Proposed Changes In Methods And Standards

SUBPART B: REIMBURSMENT AND RELATED PROVISIONS

Section 148.126 Safety Net Adjustment Payments

a) Qualifying criteria: Safety net adjustment payments shall be made to a qualifying hospital, as defined in this subsection (a). A hospital not otherwise excluded under subsection (b) of this Section shall qualify for payment if it meets one of the following criteria:

1) The hospital has, as provided in subsection (e)(6) of this Section, an MIUR equal to or greater than 40 percent.

 

2) The hospital has the highest number of obstetrical care days in the safety net hospital base year.

 

3) The hospital is, as of October 1, 2001, a sole community hospital, as defined by the United States Department of Health and Human Services (42 CFR 412.92).

 

4) The hospital is, as of October 1, 2001, a rural hospital, as described in Section 148.25(g)(3), that meets all of the following criteria:

 

A) Has an MIUR greater than 33 percent.

 

B) Is designated a perinatal level two center by the Illinois Department of Public Health.

 

C) Has fewer than 125 licensed beds.

5) The hospital is a rural hospital, as described in Section 148.25(g)(3).

 

6) The hospital meets all of the following criteria:

 

A) Has an MIUR greater than 30 percent.

 

B) Had an occupancy rate greater than 80 percent in the safety net hospital base year.

 

C) Provided greater than 15,000 total days in the safety net hospital base year.

7) The hospital meets all of the following criteria:

 

A) Does not already qualify under subsections (a)(1) through (a)(6) of this Section.

 

B) Has an MIUR greater than 25 percent.

 

C) Had an occupancy rate greater than 68 percent in the safety net hospital base year.

 

D) Provided greater than 12,000 total days in the safety net hospital base year.

8) The hospital meets all of the following criteria:

 

A) Does not already qualify under subsections (a)(1) through (a)(7) of this Section.

 

B) Located outside of HSA 6.

 

C) Has an MIUR greater than 16 percent.

 

D) Licensed beds greater than 475.

 

E) Average length of stay less than five days.

b) The following five classes of hospitals are ineligible for safety net adjustment payments associated with the qualifying criteria listed in subsections (a)(1) through (a)(4) and subsections (a)(6) through (a)(8)(7) of this Section:  

1) Hospitals located outside of Illinois.

 

2) County-owned hospitals, as described in Section 148.25(b)(1)(A).

 

3) Hospitals organized under the University of Illinois Hospital Act, as described in Section 148.25(b)(1)(B).

 

4) Psychiatric hospitals, as described in 89 Ill. Adm. Code 149.50(c)(1).

 

5) Long term stay hospitals, as described in 89 Ill. Adm. Code 149.50(c)(4).

c) Safety Net Adjustment Rates

1) For a hospital qualifying under subsection (a)(1) of this Section, the rate is the sum of the amounts for each of the following criteria for which it qualifies:

 

A) A qualifying hospital-$15.00.

 

B) A rehabilitation hospital, as described in 89 Ill. Adm. Code 149.50(c)(2)-$20.00.

 

C) A children's hospital, as described in 89 Ill. Adm. Code 149.50(c)(3)-$20.00.

 

D) A children's hospital that has an MIUR greater than or equal to 80 per centum that is:

 

i) Located within HSA 6 or HSA 7-$200.50 $80.00.

 

ii) Located outside HSA 6 or HSA 7-$35.00.

E) A children's hospital that has an MIUR less than 80 per centum, but greater than or equal to 60 per centum, that is:

 

i) Located within HSA 6 or HSA 7-$35.00.

 

ii) Located outside HSA 6 or HSA 7-$15.00.

F) A children's hospital that has an MIUR less than 60 per centum, but greater than or equal to 45 per centum, that is:

 

i) Located within HSA 6 or HSA 7-$12.00.

 

ii) Located outside HSA 6 or HSA 7-$5.00.

G) A children's hospital with more than 25 graduate medical education programs, as listed in the "2000-2001 Graduate Medical Education Directory"-$125.00.

 

H) A children's hospital that is a rural hospital-$145.00.

 

I) A qualifying hospital, that is neither a rehabilitation hospital nor a children's hospital, that is located in HSA 6 and that:

 

i) Provides obstetrical care-$10.00.

 

ii) Has at least one graduate medical education program, as listed in the "2000-2001 Graduate Medical Education Directory"-$5.00.  

 

iii) Has at least one obstetrical graduate medical education program, as listed in the "2000-2001 Graduate Medical Education Directory"-$5.00.

 

iv) Provided more than 5,000 obstetrical days during the safety net hospital base year-$35.00.

 

v) Provided fewer than 4,000 obstetrical days during the safety net hospital base year and its average length of stay is: less than or equal to 4.50 days-$5.00; less than 4.00 days-$5.00; less than 3.75 days-$5.00.

 

vi) Provides obstetrical care and has an MIUR greater than 65 percent-$11.00.

J) A qualifying hospital that is neither a rehabilitation hospital nor a children's hospital, that is located outside HSA 6, that has an MIUR greater than 50 per centum, and that:

 

i) Provides obstetrical care-$70.00.

 

ii) Does not provide obstetrical care-$30.00.  

K) A qualifying hospital that provided greater than 35,000 total days in the safety net hospital base year-$6.00. 

 

L) A qualifying hospital with two or more graduate medical education programs, as listed in the "2000-2001 Graduate Medical Education Directory", with an average length of stay fewer than 4.00 days-$48.00.  

2) For a hospital qualifying under subsection (a)(2) of this Section, the rate shall be $123.00. 

 

3) For a hospital qualifying under subsection (a)(3) of this Section, the rate is the sum of the amounts for each of the following criteria for which it qualifies:  

 

A) A qualifying hospital-$40.00.

