Section 148.110 Reimbursement Methodologies for Inpatient Psychiatric Services

Section 148

TITLE 89: SOCIAL SERVICES

CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

SUBCHAPTER d: MEDICAL PROGRAMS

PART 148 HOSPITAL SERVICES

SECTION 148.110 REIMBURSEMENT METHODOLOGIES FOR INPATIENT PSYCHIATRIC SERVICES

Section 148.110  Reimbursement

Methodologies for Inpatient Psychiatric Services

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.  Effective January 1, 2024, 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 December 31, 2023,

shall be the product of:

A)        90% of

the minimum rate in subsection (d)(3); 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 December 31, 2023, shall

be the product of:

A)        The greater

of:

i)          The

hospital's psychiatric rate in effect on December 31, 2023 multiplied by 1.1;

or

ii)         90%

of the minimum rate in subsection (d)(3);

B)        The

length of stay, as defined in 89 Ill. Adm. Code 149.100(i).

d)         Distinct

Part Psychiatric Unit

sychiatric hospitals enrolled with the Department on December 31, 2023, shall

be the product of:

A)        The greater

of:

i)          The

hospital's psychiatric rate in effect on December 31, 2023 multiplied by 1.1;

or

ii)         90%

of the minimum rate in subsection (d)(3);

B)        The

length of stay, as defined in 89 Ill. Adm. Code 149.100(i).

d)         Distinct

Part Psychiatric Unit.  Effective January 1, 2024, payment for psychiatric

services provided by a distinct part psychiatric unit, as defined in Section

148.25(c)(1):

1)         Distinct

part psychiatric units that were not enrolled with the Department on December

31, 2023 shall be the product of the following:

A)        90

percent of the minimum rate in subsection (d)(3); and

B)        The

length of stay, as defined in 89 Ill. Adm. Code 149.100(i).

2)         Distinct

part psychiatric units that were enrolled with the Department on December 31,

2023, shall be the product of the following:

A)        The greater

of:

i)          The

rate in effect on December 31, 2023 multiplied by 1.1, or;

ii)         90

percent of the minimum rate in subsection (d)(3).

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, 2024,

the per diem rate for psychiatric services is the greater of:

A)        the

rate in effect on December 31, 2023 multiplied by 1.1; or

B)        the

minimum rate of $693.

4)         For general acute care hospitals that provide

more than 9,500 inpatient psychiatric days in a calendar year, effective

January 1, 2024

, the

per diem rate for psychiatric

services

is as follows:

A)        The

greater of

i)          The

hospital's per diem rate for psychiatric services as of December 31, 2021; or

ii)         $693.

e)         Psychiatric

hospital adjustors for dates of service beginning July 1, 2014

hospitals that provide

more than 9,500 inpatient psychiatric days in a calendar year, effective

January 1, 2024

, the

per diem rate for psychiatric

services

is as follows:

A)        The

greater of

i)          The

hospital's per diem rate for psychiatric services as of December 31, 2021; or

ii)         $693.

e)         Psychiatric

hospital adjustors for dates of service beginning July 1, 2014. 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.

f)         Effective

January 1, 2022, payment for long-acting injectable antipsychotic drugs and

long-acting injectable substance use disorder drugs administered in the

inpatient psychiatric setting will be reimbursed at the Department's rate.

1)         All

rates are published on the Department's website in the Practitioner Fee

Schedule.

2)         Regarding

long-acting injectable antipsychotics, the following criteria shall be adhered

to regardless of whether the individual is enrolled with a Medicaid Managed

Care Organization or fee-for-service:

A)        The

prescriber must be a board-certified psychiatrist or a board-eligible

psychiatrist. For the purposes of this subsection, a "board-eligible

psychiatrist" is a physician who has, within the past 7 years,

successfully completed residency training accredited by the Accreditation

Council for Graduate Medical Education or approved by the American Board of

Psychiatry and Neurology in a psychiatric primary specialty or subspecialty;

B)        The

injectable atypical antipsychotic agents (AAPI) prior approval will follow the

Food and Drug Administration (FDA) approved labeling for the indication for

each medication; and

C)        The

prescriber agrees to coordinate a follow up outpatient appointment for

administration of the next recommen

ard of

Psychiatry and Neurology in a psychiatric primary specialty or subspecialty;

B)        The

injectable atypical antipsychotic agents (AAPI) prior approval will follow the

Food and Drug Administration (FDA) approved labeling for the indication for

each medication; and

C)        The

prescriber agrees to coordinate a follow up outpatient appointment for

administration of the next recommended dose of the AAPI and provide

documentation of the follow up appointment with request for prior

authorization.