Section 148.130 Outlier Adjustments for Exceptionally Costly Stays

Section 148

TITLE 89: SOCIAL SERVICES

CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

SUBCHAPTER d: MEDICAL PROGRAMS

PART 148 HOSPITAL SERVICES

SECTION 148.130 OUTLIER ADJUSTMENTS FOR EXCEPTIONALLY COSTLY STAYS

Section 148.130  Outlier

Adjustments for Exceptionally Costly Stays

a)         Outlier Adjustments.  Outlier adjustments are provided for

exceptionally costly stays provided by hospitals or distinct part units

reimbursed on a per diem basis or hospitals reimbursed in accordance with

Section 148.82(g) for discharges before July 1, 2014. For discharges on or

after July 1, 2014, this Section shall not be utilized for the basis of any

hospital payments.

b)         The determination of those services qualified for an outlier

adjustment shall be made as follows for services provided on and after October

1, 1992, and for each subsequent rate period, as defined in Section

148.25(g)(2)(B), for hospitals or distinct part units reimbursed on a per diem

basis or hospitals reimbursed in accordance with Section 148.82(g):

1)         The services must have been provided on or after October 1,

1992; and

2)         The services must have been provided to:

A)        Children who have not attained the age of six years by

hospitals defined by the Department as DSH hospitals under Section 148.120(a);

or

B)        Infants who have not attained the age of one year by hospitals

that do not meet the definition of a DSH hospital under Section 148.120(a); or

C)        Children

who have not attained the age of 19 on the date of admission for services

provided on or after January 1, 2008 by a hospital devoted exclusively to the

care of children as defined in 89 Ill. Adm. Code 149.50(c)(3)(A); or

D)        Children who have not attained the age of 19 on the date of admission

for services provided on or after July 1, 2009 by a Children's Hospital as

defined in 89 Ill. Adm. Code 149.50(c)(3)(B)

e age of 19 on the date of admission for services

provided on or after January 1, 2008 by a hospital devoted exclusively to the

care of children as defined in 89 Ill. Adm. Code 149.50(c)(3)(A); or

D)        Children who have not attained the age of 19 on the date of admission

for services provided on or after July 1, 2009 by a Children's Hospital as

defined in 89 Ill. Adm. Code 149.50(c)(3)(B).

3)         Claims with total covered charges equal to or above the mean

total covered charges plus one standard deviation shall be considered for

outlier adjustments once the following calculations have been performed:

A)        Total covered charges (less charges attributable to medical

education) equal to or exceeding one standard deviation above the mean shall be

multiplied by the hospital's cost to charge ratio.

B)        The hospital's rate for services provided on the claim shall be

multiplied by the number of covered days on the claim.

C)        The product of subsection (b)(3)(B) shall be subtracted from

the product of subsection (b)(3)(A).

D)        The difference of subsection (b)(3)(C) shall be multiplied by

.25, the product of which shall be the outlier adjustment for the claim.

E)        Third party payments (credits) shall be applied to the final

payment made on the claim.

c)         The determination of those services qualified for an outlier

adjustment shall be made in accordance with 89 Ill. Adm. Code 149.105 for

hospitals reimbursed on a per case basis.

d)         Definition of terms relating to outlier adjustments are as

follows:

1)         "Base fiscal year" means the hospital's fiscal year

cost report most recently audited by the Department.

2)         "Cost to Charge Ratio" means the hospital's Medicaid

total allowable cost for all care divided by the Medicaid total covered charges

for all care. The Cost to Charge Ratio is derived by utilizing cost report data

from the hospital's base fiscal year

ts are as

follows:

1)         "Base fiscal year" means the hospital's fiscal year

cost report most recently audited by the Department.

2)         "Cost to Charge Ratio" means the hospital's Medicaid

total allowable cost for all care divided by the Medicaid total covered charges

for all care. The Cost to Charge Ratio is derived by utilizing cost report data

from the hospital's base fiscal year.

3)         "Mean total covered charges" means the mean total

covered charges (as described in subsection (d)(5)), for services provided in

the most recent state fiscal year for which complete information is available

and which have been adjudicated by the Department, as follows:

A)        For hospitals that do not meet the definition of a DSH hospital

under Section 148.120(a) in the DSH determination year, the mean total covered

charges for all claims for inpatient services provided to individuals under the

age of one year; and

B)        For hospitals defined by the Department as DSH hospitals under

Section 148.120(a) in the DSH determination year, the mean total covered

charges for all claims for inpatient services provided to individuals under the

age of six years.

4)         "Rate for services provided" means the inpatient

rate in effect for the type of services provided.

5)         "Total covered charges" means the amount entered on

the UB-82 or UB-92 Uniform Billing Form for revenue code 001 in column 53

(Total Charges).