-45 of the Illinois Administrative Procedure Act.
24For purposes of that Act, the General Assembly finds that the
25adoption of rules on a one-time-only basis to implement the
26changes to Articles 5A and 14 of this Code under this

 

 

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1amendatory Act of the 100th General Assembly is deemed an
2emergency and necessary for the public interest, safety, and
3welfare. The 24-month limitation on the adoption of emergency
4rules does not apply to rules adopted to initially implement
5the changes to Articles 5A and 14 of this Code under this
6amendatory Act of the 100th General Assembly.
7    (e) The Department of Healthcare and Family Services may
8adopt rules necessary to initially implement the changes made
9by this amendatory Act of the 101st General Assembly to
10Sections 5A-2, 5A-12.6, 5A-14, and 14-12 of this Code through
11the use of emergency rulemaking in accordance with the Illinois
12Administrative Procedure Act. For purposes of the Illinois
13Administrative Procedure Act Act, the General Assembly finds
14that the adoption of rules to implement the changes made by
15this amendatory Act of the 101st General Assembly to Sections
165A-2, 5A-12.6, 5A-14, and 14-12 of this Code is deemed an
17emergency and necessary for the public interest, safety, and
18welfare. The 24-month limitation on the adoption of emergency
19rules does not apply to rules adopted to initially implement
20the changes made by this amendatory Act of the 101st General
21Assembly to Sections 5A-2, 5A-12.6, 5A-14, and 14-12 of this
22Code. As used in this subsection, "initially" means any
23emergency rules necessary to immediately implement the changes
24made by this amendatory Act of the 101st General Assembly to
25Sections 5A-2, 5A-12.6, 5A-14, and 14-12 of this Code. However,
26emergency rulemaking authority shall not be used to make

 

 

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1changes that could otherwise be made following the process
2established in the Illinois Administrative Procedure Act.
3(Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19.)
 
4    (305 ILCS 5/5A-14)
5    Sec. 5A-14. Repeal of assessments and disbursements.
6    (a) Section 5A-2 is repealed on July 1, 2022 2020.
7    (b) Section 5A-12 is repealed on July 1, 2005.
8    (c) Section 5A-12.1 is repealed on July 1, 2008.
9    (d) Section 5A-12.2 and Section 5A-12.4 are repealed on
10July 1, 2018, subject to Section 5A-16.
11    (e) Section 5A-12.3 is repealed on July 1, 2011.
12    (f) Section 5A-12.6 is repealed on July 1, 2022 2020.
13(Source: P.A. 100-581, eff. 3-12-18.)
 
14    (305 ILCS 5/14-12)
15    Sec. 14-12. Hospital rate reform payment system. The
16hospital payment system pursuant to Section 14-11 of this
17Article shall be as follows:
18    (a) Inpatient hospital services. Effective for discharges
19on and after July 1, 2014, reimbursement for inpatient general
20acute care services shall utilize the All Patient Refined
21Diagnosis Related Grouping (APR-DRG) software, version 30,
22distributed by 3MTM Health Information System.
23        (1) The Department shall establish Medicaid weighting
24    factors to be used in the reimbursement system established

 

 

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1    under this subsection. Initial weighting factors shall be
2    the weighting factors as published by 3M Health Information
3    System, associated with Version 30.0 adjusted for the
4    Illinois experience.
5        (2) The Department shall establish a
6    statewide-standardized amount to be used in the inpatient
7    reimbursement system. The Department shall publish these
8    amounts on its website no later than 10 calendar days prior
9    to their effective date.
10        (3) In addition to the statewide-standardized amount,
11    the Department shall develop adjusters to adjust the rate
12    of reimbursement for critical Medicaid providers or
13    services for trauma, transplantation services, perinatal
14    care, and Graduate Medical Education (GME).
15        (4) The Department shall develop add-on payments to
16    account for exceptionally costly inpatient stays,
17    consistent with Medicare outlier principles. Outlier fixed
18    loss thresholds may be updated to control for excessive
19    growth in outlier payments no more frequently than on an
20    annual basis, but at least triennially. Upon updating the
21    fixed loss thresholds, the Department shall be required to
22    update base rates within 12 months.
23        (5) The Department shall define those hospitals or
24    distinct parts of hospitals that shall be exempt from the
25    APR-DRG reimbursement system established under this
26    Section. The Department shall publish these hospitals'