 

B) A hospital that has an average length of stay of fewer than 4.00 days, and: 

i) More than 150 licensed beds-$20.00.

 

ii) Fewer than 150 licensed beds-$40.00.

C) A qualifying hospital with the lowest average length of stay-$15.00.

 

D) A hospital that has a CMIUR greater than 65 per centum-$35.00.

 

E) A hospital that has fewer than 25 total admissions in the safety net hospital base year-$160.00.

4) For a hospital qualifying under subsection (a)(4) of this Section, the rate shall be $55.00.

 

 5) For a hospital qualifying under subsection (a)(5) of this Section, the rate is the sum of the amounts for each of the following for which it qualifies, divided by the hospital's total days:

 

A) The hospital that has the highest number of obstetrical care admissions-$30,840.00.

 

 B) The greater of: 

i) The product of $115.00 multiplied by the number of obstetrical care admissions.

  

ii) The product of $11.50 multiplied by the number of general care admissions.

6) For a hospital qualifying under subsection (a)(6) of this Section, the rate is $30.00.  

7) For a hospital qualifying under subsection (a)(7) of this Section, the rate is $117.00. 

8) For a hospital qualifying under subsection (a)(8) of this Section, the rate is $34.50.

d) Payment to a Qualifying Hospital

1) The total annual payments to a qualifying hospital shall be the product of the hospital's rate multiplied by two multiplied by total days.  

 

2) For the safety net adjustment period occurring in State fiscal year 2006, total payments will equal the methodologies described in subsection (c) of this Section. For the period October 1, 2005, through June 30, 2006, payment will equal the State fiscal year 2006 amount less the amount the hospital received under the safety net adjustment period for the quarter ending September 30, 2005.  

 

3)2) For safety net adjustment periods occurring after State fiscal year 2006 2003, total payments will equal the methodologies described in subsection (c) of this Section and shall be paid to the hospital during the safety net adjustment period in installments on, at least, a quarterly basis.

e) Definitions  

1) "Average length of stay" means, for a given hospital, a fraction in which the numerator is the number of total days and the denominator is the number of total admissions.

 

2) "CMIUR" means, for a given hospital, the sum of the MIUR plus the Medicaid obstetrical inpatient utilization rate, determined as of October 1, 2001, as defined in Section 148.120(k)(6).

 

3) "General care admissions" means, for a given hospital, the number of hospital inpatient admissions for recipients of medical assistance under Title XIX of the Social Security Act, as tabulated from the Department's claims data for admissions occurring in the safety net hospital base year that were adjudicated by the Department by June 30, 2001, excluding admissions for: obstetrical care, as defined in subsection (e)(7) of this Section; normal newborns; psychiatric care; physical rehabilitation; and those covered in whole or in part by Medicare (Medicaid/Medicare crossover admissions).

 

4) "HSA" means Health Service Area, as defined by the Illinois Department of Public Health.

 

5) "Licensed beds" means, for a given hospital, the number of licensed beds, excluding long term care and substance abuse beds, as listed in the July 25, 2001, Illinois Department of Public Health report entitled "Percent Occupancy by Service in Year 2000 for Short Stay, Non-Federal Hospitals in Illinois."

 

6) "MIUR", for a given hospital, has the meaning as defined in Section 148.120(k)(5) and shall be determined in accordance with Section 148.120(c) and (f). For purposes of this Section, the MIUR determination that was used to determine a hospital's eligibility for Disproportionate Share Hospital Adjustment payments in rate year 2002 shall be the same determination used to determine a hospital's eligibility for safety net adjustment payments in the Safety Net Adjustment Period.

 

7) "Obstetrical care admissions" means, for a given hospital, the number of hospital inpatient admissions for recipients of medical assistance under Title XIX of the Social Security Act, as tabulated from the Department's claims data, for admissions occurring in the safety net hospital base year that were adjudicated by the Department through June 30, 2001, and were assigned by the Department a diagnosis related grouping (DRG) code of 370 through 375.

 

8) "Obstetrical care days" means, for a given hospital, days of hospital inpatient service associated with the obstetrical care admissions described in subsection (e)(7) of this Section.

 

9) "Occupancy rate" means a fraction, the numerator of which is the hospital's total days, excluding long term care and substance abuse days, and the denominator of which is the hospital's total beds, excluding long term care and substance abuse beds, multiplied by 365 days. The data used for calculation of the hospital occupancy rate is as listed in the July 25, 2001, Illinois Department of Public Health report entitled "Percent Occupancy by Service in Year 2000 for Short Stay, Non-Federal Hospitals in Illinois."

 

10) "Safety net hospital base year" means the 12-month period beginning on July 1, 1999, and ending on June 30, 2000.

 

11) "Safety net adjustment period" means, beginning July 1, 2002, the 12 month period beginning on July 1 of a year, and ending on June 30 of the following year.

 

12) "Total admissions" means, for a given hospital, the number of hospital inpatient admissions for recipients of medical assistance under Title XIX of the Social Security Act, excluding admissions for individuals eligible for Medicare under Title XVIII of that Act (Medicaid/Medicare crossover admissions), as tabulated from the Department's claims data for admissions occurring in the safety net hospital base year that were adjudicated by the Department through June 30, 2001.

 

13) "Total days" means, for a given hospital, the sum of days of inpatient hospital service provided to recipients of medical assistance under Title XIX of the federal Social Security Act, excluding days for individuals eligible for Medicare under Title XVIII of that Act (Medicaid/Medicare crossover days), as tabulated from the Department's claims data for admissions occurring in the safety net hospital base year that were adjudicated by the Department through June 30, 2001.

(Source: Amended at 29 Ill. Reg. _______ effective _____________________)
 

ILLINOIS REGISTER
 

DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

NOTICE OF PROPOSED AMENDMENT