Provider Notice issued 11/28/2023

This is to inform you that the department has determined that your facility is subject to the inpatient and outpatient assessments imposed on Illinois hospital inpatient and outpatient services under the provisions of 305 ILCS 5/5-A and that the Department has posted the Hospital Reimbursement Notifications | HFS (illinois.gov) to the Hospital Reimbursement Notifications Website under the Section Directed Payment and Passthrough Reports.

Your facility’s inpatient and outpatient assessment remittance notices for January through June of fiscal year 2024 per Public Act 101-0650, have been mailed via USPS Attn: Chief Financial Officer.  Please make your mailroom aware of these important documents.

Also enclosed will be tax calculation worksheets detailing the bases for the inpatient and outpatient assessments. The remittance notice has the facility’s name and address, the tax identification number, the total amount due, and the due date. 

Each hospital facility mandated to pay the Hospital Provider Assessment will be required to complete the attached ACH Vendor/Miscellaneous Payment Enrollment form (Standard Form 3881 - https://www.fiscal.treasury.gov/files/forms/3881.pdf), and submit it to HFS.ProviderAssessmentUnit@Illinois.gov.  Once the Treasurer’s Office has completed their portion of the form, we will return it via email to the facility.  This should then be shared with the facility’s banking institution.  Included with the completed SF 3881 form, the Department will provide a list of informational fields which are required to be completed when submitting payment.

ACH/Wire Transfers Form Completion Instructions

AGENCY INFORMATION

Federal Program Name:           Name of facility

Agency Identifier:                   HFS

Agency Location Code:           478

ACH Format:                          CCD+ (ACH Credit)  OR  CTX (Wire Transfer)

Address:                                 Facility address

Contact Person Name:             The person the IL Treasurer’s Office contacts to set up the ACH

Telephone Number:                Telephone number of Contact

Additional Information:           Email address of Contact

PAYEE/COMPANY INFORMATION

Name:                                    Illinois Healthcare and Family Services

SSN No or Taxpayer ID No:    371320188

Address:                                 201 South Grand Avenue East
                                              Springfield, IL 62763

Contact Person Name:             Donavon Patton

Telephone Number:                217-785-9623

FINANCIAL INSTITUTION INFORMATION

This is completed by our Treasurer’s Office

If you have any questions concerning this information, please do not hesitate to contact the Bureau of Rate Development and Analysis by e-mail at HFS.ProviderAssessmentUnit@illinois.gov, or by telephone at 217-524-7110.

Kathleen Staley, Chief
Bureau of Rate Development and Analysis     

Authorization for Direct Debit Form (HFS 3848G) (pdf)

*Assessment due date extended