 

 

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1    inpatient rates on its website no later than 10 calendar
2    days prior to their effective date.
3        (6) Beginning July 1, 2014 and ending on June 30, 2024,
4    in addition to the statewide-standardized amount, the
5    Department shall develop an adjustor to adjust the rate of
6    reimbursement for safety-net hospitals defined in Section
7    5-5e.1 of this Code excluding pediatric hospitals.
8        (7) Beginning July 1, 2014 and ending on June 30, 2020,
9    or upon implementation of inpatient psychiatric rate
10    increases as described in subsection (n) of Section
11    5A-12.6, in addition to the statewide-standardized amount,
12    the Department shall develop an adjustor to adjust the rate
13    of reimbursement for Illinois freestanding inpatient
14    psychiatric hospitals that are not designated as
15    children's hospitals by the Department but are primarily
16    treating patients under the age of 21.
17        (7.5) (Blank). Beginning July 1, 2020, the
18    reimbursement for inpatient psychiatric services shall be
19    so that base claims projected reimbursement is increased by
20    an amount equal to the funds allocated in paragraph (2) of
21    subsection (b) of Section 5A-12.6, less the amount
22    allocated under paragraphs (8) and (9) of this subsection
23    and paragraphs (3) and (4) of subsection (b) multiplied by
24    13%. Beginning July 1, 2022, the reimbursement for
25    inpatient psychiatric services shall be so that base claims
26    projected reimbursement is increased by an amount equal to

 

 

HB4543- 51 -LRB101 19021 KTG 68481 b

1    the funds allocated in paragraph (3) of subsection (b) of
2    Section 5A-12.6, less the amount allocated under
3    paragraphs (8) and (9) of this subsection and paragraphs
4    (3) and (4) of subsection (b) multiplied by 13%. Beginning
5    July 1, 2024, the reimbursement for inpatient psychiatric
6    services shall be so that base claims projected
7    reimbursement is increased by an amount equal to the funds
8    allocated in paragraph (4) of subsection (b) of Section
9    5A-12.6, less the amount allocated under paragraphs (8) and
10    (9) of this subsection and paragraphs (3) and (4) of
11    subsection (b) multiplied by 13%.
12        (8) Beginning July 1, 2018, in addition to the
13    statewide-standardized amount, the Department shall adjust
14    the rate of reimbursement for hospitals designated by the
15    Department of Public Health as a Perinatal Level II or II+
16    center by applying the same adjustor that is applied to
17    Perinatal and Obstetrical care cases for Perinatal Level
18    III centers, as of December 31, 2017.
19        (9) Beginning July 1, 2018, in addition to the
20    statewide-standardized amount, the Department shall apply
21    the same adjustor that is applied to trauma cases as of
22    December 31, 2017 to inpatient claims to treat patients
23    with burns, including, but not limited to, APR-DRGs 841,
24    842, 843, and 844.
25        (10) Beginning July 1, 2018, the
26    statewide-standardized amount for inpatient general acute

 

 

HB4543- 52 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 53 -LRB101 19021 KTG 68481 b

1    subsection (b) of Section 5A-12.6, less the amount
2    allocated under paragraphs (8) and (9) of this subsection
3    and paragraphs (3) and (4) of subsection (b) multiplied by
4    40%.
5        (11) Beginning July 1, 2018, the reimbursement for
6    inpatient rehabilitation services shall be increased by
7    the addition of a $96 per day add-on.
8        Beginning July 1, 2020, the reimbursement for
9    inpatient rehabilitation services shall be uniformly
10    increased so that the $96 per day add-on is increased by an
11    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    0.9%.
16        Beginning July 1, 2022, the reimbursement for
17    inpatient rehabilitation services shall be uniformly
18    increased so that the $96 per day add-on as adjusted by the
19    July 1, 2020 increase, is increased by an amount equal to
20    the funds allocated in paragraph (3) of subsection (b) of
21    Section 5A-12.6, less the amount allocated under
22    paragraphs (8) and (9) of this subsection and paragraphs
23    (3) and (4) of subsection (b) multiplied by 0.9%.
24        Beginning July 1, 2023, the reimbursement for
25    inpatient rehabilitation services shall be uniformly
26    increased so that the $96 per day add-on as adjusted by the

