Section 148.140 Hospital Outpatient and Clinic Services

Section 148

TITLE 89: SOCIAL SERVICES

CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

SUBCHAPTER d: MEDICAL PROGRAMS

PART 148 HOSPITAL SERVICES

SECTION 148.140 HOSPITAL OUTPATIENT AND CLINIC SERVICES

Section 148.140  Hospital Outpatient and Clinic Services

Effective for dates of service on or after July 1, 2014,

unless another date is specified:

a)         Fee-For-Service

Professional Services Reimbursement. Effective for dates of service on or after

July 1, 2020, all fee-for-service hospital outpatient professional services

will be reimbursed in accordance with subsection (b)(1) except for end stage

renal disease treatment (ESRDT) services, as described in subsection (g).

b)         EAPG

PPS Reimbursement.  Reimbursement under EAPG PPS, described in subsection (c),

shall be all-inclusive for all services provided by the hospital, without

regard to the amount charged by a hospital.  Except as provided in subsection

(b)(3), no separate reimbursement will be made for ancillary services or the

services of hospital personnel.

1)         Outpatient

hospital services reimbursed through the EAPG PPS shall include:

A)        Surgical

services.

B)        Diagnostic

and therapeutic services.

C)        Emergency

department services.

D)        Observation

services.

E)        Psychiatric

treatment services.

2)         Excluded

from reimbursement under the EAPG PPS are outpatient hospital services

reimbursed pursuant to 59 Ill. Adm. Code 131 and 132, 77 Ill. Adm. Code 2090,

and Section 148.330 of this Part.

3)         As an

exception to the all-inclusive EAPG PPS rate, a separate professional claim may

be submitted under a physician's name and NPI for a physician who provided

direct patient care. For purposes of this subsection (b)(3), a physician means:

A)        A

physician salaried by the hospital

uant to 59 Ill. Adm. Code 131 and 132, 77 Ill. Adm. Code 2090,

and Section 148.330 of this Part.

3)         As an

exception to the all-inclusive EAPG PPS rate, a separate professional claim may

be submitted under a physician's name and NPI for a physician who provided

direct patient care. For purposes of this subsection (b)(3), a physician means:

A)        A

physician salaried by the hospital.  Physicians salaried by the hospital do not

include radiologists, pathologists, nurse practitioners, or certified

registered nurse anesthetists; no separate reimbursement will be allowed for those

providers.

B)        A

physician who is reimbursed by the hospital through a contractual arrangement

to provide direct patient care.

C)        A

group of physicians with a financial contract to provide emergency department

care.

4)         Effective

for dates of service on or after January 1, 2023, a general acute care hospital

that provides more than 500 outpatient psychiatric Medicaid services to persons

under 19 years of age in any calendar year prior to the rate year shall be paid

a $113 add-on payment. "Rate Year" means the calendar year beginning

January 1

st

, with the first rate year being calendar year 2023.

c)         EAPG

PPS Payment.  The reimbursement to hospitals for outpatient services provided

on the same day shall be the product, rounded to the nearest hundredth, of the

following:

1)         The

EAPG weighting factor of the EAPG to which the service was assigned by the EAPG

grouper.

2)         The

EAPG conversion factor, based on the sum of:

A)        The

product, rounded to the nearest hundredth, of:

i)          the

labor-related share;

ii)         the

Medicare IPPS wage index; and

iii)        the

applicable EAPG standardized amount.

B)        The

product, rounded to the nearest hundredth, of:

i)          non-labor

share; and

ii)         the

applicable EAPG standardized amount.

3)         The

applicable consolidation factor.

4)         The

applicable packaging factor

est hundredth, of:

i)          the

labor-related share;

ii)         the

Medicare IPPS wage index; and

iii)        the

applicable EAPG standardized amount.

B)        The

product, rounded to the nearest hundredth, of:

i)          non-labor

share; and

ii)         the

applicable EAPG standardized amount.

3)         The

applicable consolidation factor.

4)         The

applicable packaging factor.

5)         The

applicable discounting factor.

