# 89 Ill. Adm. Code 1480.148.130: Section 148.130 Outlier Adjustments for Exceptionally Costly Stays

> Illinois · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_130

## Section

- **Citation:** 89 Ill. Adm. Code 1480.148.130
- **Heading:** Section 148.130 Outlier Adjustments for Exceptionally Costly Stays
- **Jurisdiction:** Illinois
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Illinois Administrative Code / Title 89  /  / Part 1480  / Section 148.130 Outlier Adjustments for Exceptionally Costly Stays

## Text

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).

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_130. Check the current official text before relying on it. Not legal advice.