 

 

HB4543- 54 -LRB101 19021 KTG 68481 b

1    July 1, 2022 increase, is increased by an amount equal to
2    the funds allocated in paragraph (4) of subsection (b) of
3    Section 5A-12.6, less the amount allocated under
4    paragraphs (8) and (9) of this subsection and paragraphs
5    (3) and (4) of subsection (b) multiplied by 0.9%.
6        (12) Beginning July 1, 2020, the reimbursement for
7    inpatient general acute care services to non-publicly
8    owned safety net hospitals, as defined in Section 5-5e.1 of
9    this Code for Rate Year 2017, shall be increased by a
10    uniform dollar amount so that base claims projected
11    reimbursement is increased by an amount equal to
12    $400,000,000 of the funds allocated in paragraph (2) of
13    subsection (b) of Section 5A-12.6.
14        (13) Beginning July 1, 2020, the reimbursement for
15    inpatient general acute care services to non-publicly
16    owned critical access hospitals shall be increased by a
17    uniform dollar amount so that base claims projected
18    reimbursement is increased by an amount equal to
19    $100,000,000 of the funds allocated in paragraph (2) of
20    subsection (b) of Section 5A-12.6.
21        (14) Beginning July 1, 2020, the reimbursement for
22    inpatient general acute care services to hospital
23    providers in high-need communities shall be increased by a
24    uniform dollar amount so that base claims projected
25    reimbursement is increased by an amount equal to
26    $500,000,000 of the funds allocated in paragraph (2) of

 

 

HB4543- 55 -LRB101 19021 KTG 68481 b

1    subsection (b) of Section 5A-12.6. A hospital shall qualify
2    as a hospital in a high-need community if it is located in
3    a census tract with median household income below the
4    statewide median household income, is located in a census
5    tract with life expectancy below the statewide average, and
6    has a Medicaid inpatient utilization rate at or above the
7    statewide median.
8        (15) Beginning July 1, 2020, the reimbursement for
9    inpatient psychiatric services to non-publicly owned
10    general acute care hospitals shall be increased by a
11    uniform dollar amount so that base claims projected
12    reimbursement is increased by an amount equal to
13    $61,000,000 of the funds allocated in paragraph (2) of
14    subsection (b) of Section 5A-12.6.
15    (b) Outpatient hospital services. Effective for dates of
16service on and after July 1, 2014, reimbursement for outpatient
17services shall utilize the Enhanced Ambulatory Procedure
18Grouping (EAPG) software, version 3.7 distributed by 3MTM
19Health Information System.
20        (1) The Department shall establish Medicaid weighting
21    factors to be used in the reimbursement system established
22    under this subsection. The initial weighting factors shall
23    be the weighting factors as published by 3M Health
24    Information System, associated with Version 3.7.
25        (2) The Department shall establish service specific
26    statewide-standardized amounts to be used in the

 

 

HB4543- 56 -LRB101 19021 KTG 68481 b

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

 

 