6)         The

applicable policy adjustment factors, as defined in subsection (f), for which

the service qualifies.

d)         EAPG Standardized

Amount.  The standardized amount established by the Department as the basis for

EAPG conversion factor differs based on the provider type:

1)         County-operated

Large Public Hospital EAPG Standardized Amount.  For a large public hospital,

as defined in Section 148.25(a)(1), the EAPG standardized amount is determined

in Section 148.160.

2)         University-operated

Large Public Hospital EAPG Standardized Amount.  For a large public hospital,

as defined in Section 148.25(a)(2), the EAPG standardized amount is determined

in Section 148.170.

3)         Critical

Access Hospital EAPG Standardized Amount.

A)        For

critical access hospitals, as defined in Section 148.25(g), the EAPG

standardized amounts are determined separately for each critical access

hospital such that simulated EAPG payments using outpatient base period paid

claim data plus payments as defined in Section 148.423 net of tax costs are

equal to the estimated costs of outpatient base period claims data with a rate

year cost inflation factor applied.

B)        Effective

January 1, 2024, simulated EAPG payments using outpatient base period paid

claim data are calculated to be budget neutral to simulated payments using the

rates in effect as of December 31, 2023. The budget neutral hospital specific

EAPG rates are then increased by 10%, except as limited by the federally

required upper payment limit (UPL)

year cost inflation factor applied.

B)        Effective

January 1, 2024, simulated EAPG payments using outpatient base period paid

claim data are calculated to be budget neutral to simulated payments using the

rates in effect as of December 31, 2023. The budget neutral hospital specific

EAPG rates are then increased by 10%, except as limited by the federally

required upper payment limit (UPL).

4)         Acute

EAPG Standardized Amount

A)        Qualifying

Criteria.  General acute hospitals and freestanding emergency centers as

defined in 148.25(e) excluding providers in subsections (d)(1) through (d)(3),

freestanding psychiatric hospitals, psychiatric distinct part units,

freestanding rehabilitation hospitals, and rehabilitation distinct part units.

B)        Effective

January 1, 2024, the acute EAPG standardized amount is based on a single

statewide amount determined such that simulated EAPG allowed amount using

general acute hospital outpatient base period paid claims data, is equal to the

sum of general acute hospital base period paid claims data allowed amount

increased by 10%. For subsequent years, acute EAPG standardized amount is based

on a single statewide amount determined such that simulated EAPG allowed amount

using general acute hospital outpatient base period paid claims data is equal

to the sum of general acute hospital base period paid claims data allowed

amount

.

5)         Psychiatric

EAPG Standardized Amount

A)        Qualifying

Criteria.  Freestanding psychiatric hospitals and psychiatric distinct part

units

d

on a single statewide amount determined such that simulated EAPG allowed amount

using general acute hospital outpatient base period paid claims data is equal

to the sum of general acute hospital base period paid claims data allowed

amount

.

5)         Psychiatric

EAPG Standardized Amount

A)        Qualifying

Criteria.  Freestanding psychiatric hospitals and psychiatric distinct part

units.

B)        Effective

January 1, 2024, the psychiatric EAPG standardized amount is based on a single

statewide amount, determined such that simulated EAPG allowed amount, using

freestanding psychiatric hospitals and psychiatric distinct part units

outpatient base period paid claims data, is approximately equal to the sum of

the freestanding psychiatric hospitals and psychiatric distinct part units

outpatient base period paid claims data allowed amount increased by 10%.  For

subsequent years, psychiatric EAPG standardized amount is based on a single

statewide amount determined such that simulated EAPG allowed amount using

freestanding psychiatric hospitals and psychiatric distinct part units

outpatient base period paid claims data, is approximately equal to the sum of

the freestanding psychiatric hospitals and psychiatric distinct part units

outpatient base period paid claims data allowed amount.

6)         Rehabilitation

EAPG Standardized Amount

A)        Qualifying

Criteria.  Freestanding rehabilitation hospitals and rehabilitation distinct

part units.

