General Provisions – Inpatient

Section 148.403  General Provisions – Inpatient Effective for dates of service starting July 1, 2018, except when specifically designated otherwise in this Section: a)         General Provisions. Unless otherwise indicated, the following apply to these Sections: 148.401 and 148.421. 1)         Payments A)        Effective July 1, 2018, payments shall be paid in 12 installments on or before the 7 th State business day of the month. B)        The Department may adjust payments made under these Sections to comply with federal law or regulations regarding disproportionate share, hospital-specific payment limitations on government-owned or government-operated hospitals. C)        If the State or federal Centers for Medicare and Medicaid Services finds that any federal upper payment limit applicable to the payments under these Sections is exceeded, then the payments under these Sections that exceed the applicable federal upper payment limit shall be reduced uniformly to the extent necessary to comply with the federal limit. b)         Definitions. As used in this Section, unless the context requires otherwise: 1) "General acute care admissions" means, for a given hospital, the sum of inpatient hospital admissions provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, excluding admissions for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover admissions), as tabulated from the Department's paid claims data for general acute care admissions occurring during SFY 2015 as of October 28, 2016. 2) "Occupancy ratio" is determined utilizing the Illinois Department of Public Health Hospital Profile CY15 – Facility Utilization Data – Source 2015 Annual Hospital Questionnaire. Utilizes all beds and days including observation days but excludes Long Term Care and Swing bed and their associated beds and days. 3) "Outpatient services" means, for a given hospital, the sum of the number of outpatient encounters identified as unique services provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding outpatient services for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover services), as tabulated from the Department's paid claims data for outpatient services occurring during SFY 2015 as of October 28, 2016. 4) "Total days" means, for a given hospital, the sum of inpatient hospital days provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding days for individuals eligible for Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare crossover days), as tabulated from the Department's paid claims data for total days occurring during SFY 2015 as of October 28, 2016. 5) "Total admissions" means, for a given hospital, the sum of inpatient hospital admissions provided to recipients of medical assistance under Title XIX of the Social Security Act for general acute care, psychiatric care, and rehabilitation care, excluding admissions for individuals eligible for Medicare under Title XVIII of that Act (Medicaid/Medicare crossover admissions), as tabulated from the Department's paid claims data for admissions occurring during SFY 2015 as of October 28, 2016. [305 ILCS 5/5A-12.6(p)] 6)         "Academic medical centers and major teaching hospital" means the academic medical centers and major teaching hospital definition found in Section 148.25. 7)         "MIUR" means Medicaid inpatient utilization rate for rate year 2017. 8)         "Publicly owned hospital" means any hospital owned by a political subdivision. 9)         As used in this subsection, "service credit factor" is determined based on a hospital's rate year 2017 Medicaid inpatient utilization rate ("MIUR") rounded to the nearest whole percentage. c)         Rate reviews 1)         A hospital shall be notified in writing of the results of the payment determination pursuant to the applicable Section. 2)         Hospitals shall have a right to appeal the calculation of, or their ineligibility for, payment if the hospital believes that the Department has made a technical error. The appeal must be submitted in writing to the Department and must be received or postmarked within 30 days after the date of the Department's notice to the hospital of its qualification for the payment amounts, or a letter of notification that the hospital does not qualify for payments. Such a request must include a clear explanation of the reason for the appeal and documentation that supports the desired correction. The Department shall notify the hospital of the results of the review within 30 days after receipt of the hospital's request for review.