HB4543- 57 -LRB101 19021 KTG 68481 b

1    by $79,200,000, based on the State Fiscal Year 2015 base
2    year data and this adjustor shall apply to public
3    hospitals, except for large public hospitals, as defined
4    under 89 Ill. Adm. Code 148.25(a).
5        (4) Beginning July 1, 2018, in addition to the
6    statewide standardized amounts, the Department shall make
7    an add-on payment for outpatient expensive devices and
8    drugs. This add-on payment shall at least apply to claim
9    lines that: (i) are assigned with one of the following
10    EAPGs: 490, 1001 to 1020, and coded with one of the
11    following revenue codes: 0274 to 0276, 0278; or (ii) are
12    assigned with one of the following EAPGs: 430 to 441, 443,
13    444, 460 to 465, 495, 496, 1090. The add-on payment shall
14    be calculated as follows: the claim line's covered charges
15    multiplied by the hospital's total acute cost to charge
16    ratio, less the claim line's EAPG payment plus $1,000,
17    multiplied by 0.8.
18        (5) Beginning July 1, 2018, the statewide-standardized
19    amounts for outpatient services shall be increased by a
20    uniform dollar amount percentage so that base claims
21    projected reimbursement is increased by an amount equal to
22    no less than the funds allocated in paragraph (1) of
23    subsection (b) of Section 5A-12.6, less the amount
24    allocated under paragraphs (8), (9), and (12) through (15)
25    and (9) of subsection (a) and paragraphs (3) and (4) of
26    this subsection multiplied by 46%. Beginning July 1, 2020,

 

 

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1    the statewide-standardized amounts for outpatient services
2    shall be increased by a uniform percentage so that base
3    claims projected reimbursement is increased by an amount
4    equal to no less than the funds allocated in paragraph (2)
5    of subsection (b) of Section 5A-12.6, less the amount
6    allocated under paragraphs (8) and (9) of subsection (a)
7    and paragraphs (3) and (4) of this subsection multiplied by
8    46%. Beginning July 1, 2022, the statewide-standardized
9    amounts for outpatient services shall be increased by a
10    uniform percentage so that base claims projected
11    reimbursement is increased by an amount equal to the funds
12    allocated in paragraph (3) of subsection (b) of Section
13    5A-12.6, less the amount allocated under paragraphs (8) and
14    (9) of subsection (a) and paragraphs (3) and (4) of this
15    subsection multiplied by 46%. Beginning July 1, 2023, the
16    statewide-standardized amounts for outpatient services
17    shall be increased by a uniform percentage so that base
18    claims projected reimbursement is increased by an amount
19    equal to no less than the funds allocated in paragraph (4)
20    of subsection (b) of Section 5A-12.6, less the amount
21    allocated under paragraphs (8) and (9) of subsection (a)
22    and paragraphs (3) and (4) of this subsection multiplied by
23    46%.
24        (6) Effective for dates of service on or after July 1,
25    2018, the Department shall establish adjustments to the
26    statewide-standardized amounts for each Critical Access

 

 

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

 

 

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

 

 

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

 

 

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1    hospital access payments in effect on June 30, 2018 shall
2    continue to be paid, if continued under Section 5A-16.
3        (2) After the transition period, if the Department
4    reduces payments from the transitional hospital access
5    pool, it shall increase base rates, develop new adjustors,
6    adjust current adjustors, develop new hospital access
7    payments based on updated information, or any combination
8    thereof by an amount equal to the decreases proposed in the
9    transitional hospital access pool payments, ensuring that
10    the entire transitional hospital access pool amount shall
11    continue to be used for hospital payments.
12    (d-5) Hospital transformation program. The Department, in
13conjunction with the Hospital Transformation Review Committee
14created under subsection (d-5), shall develop a hospital
15transformation program to provide financial assistance to
16hospitals in areas of greatest health need and areas most
17adversely affected by health disparities that require such
18assistance to transform or expand in transforming their
19services and care models to better meet align with the needs of
20the communities they serve. The payments authorized in this
21Section shall be subject to approval by the federal government.
22        (1) Phase 1. In State fiscal years 2019 through 2020,
23    the Department shall allocate funds from the transitional
24    access hospital pool to create a hospital transformation
25    pool of at least $262,906,870 annually and make hospital
26    transformation payments to hospitals. Subject to Section

 

 

