Effective for dates of discharge on or after July 1,
2014:
a) Inpatient psychiatric services
not excluded from the DRG PPS pursuant to 89 Ill. Adm. Code
149.50(b)
shall be reimbursed through the DRG PPS.
b) Inpatient psychiatric services excluded
from the DRG PPS shall be reimbursed a hospital-specific rate paid per day of
covered inpatient care, determined pursuant to subsection (c), (d) or (g), as
applicable. The total payment for an inpatient stay will equal the sum of:
1) the payment determined in this Section;
and
2) any applicable adjustments
to the payment specified in Section
148.290.
c) Psychiatric Hospital. Payment for
inpatient psychiatric services provided by a psychiatric hospital, as defined
in Section
148.25(d)(1):
1) For psychiatric hospitals not enrolled
with the Department on June 30, 2014, shall be the product of:
A) The lowest hospital psychiatric rate
determined pursuant to subsection (e); and
B) The length of stay, as defined in 89 Ill.
Adm. Code
149.100(i).
2) For psychiatric hospitals enrolled with
the Department on June 30, 2014, shall be the product of:
A) The hospital's psychiatric rate, as
determined in subsection (e).
B)
The length of stay, as defined in 89 Ill. Adm. Code
149.100(i).
d) Distinct Part Psychiatric Unit. Payment
for psychiatric services provided by a distinct part psychiatric unit, as
defined in Section
148.25(c)(1):
1) For which the Department had no inpatient
base period paid claims data, shall be the product of the following:
A) 80 percent of the arithmetic mean
transition rate for psychiatric distinct part units; and
B) The length of stay, as defined in 89 Ill.
Adm. Code
149.100(i).
2) For which the Department had inpatient
base period paid claims data, shall be the product of the following:
A) The lesser of:
i) The greater of:
* The distinct part psychiatric unit rate, as determined in
subsection (e); and
* 80 percent of the arithmetic mean psychiatric rate for
psychiatric distinct part units.
ii) The arithmetic mean rate for psychiatric
distinct part units plus the value of two standard deviations of the
psychiatric rate for psychiatric distinct part units.
B) The length of stay, as defined in 89 Ill.
Adm. Code
149.100(i).
3) For Safety Net Hospitals, as defined in
305 ILCS
5/5-5e.1(a), effective January 1, 2021, shall be the
product of the following:
A) The greater of
i) the hospital's inpatient psychiatric rate
as of June 30, 2021, or
ii)
$630.
B) The length of
stay, as defined in 89 Ill. Adm. Code
149.100(i).
e) The psychiatric rate is
calculated as the sum of:
1) The per diem rate
for psychiatric services in effect on June 30, 2014.
2) The quotient, rounded to the nearest
hundredth, of the psychiatric provider's allocated static payments divided by
the psychiatric provider's inpatient covered days in the inpatient base period
paid claims data.
f)
Definitions
"Allocated static payments" means the adjustment payments
made to the hospital pursuant to Sections
148.105,
148.115,
148.126,
148.295,
148.296
and
148.298
during the SFY 2011, excluding those payments that continue after July 1, 2014,
pursuant to the methodologies outlined in rule as of February 21, 2014 (see
http://www2.illinois.gov/hfs/PublicInvolvement/hospitalratereform/Pages/Rules.aspx),
as determined by the Department, allocated to psychiatric services based on the
ratio of psychiatric claim charges to total inpatient claim charges determined
using inpatient base period claims data.
"Inpatient base period paid claims data" means SFY 2011
inpatient Medicaid fee-for-service paid claims data, excluding Medicare dual
eligible claims, for psychiatric payment for services provided in SFY 2015 and
2016.
g) Psychiatric
hospital adjustors for dates of service beginning July 1, 2014 through June 30,
2018. For Illinois freestanding psychiatric hospitals, defined in Section
148.25(d)(1),
that were not children's hospitals as defined in Section
148.25(d)(3)
in FY 2013 and whose Medicaid covered days were 90% or more for individuals
under 20 years of age in FY 2013, the Department shall pay a per day add-on of
$48.25.