B)        The

rehabilitation EAPG standardized amount is based on a single statewide amount,

determined such that simulated EAPG payments using freestanding rehabilitation

hospitals and rehabilitation distinct part units outpatient base period paid

claims data, results in allowed amount approximately equal to freestanding

rehabilitation hospitals and rehabilitation distinct part units outpatient base

period paid claims data allowed amount increased by 10%

n a single statewide amount,

determined such that simulated EAPG payments using freestanding rehabilitation

hospitals and rehabilitation distinct part units outpatient base period paid

claims data, results in allowed amount approximately equal to freestanding

rehabilitation hospitals and rehabilitation distinct part units outpatient base

period paid claims data allowed amount increased by 10%.  For subsequent years,

simulated EAPG payments using freestanding rehabilitation hospitals and

rehabilitation distinct part units outpatient base period paid claims data,

results in allowed amount approximately equal to freestanding rehabilitation

hospitals and rehabilitation distinct part units outpatient base period paid

claims data allowed amount.

7)         Ambulatory

Surgical Treatment Center (ASTC) EAPG Standardized Amount.  For ASTC's, as

defined in 89 Ill. Adm. Code 146.105, the EAPG standardized amount is

determined such that simulated EAPG payments using outpatient base period paid

claims data are equal to reported payments of outpatient base period paid

claims data as contained in the Department's claims data warehouse.

8)         Out-of-State

Non-Cost Reporting Hospital EAPG Standardized Amount.  For non-cost reporting

hospitals, the EAPG standardized amount is $362.32, and is not wage adjusted.

e)         Discounting

Factor.  The applicable discounting factor is based on the discounting flags

designated by the EAPG grouper under default EAPG settings:

1)         The

discounting factor will be 1.0000, if the following criteria are met:

A)        The

service has not been designated with a Bilateral Procedure Discounting flag,

Multiple Procedure Discounting flag, Repeat Ancillary Discounting flag or

Terminated Procedure Discounting flag by the EAPG grouper under default EAPG

settings; or

B)        The

service has not been designated with a Bilateral Procedure Discounting flag and

has been designated with a Multiple Procedure Discounting flag by the EAPG

grouper under default EAPG setting

rocedure Discounting flag,

Multiple Procedure Discounting flag, Repeat Ancillary Discounting flag or

Terminated Procedure Discounting flag by the EAPG grouper under default EAPG

settings; or

B)        The

service has not been designated with a Bilateral Procedure Discounting flag and

has been designated with a Multiple Procedure Discounting flag by the EAPG

grouper under default EAPG settings and the service has the highest EAPG

weighting factor among other services with a Multiple Procedure Discounting

flag provided on the same day.

2)         The

discounting factor will be 0.5000 if the following criteria are met:

A)        The

service has been designated with a Multiple Procedure Discounting flag, Repeat

Ancillary Discounting flag or Terminated Procedure Discounting flag by the EAPG

grouper under default EAPG settings; and if the Multiple Procedure Discounting

flag is present, the service does not have the highest EAPG weighting factor

among other services with a Multiple Procedure Discounting flag provided on the

same day; and

B)        The

service has not been designated with a Bilateral Procedure Discounting flag by

the EAPG grouper under default EAPG settings.

3)         The

discounting factor will be 0.7500 if the following criteria are met:

A)        The

service has been designated with a Bilateral Procedure Discounting flag by the

EAPG grouper under default EAPG settings; and

B)        The

service has been designated with a Multiple Procedure Discounting flag, the

Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by

the EAPG grouper under default EAPG settings; and if the Multiple Procedure

Discounting flag is present, the service does not have the highest EAPG

weighting factor among other services with a Multiple Procedure Discounting

flag provided on the same day

been designated with a Multiple Procedure Discounting flag, the

Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by

the EAPG grouper under default EAPG settings; and if the Multiple Procedure

Discounting flag is present, the service does not have the highest EAPG

weighting factor among other services with a Multiple Procedure Discounting

flag provided on the same day.

4)         The

discounting factor will be 1.5000 if the following criteria are met:

A)        The

service has been designated with a Bilateral Procedure Discounting flag by the

EAPG grouper under default EAPG settings; and

B)        The

service has not been designated with a Multiple Procedure Discounting flag, the

Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by

the EAPG grouper under default EAPG settings; or if the Multiple Procedure

Discounting flag is present, the service has the highest EAPG weighting factor

among other services with a Multiple Procedure Discounting flag provided on the

same day.

f)         Policy

Adjustments.  Claims for services by providers that meet certain criteria shall

qualify for further adjustments to payment.  If a claim qualifies for more than

one policy adjustment, then the EAPG PPS payment will be multiplied by both

factors.