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1    5A-16, in State fiscal years 2019 and 2020, an Illinois
2    hospital that received either a transitional hospital
3    access payment under subsection (d) or a supplemental
4    payment under subsection (f) of this Section in State
5    fiscal year 2018, shall receive a hospital transformation
6    payment as follows:
7            (A) If the hospital's Rate Year 2017 Medicaid
8        inpatient utilization rate is equal to or greater than
9        45%, the hospital transformation payment shall be
10        equal to 100% of the sum of its transitional hospital
11        access payment authorized under subsection (d) and any
12        supplemental payment authorized under subsection (f).
13            (B) If the hospital's Rate Year 2017 Medicaid
14        inpatient utilization rate is equal to or greater than
15        25% but less than 45%, the hospital transformation
16        payment shall be equal to 75% of the sum of its
17        transitional hospital access payment authorized under
18        subsection (d) and any supplemental payment authorized
19        under subsection (f).
20            (C) If the hospital's Rate Year 2017 Medicaid
21        inpatient utilization rate is less than 25%, the
22        hospital transformation payment shall be equal to 50%
23        of the sum of its transitional hospital access payment
24        authorized under subsection (d) and any supplemental
25        payment authorized under subsection (f).
26        (2) Phase 2. In State Fiscal Year 2021, the Department

 

 

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1    shall allocate the funds from the transitional access
2    hospital pool in the same manner as for Phase 1 as
3    described in paragraph (1). In addition, during State
4    Fiscal Year 2021 the Department shall prepare and make
5    available to hospitals data on health disparities for their
6    use in planning improvements by which they can address
7    negative impacts of health disparities in communities they
8    serve. If necessary an amount not to exceed $20,000,000
9    shall be available from the Hospital Provider Fund for the
10    Department as a health disparities pay-for-collection pool
11    to pay health care providers for collection of
12    patient-level data, such as on race and ethnicity,
13    sufficient to serve as the baseline year for measuring
14    improvement or lack of improvement in health disparities
15    and for adjustment of payments based on health disparities
16    in future years. In addition, during State Fiscal Year
17    2021, the Department, in conjunction with the Hospital
18    Transformation Review Committee, shall complete a
19    stakeholder process to determine the priorities of the
20    hospital transformation program, including at a minimum
21    the following:
22            (A) The Department, in conjunction with the
23        Hospital Transformation Review Committee, shall
24        provide an opportunity for public input and formal
25        mechanism for stakeholder participation in identifying
26        priority delivery system reform and improvement

 

 

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

 

 

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1    physical structure to transition to a new delivery model,
2    must submit to the Department in writing a transformation
3    plan, based on the Department's guidelines, that describes
4    the changes or service expansions it seeks to make and
5    selects process and outcome measures, from a set developed
6    by the Department, the hospital will meet through the
7    course of the transformation project; a timeline for the
8    transformation plan; as well as financial information
9    sufficient to allow the Department to determine whether the
10    changes or service expansions could occur but for
11    transformation program funding. desired delivery model
12    with projections of patient volumes by service lines and
13    projected revenues, expenses, and net income that
14    correspond to the new delivery model. In Phase 3 2, subject
15    to the approval of rules, the Department may use the
16    hospital transformation pool to increase base rates,
17    develop new adjustors, or adjust current adjustors, or
18    develop new access payments in order to support and
19    incentivize hospitals pursuing to pursue such
20    transformation. In developing such methodologies, the
21    Department shall ensure that the entire hospital
22    transformation pool continues to be expended to ensure
23    access to hospital services. If necessary an amount not to
24    exceed $20,000,000 per year shall be available from the
25    Hospital Provider Fund for the Department as a disparities
26    pay-for-collection pool to pay health care providers for

 

 

