a) Effective for
dates of outpatient services on or after July 1, 2014 and inpatient discharges
on July 1, 2014 through December 31, 2015:
1)
Inpatient Reimbursement Methodology
In accordance with 89 Ill. Adm. Code
149.50(b)(5),
county-owned hospitals, as defined in Section
148.25(a)(1),
are excluded from the DRG PPS for reimbursement for inpatient hospital services
and are reimbursed on a per diem basis.
A) Inpatient Per Diem Rate Calculation
County-owned hospital inpatient per diem rates are calculated
as follows:
i) Each county-owned
hospital's inpatient base year costs, including operating capital and direct
medical education costs, shall be calculated using inpatient base period claims
data and Medicare cost report data with reporting periods matching the
inpatient base period. Effective July 1, 2018, direct and indirect medical
education costs shall be reduced from the inpatient base year cost.
ii) The inpatient base year costs shall be
inflated from the midpoint of the inpatient base period claims data to the
midpoint of the time period for which rates are being set (rate period) based
on an inflation methodology determined by the Department and approved by
Centers for Medicare and Medicaid Services (CMMS).
iii) Calculate the sum of:
* The total hospital inflated base year costs, excluding
non-Medicare crossover claims, in the inpatient base period claims data;
and
* Total uncovered Medicare crossover claim cost in the
inpatient base period claims data.
iv) The inpatient per diem rate shall be the
quotient of:
* Combined inflated base year cost and uncovered Medicare
crossover claims cost, per subsection (a)(1)(C); and
* Total hospital base year covered days, excluding
non-Medicare crossover claims, in the inpatient base period claims data.
v) The inpatient per diem rates
shall be reduced if resulting payments exceed available Department funding or
the CMMS Upper Payment Limit.
B) Rate Updates
County-owned hospital per diem rates shall be updated on an
annual basis using more recent inpatient base period claims data, Medicare cost
report data and cost inflation data.
C) New hospitals, for which inpatient base
period claims data or Medicare cost reports are not on file, will be reimbursed
the per diem rate calculated in subsection (a)(1)(A).
D) Review Procedure
The review procedure shall be in accordance with Section
148.310.
2) Outpatient Reimbursement
Methodology
Large public hospitals, as defined in Section
148.25(a),
are included in the EAPG PPS for reimbursement for outpatient hospital services
as described in Section
148.140,
and are to receive provider-specific EAPG standardized amounts.
A) Outpatient EAPG Standardized Amount
Calculation
County-owned hospital outpatient EAPG standardized amounts
are calculated as follows:
i) Each
county-owned hospital's outpatient base year costs, including operating,
capital and direct medical education costs, shall be calculated using
outpatient base period claims data and Medicare cost report data with reporting
periods matching the outpatient base period.
ii) The outpatient base year costs shall be
inflated from the midpoint of the outpatient base period claims data to the
midpoint of the rate period based on an inflation methodology determined by the
Department and approved by CMMS.
iii) Prior to July 1, 2018, EAPG standardized
amounts shall be determined for each county-owned hospital such that simulated
EAPG payments are equal to outpatient base period costs inflated to the rate
period, based on outpatient based period paid claims data. Effective July 1,
2018, EAPG standardized amounts shall be determined for each county-owned
hospital such that simulated EAPG payments are equal to outpatient base period
costs inflated to the rate period, based on outpatient based period claims
data, less an amount calculated in Section
148.406(f).
iv) EAPG standardized amounts shall be
reduced if resulting payments exceed available HFS funding or the CMMS Upper
Payment Limit.
B) Rate
Updates and Adjustments
i) County-owned
hospital EAPG standardized amounts shall be updated on an annual basis using
more recent outpatient base period claims data, Medicare cost report data, and
costs inflation data.
ii)
Restructuring Adjustments
Adjustments to outpatient base year costs, as described in
subsection (a)(2)(A), will be made to reflect restructuring since filing the
base year costs reports. The restructuring must have been mandated to meet
State, federal or local health and safety standards. The allowable
Medicare/Medicaid costs (see 42 CFR 405, Subpart D, (1982)) must be incurred as
a result of mandated restructuring and identified from the most recent audited
cost reports available before or during the rate year. The restructuring cost
must be significant, i.e., on a per unit basis; they must constitute one
percent or more of the total allowable Medicare/Medicaid unit costs for the
same time period. The Department will use the most recent available cost
reports to determine restructuring costs.
C) New hospitals, for which outpatient base
period claims data or Medicare cost reports are not on file, will be reimbursed
the EAPG standardized amount calculated in subsection (a)(2)(A).
D) Review Procedure
The review procedure shall be in accordance with Section
148.320.
3) Definitions, as used in this
Section:
"Inpatient base period paid claims data" means:
Prior to July 1, 2018, Medicaid fee-for-service inpatient
paid claims data from the State fiscal year ending 36 months prior to the
beginning of the rate period.
Effective July 1, 2018, Medicaid fee-for-service and MCO
encounter inpatient claims data from the State fiscal year ending 12 months
prior to the beginning of the rate period.
"Outpatient base period paid claims data" means:
Prior to July 1, 2018, Medicaid fee-for-service outpatient
paid claims data from the State fiscal year ending 36 months prior to the
beginning of the rate period, excluding crossover claims.
Effective July 1, 2018, Medicaid fee-for-service and MCO
encounter outpatient claims data from the State fiscal year ending 12 months
prior to the beginning of the rate period, excluding crossover claims.
"Rate period" means the State fiscal year for which the
county-owned hospital inpatient and outpatient rates are
effective.
b)
Effective for inpatient acute care discharges on or after January 1, 2016,
county-owned hospitals, as defined in Section
148.25(a)(1),
shall be reimbursed at allowable cost on a DRG basis. The DRG base payment
shall be the product, rounded to the nearest hundredth, of:
1) The DRG weighting factor of the DRG and
SOI (severity of illness), to which the inpatient stay was assigned by the
grouper.
2) The DRG base rate
determined:
A) Prior to July 1, 2018, such
that simulated base period as defined in subsection (a)(3) DRG payments are
equal to adjusted base period costs, as determined in subsection (a)(1)(A)(ii);
and
B) Effective July 1, 2018, such
that simulated DRG payments are equal to inpatient base period costs inflated
to the rate period, based on inpatient based period claims data, less an amount
calculated in Section
148.406(c).