1)         Crossover

Adjustment Factor

A)        Acute

EAPG standardized amounts, as defined in subsection (d)(4), shall be reduced by

a Crossover Adjustment factor such that:

i)          The

absolute value of the total simulated payment reduction that occurs when

applying the Crossover Adjustment Factor to simulated EAPG payments, including

Policy Adjustments, using general acute hospital outpatient base period paid

claims data, is equal to the amount derived in subsection (f)(1)(A)(ii):

ii)         The

difference of total simulated EAPG payments using general acute hospital

outpatient crossover paid claims data, and general acute hospital outpatient

crossover paid claims data total reported Medicaid net liabil

yments, including

Policy Adjustments, using general acute hospital outpatient base period paid

claims data, is equal to the amount derived in subsection (f)(1)(A)(ii):

ii)         The

difference of total simulated EAPG payments using general acute hospital

outpatient crossover paid claims data, and general acute hospital outpatient

crossover paid claims data total reported Medicaid net liability.

B)        Crossover

Adjustment Factor effective SFY 2015 and 2016 is 0.98912.  Effective July 1,

2018, the Crossover Adjustment Factor is defined in (f)(1)(A)(i).

2)         If a

claim does not qualify for a Policy Adjustment described in subsection (f)(3)

or (f)(4), the policy adjustment factor is 1.0.

3)         High Outpatient Volume Hospital

Effective July 1, 2018

A)        High

Outpatient Volume Hospital is defined as:

i)          an Illinois

hospital for which the high outpatient volume is at least one and one-half

standard deviations above the mean regional high outpatient volume;

ii)         an Illinois

hospital for which the high outpatient volume is at least one and one-half

standard deviations above the mean statewide high outpatient volume;

iii)        an Illinois

Safety-Net Hospital as defined in Section 149.100; or

iv)        an Illinois

Small Public Hospital, which is defined as any publicly owned hospital that is

not a large public hospital as defined in Section 148.25.

B)        Policy

adjustment factor is set:

i)          For

acute care claims such that total expenditures on qualifying claims less the

rate reductions defined in P.A. 97-0689 is increased by $79.2 million more than

base period qualifying claims allowed amount.

ii)         For

non-acute care claims to equal the factor in place prior to July 1, 2018

ublic hospital as defined in Section 148.25.

B)        Policy

adjustment factor is set:

i)          For

acute care claims such that total expenditures on qualifying claims less the

rate reductions defined in P.A. 97-0689 is increased by $79.2 million more than

base period qualifying claims allowed amount.

ii)         For

non-acute care claims to equal the factor in place prior to July 1, 2018.

4)         For

High Outpatient Volume Hospitals effective on or after January 1, 2023:

A)        The

hospital is a High Outpatient Volume hospital, defined as:

i)          an Illinois

hospital for which the high outpatient volume is at least two times above the

mean regional high outpatient volume;

ii)         an Illinois

hospital for which the high outpatient volume is at least one and one-half

standard deviations above the mean statewide high outpatient volume;

iii)        an

Illinois Safety-Net Hospital as defined in 89 Ill. Adm. Code 149.100(f)(4); or

iv)        an

Illinois Small Public Hospital, which is defined as any publicly owned hospital

that is not a large public hospital as defined in 89 Ill. Adm. Code 148.25.

B)        Upon

any update of EAPG groupers, the policy adjustment factor shall be set so that

expenditures attributed to the adjustment factor on claims in the base period

is equal to the expenditures attributed to the adjustment factor on the same

claims under the new grouper.

g)         Payment

for outpatient end-stage renal disease treatment (ESRDT) services provided

pursuant to Section 148.40(b) shall be made at the Department's payment rates,

as follows:

1)         For

outpatient services or home dialysis treatments provided pursuant to Section

148.40(c)(2) or (c)(3), the Department will reimburse hospitals and clinics for

ESRDT services at a rate that will reimburse the provider for the dialysis

treatment and all related supplies and equipment, as defined in 42 CFR 405.2124

and 413.170 (2010)

e at the Department's payment rates,

as follows:

1)         For

outpatient services or home dialysis treatments provided pursuant to Section

148.40(c)(2) or (c)(3), the Department will reimburse hospitals and clinics for

ESRDT services at a rate that will reimburse the provider for the dialysis

treatment and all related supplies and equipment, as defined in 42 CFR 405.2124

and 413.170 (2010).  This rate will be the rate established by Medicare

pursuant to 42 CFR 405.2124 and 413.170 (2010).