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1    collection of patient-level data, such as on race and
2    ethnicity, sufficient to serve as the baseline year for
3    measuring improvement or lack of improvement in health
4    disparities and for adjustment of payments based on health
5    disparities in future years. The Department annually shall
6    allocate to the hospital transformation pool funds from the
7    transitional access hospital pool; any unused amount from
8    the $20,000,000 health disparities pay-for-collection
9    pool; and $120,000,000 from the Hospital Provider Fund. or
10    to support organizations that had received hospital
11    transformation payments under this Section.
12            (A) Any hospital participating in the hospital
13        transformation program shall provide an opportunity
14        for public input by local community groups, hospital
15        workers, and healthcare professionals and assist in
16        facilitating discussions about any transformations or
17        changes to the hospital.
18            (A-5) Any hospital that seeks to commit
19        transformation funding to capital spending shall
20        submit to the Department in writing a transformation
21        plan, based on the Department's guidelines, that
22        describes the proposed changes to the hospital's
23        physical facilities with projections of patient
24        volumes by service lines and projected revenues,
25        expenses, and net income.
26            (B) As provided in paragraph (9) of Section 3 of

 

 

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1        the Illinois Health Facilities Planning Act, any
2        hospital seeking to expand services through
3        participating in the transformation program may be
4        excluded from the requirements of the Illinois Health
5        Facilities Planning Act for those projects related to
6        the hospital's transformation. To be eligible, the
7        hospital must submit to the Health Facilities and
8        Services Review Board certification from the
9        Department, approved by the Hospital Transformation
10        Review Committee, that the project is a part of the
11        hospital's transformation.
12            (C) (Blank). As provided in subsection (a-20) of
13        Section 32.5 of the Emergency Medical Services (EMS)
14        Systems Act, a hospital that received hospital
15        transformation payments under this Section may convert
16        to a freestanding emergency center. To be eligible for
17        such a conversion, the hospital must submit to the
18        Department of Public Health certification from the
19        Department, approved by the Hospital Transformation
20        Review Committee, that the project is a part of the
21        hospital's transformation.
22        (4)(A) By August 1, 2020 the Department, in conjunction
23    with the Hospital Transformation Review Committee, shall
24    develop and file administrative rules with the Secretary of
25    State setting forth processes for data collection and
26    payment from the health disparities pay-for-collection

 

 

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1    pool.
2        (B) By March 1, 2021 (3) By April 1, 2019 March 12,
3    2018 (Public Act 100-581) the Department, in conjunction
4    with the Hospital Transformation Review Committee, shall
5    develop and file as an administrative rule with the
6    Secretary of State the goals, objectives, policies,
7    standards, payment models, process and outcome measures,
8    or criteria to be applied in Phase 3 2 of the program to
9    allocate the hospital transformation funds. The goals,
10    objectives, and policies to be considered may include, but
11    are not limited to, reducing health disparities; achieving
12    unmet needs of a community that a hospital serves such as
13    behavioral health services, outpatient services, or drug
14    rehabilitation services; attaining certain quality or
15    patient safety benchmarks for health care services; or
16    improving the coordination, effectiveness, and efficiency
17    of care delivery. The rulemaking shall direct managed care
18    organizations (MCOs) to make payments under this
19    subsection (d-5) in a manner conforming with 42 CFR 438.6
20    regarding payments directed to be made by MCOs as part of a
21    delivery system reform and improvement initiatives.
22    Notwithstanding any other provision of law, any rule
23    adopted in accordance with this subsection (d-5) may be
24    submitted to the Joint Committee on Administrative Rules
25    for approval only if the rule has first been approved by 9
26    of the 14 members of the Hospital Transformation Review

 

 

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

 

 

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1    Section. In addition to reviewing and approving the
2    policies, procedures, and rules for the hospital
3    transformation program, the Committee shall consider and
4    make recommendations related to qualifying criteria and
5    payment methodologies related to safety-net hospitals and
6    children's hospitals. Members of the Committee appointed
7    by the legislative leaders shall be subject to the
8    jurisdiction of the Legislative Ethics Commission, not the
9    Executive Ethics Commission, and all requests under the
10    Freedom of Information Act shall be directed to the
11    applicable Freedom of Information officer for the General
12    Assembly. The Department shall provide operational support
13    to the Committee as necessary. The Committee is dissolved
14    on April 1, 2019.
15        (6) Definitions. As used in this Section:
16        "Managed care organization" or "MCO" means an entity
17    which contracts with the Department to provide services
18    where payment for medical services is made on a capitated
19    basis.
20        "Health disparities" mean preventable differences in
21    the burden of disease, injury, violence, or opportunities
22    to achieve optimal health that are experienced by socially
23    disadvantaged populations.
24    
25    (e) Beginning 36 months after initial implementation, the
26Department shall update the reimbursement components in