2)         Payment

for Non-routine Services.  For services that are provided during outpatient or

home dialysis treatment pursuant to Section 148.40(c)(2) or (c)(3), but are not

defined as a routine service under 42 CFR 405.2163 (1994), separate payment

will be made to independent laboratories, pharmacies, and medical supply

providers pursuant to 89 Ill. Adm. Code 140.430 through 140.434, 140.440

through 140.50, and 140.75 through 140.481, respectively.

3)         Payment

for physician services relating to ESRDT will be made separately to physicians,

pursuant to 89 Ill. Adm. Code 140.400.

4)         Effective

with dates of service July 1, 2013, hospital and freestanding chronic dialysis

centers will receive an add-on payment of $60 per treatment day to the rate

described in subsection (g)(1) for outpatient renal dialysis treatments or home

dialysis treatments provided to Medicaid recipients under Title XIX of the

Social Security Act, excluding services for individuals eligible for Medicare

under Title XVIII of that Act (Medicaid/Medicare crossovers) and excluding

services provided under Subpart D:  State Chronic Renal Disease Program, as

defined in Sections 148.600 through 148.640.

h)         Updates

to EAPG PPS Reimbursement.  The Department may annually review the components

listed in subsection (c) and make adjustments as needed. Grouper shall be

updated at least triennially and no more frequently than annually

id/Medicare crossovers) and excluding

services provided under Subpart D:  State Chronic Renal Disease Program, as

defined in Sections 148.600 through 148.640.

h)         Updates

to EAPG PPS Reimbursement.  The Department may annually review the components

listed in subsection (c) and make adjustments as needed. Grouper shall be

updated at least triennially and no more frequently than annually.

i)          Definitions, as used in

this Section:

"Aggregate ancillary

cost-to-charge ratio" means the ratio of each hospital's total ancillary

costs and charges reported in the Medicare cost report, excluding special

purpose cost centers and the ambulance cost center, for the cost reporting

period matching the outpatient base period claims data.  Aggregate ancillary

cost-to-charge ratios applied to SFY 2011 outpatient base period claims data

will be based on fiscal year ending 2011 Medicare cost report data.

"Allowed amounts" means

the calculated fee schedule amount prior to any adjustment for secondary payer

amounts for outpatient base period claims data.  If volume in base period data

is estimated to differ from rate year volume, then completion factors are

applied.

"Consolidation factor"

means a factor of 0 percent applicable for services designated with a Same

Procedure Consolidation flag or Clinical Procedure Consolidation flag by the

EAPG grouper under default EAPG settings.

"Default EAPG settings"

means the default EAPG grouper options in 3M's Core Grouping Software for each

EAPG grouper version, except where the Department made adjustments.

"Detailed ancillary cost-to-charge

ratios" means for each standardized ancillary Medicare cost-center

cost-to-charge ratios for each hospital calculated by dividing total costs in

Worksheet C, Part 1, Column 5 and Worksheet B, Part 1, Columns 21 and 22 by

total charges for each standardized ancillary Medicare cost center in Worksheet

C, Part 1, Columns 6 and 7

the Department made adjustments.

"Detailed ancillary cost-to-charge

ratios" means for each standardized ancillary Medicare cost-center

cost-to-charge ratios for each hospital calculated by dividing total costs in

Worksheet C, Part 1, Column 5 and Worksheet B, Part 1, Columns 21 and 22 by

total charges for each standardized ancillary Medicare cost center in Worksheet

C, Part 1, Columns 6 and 7.  For all hospitals missing Worksheet C, Part 1,

Column 5 data, use Worksheet C, Part 1, Column 3 data.  Use aggregate ancillary

cost-to-charge ratios as a default when a cost-center specific cost-to-charge

ratio is not available or the claim revenue code is all-inclusive ancillary.

"EAPG" means Enhanced

Ambulatory Patient Groups, as defined in the EAPG grouper, which is a patient

classification system designed to explain the amount and type of resources used

in an ambulatory visit.  Services provided in each EAPG have similar clinical

characteristics and similar resource use and cost.

"EAPG grouper" means the

version of the EAPG software, distributed by 3M Health Information Systems, being

used by the Department for pricing hospital outpatient services in accordance

with 305 ILCS 5/14-12(a), (b) and (e).

"EAPG PPS" means the

EAPG prospective payment system as described in this Section.

"EAPG weighting factor"

means, for each EAPG, the product, rounded to the nearest ten-thousandth, of:

the national weighting factor, as

published by 3M Health Information Systems for the EAPG grouper; and

the Illinois

experience adjustment.

"Estimated

cost of outpatient base period claims data" means:

Prior to July 1,

2018, the product of:

outpatient base

period paid claims data total covered charges;

the critical access hospital's

aggregate ancillary cost-to-charge ratio; and

a rate year cost

inflation factor

ng factor, as

published by 3M Health Information Systems for the EAPG grouper; and

the Illinois

experience adjustment.

"Estimated

cost of outpatient base period claims data" means:

Prior to July 1,

2018, the product of:

outpatient base

period paid claims data total covered charges;

the critical access hospital's

aggregate ancillary cost-to-charge ratio; and

a rate year cost

inflation factor.

Effective July

1, 2018, the product of:

Outpatient base period claims data

total covered charges;

The critical access hospital's

detailed ancillary cost-to-charge ratios; and

A rate year cost inflation factor.

"High outpatient volume"

means the number paid outpatient claims described in subsection (b)(1) provided

during the high volume outpatient base period paid claims data.

"High volume outpatient base

period paid claims data" means:

Prior to July 1, 2018, SFY 2011

outpatient Medicaid fee-for-service paid claims data, excluding Medicare dual

eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS

payment for services provided in SFY 2015 and 2016.  For subsequent dates of

service, the term means the SFY ending 30 months prior to the beginning of the

calendar year during which the service is provided.

Effective July 1, 2018, SFY 2015

outpatient Medicaid fee-for-service paid claims data and completed MCO

encounter claims data, excluding Medicare dual eligible claims, renal dialysis

claims, and therapy claims, for EAPG PPS payment for services provided in SFY

2019 and 2020; for subsequent dates of service, the most recently available

adjudicated 12 months of outpatient paid claims data to be identified by the

Department

15

outpatient Medicaid fee-for-service paid claims data and completed MCO

encounter claims data, excluding Medicare dual eligible claims, renal dialysis

claims, and therapy claims, for EAPG PPS payment for services provided in SFY

2019 and 2020; for subsequent dates of service, the most recently available

adjudicated 12 months of outpatient paid claims data to be identified by the

Department.

"Illinois experience

adjustment" means, for the calendar year beginning January 1, 2014, a

factor of 1.0; for subsequent calendar years, means the factor applied to 3M

EAPG national weighting factors when updating EAPG grouper versions determined

such that the arithmetic mean EAPG weighting factor under the new EAPG grouper

version is equal to the arithmetic mean EAPG weighting factor under the prior

EAPG grouper version using outpatient base period claims data.

"In-state" means all:

Illinois

hospitals; and

out-of-state hospitals that are

designated a level I pediatric trauma center or a level I trauma center by the

Illinois Department of Public Health as of December 1, 2017.

"Labor-related share"

means that portion of the statewide standardized amount that is allocated in

the EAPG PPS methodology to reimburse the costs associated with personnel.  The

labor-related share for a hospital is 0.60.

"Mean regional high

outpatient volume" means the quotient, rounded to the nearest tenth,

resulting from the number of paid outpatient services described in subsections

(b)(1)(A) through (D), provided by hospitals within a region, based on

outpatient base period paid claims data.