 

 

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1subsections (a) and (b), including standardized amounts and
2weighting factors, and at least triennially and no more
3frequently than annually thereafter. The Department shall
4publish these updates on its website no later than 30 calendar
5days prior to their effective date.
6    (f) Continuation of supplemental payments. Any
7supplemental payments authorized under Illinois Administrative
8Code 148 effective January 1, 2014 and that continue during the
9period of July 1, 2014 through December 31, 2014 shall remain
10in effect as long as the assessment imposed by Section 5A-2
11that is in effect on December 31, 2017 remains in effect.
12    (g) Notwithstanding subsections (a) through (f) of this
13Section and notwithstanding the changes authorized under
14Section 5-5b.1, any updates to the system shall not result in
15any diminishment of the overall effective rates of
16reimbursement as of the implementation date of the new system
17(July 1, 2014). These updates shall not preclude variations in
18any individual component of the system or hospital rate
19variations. Nothing in this Section shall prohibit the
20Department from increasing the rates of reimbursement or
21developing payments to ensure access to hospital services.
22Nothing in this Section shall be construed to guarantee a
23minimum amount of spending in the aggregate or per hospital as
24spending may be impacted by factors, including, but not limited
25to, the number of individuals in the medical assistance program
26and the severity of illness of the individuals.

 

 

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1    (h)(1) The Department shall have the authority to modify by
2rulemaking any changes to the rates or methodologies in this
3Section as required by the federal government to obtain federal
4financial participation for expenditures made under this
5Section.
6    (2) The Department shall have the authority to adjust by
7rulemaking payment methodologies in this Section if such
8adjustments are required by the federal government to conform
9with 42 CFR 438.6 regarding payments directed to be made by
10MCOs.
11    (i) Except for subsections (g) and (h) of this Section, the
12Department shall, pursuant to subsection (c) of Section 5-40 of
13the Illinois Administrative Procedure Act, provide for
14presentation at the June 2014 hearing of the Joint Committee on
15Administrative Rules (JCAR) additional written notice to JCAR
16of the following rules in order to commence the second notice
17period for the following rules: rules published in the Illinois
18Register, rule dated February 21, 2014 at 38 Ill. Reg. 4559
19(Medical Payment), 4628 (Specialized Health Care Delivery
20Systems), 4640 (Hospital Services), 4932 (Diagnostic Related
21Grouping (DRG) Prospective Payment System (PPS)), and 4977
22(Hospital Reimbursement Changes), and published in the
23Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
24(Specialized Health Care Delivery Systems) and 6505 (Hospital
25Services).
26    (j) Out-of-state hospitals. Beginning July 1, 2018, for

 

 

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1purposes of determining for State fiscal years 2019 and 2020
2the hospitals eligible for the payments authorized under
3subsections (a) and (b) of this Section, the Department shall
4include out-of-state hospitals that are designated a Level I
5pediatric trauma center or a Level I trauma center by the
6Department of Public Health as of December 1, 2017.
7    (k) The Department shall notify each hospital and managed
8care organization, in writing, of the impact of the updates
9under this Section at least 30 calendar days prior to their
10effective date.
11(Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19;
12101-81, eff. 7-12-19; revised 7-29-19.)
 
13    Section 99. Effective date. This Act takes effect upon
14becoming law.

 

 

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1 INDEX
2 Statutes amended in order of appearance
3    5 ILCS 100/5-45.1 new
4    210 ILCS 50/32.5
5    305 ILCS 5/5A-2from Ch. 23, par. 5A-2
6    305 ILCS 5/5A-12.6
7    305 ILCS 5/5A-13
8    305 ILCS 5/5A-14
9    305 ILCS 5/14-12