"Mean statewide high

outpatient volume" means the quotient, rounded to the nearest tenth,

resulting from the number of paid outpatient services described in subsections

ent, rounded to the nearest tenth,

resulting from the number of paid outpatient services described in subsections

(b)(1)(A) through (D), provided by hospitals within a region, based on

outpatient base period paid claims data.

"Mean statewide high

outpatient volume" means the quotient, rounded to the nearest tenth,

resulting from the number of paid outpatient services described in subsections

(b)(1)(A) through (D), provided by hospitals within the state, based on

outpatient base period paid claims data.

"Medicare IPPS wage

index" means for in-state providers and out-of-state Illinois Medicaid

cost reporting providers, the wage index used for inpatient reimbursement as

described in 89 Ill. Adm. Code 149.100.  For out-of-state non‑cost reporting

providers, the wage index used to adjust the EAPG standardized amount shall be

a factor of 1.0.

"Non-labor share" means

the difference resulting from the labor-related share being subtracted from

1.0.

"Outpatient base period paid

claims data" means:

Prior to July 1, 2018, SFY 2011

outpatient Medicaid fee-for-service paid claims data, excluding Medicare dual

eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS

payment for services provided in SFY 2015, 2016 and 2017;

Effective July 1, 2018 through

June 30, 2020, for in-state SFY 2015 outpatient Medicaid fee-for-service paid

claims data and completed MCO encounter claims data, excluding Medicare dual

eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS

payment for services provided in SFY 2019 and 2020.

Effective July 1, 2020:

SFY 2017, or the most recent 12

months of available data as identified by the Department, outpatient Medicaid

claims data, for in-state hospitals that are not large public hospitals; and

SFY 2017 and 2018, or the most

recent 12 months of available data as identified by the Department, outpatient

Medicaid claims data for out-of-state hospitals

vided in SFY 2019 and 2020.

Effective July 1, 2020:

SFY 2017, or the most recent 12

months of available data as identified by the Department, outpatient Medicaid

claims data, for in-state hospitals that are not large public hospitals; and

SFY 2017 and 2018, or the most

recent 12 months of available data as identified by the Department, outpatient

Medicaid claims data for out-of-state hospitals.

"Outpatient crossover paid

claims data" means:

Outpatient Medicaid/Medicare dual

eligible fee-for-service and managed care paid claims data, excluding renal

dialysis claims and therapy claims, with dates of service from the same time

period as outpatient base period claims data.

"Packaging factor" means

a factor of 0 percent applicable for services designated with a Packaging flag

by the EAPG grouper under default EAPG settings plus EAPG 430 (Class I

Chemotherapy Drugs), EAPG 435 (Class I Pharmacotherapy), EAPG 495 (Minor

Chemotherapy Drugs), EAPG 496 (Minor Pharmacotherapy), and EAPGs 1001-1020 (Durable

Medical Equipment Level 1-20), and non-covered revenue codes defined in the

Handbook for Hospital Services.

"Rate year cost inflation

factor" means the cost inflation from the midpoint of the outpatient base

period paid claims data to the midpoint of the rate year based on changes in

Centers for Medicare and Medicaid Services (CMMS) input price index levels.

For critical access hospital rates effective SFY 2015, the rate year cost

inflation factor will be based on changes in CMMS input price index levels from

the midpoint of SFY 2011 to SFY 2015.

"Region" means, for a

given hospital, the rate region, as defined in 89 Ill. Adm. Code

140.Table J

, within

which the hospital is located.

"SFY" means State fiscal

year.

"Total covered charges"

means the amount entered for revenue code 001 in column 53 (Total Charges) on

the Uniform Billing Form (form CMMS 1450), or one of its electronic transaction

equivalents.

j)          Supplemental

Payment

ion" means, for a

given hospital, the rate region, as defined in 89 Ill. Adm. Code

140.Table J

, within

which the hospital is located.

"SFY" means State fiscal

year.

"Total covered charges"

means the amount entered for revenue code 001 in column 53 (Total Charges) on

the Uniform Billing Form (form CMMS 1450), or one of its electronic transaction

equivalents.

j)          Supplemental

Payment. A one-time supplemental payment will be made to a critical access

hospital (which is an Illinois hospital designated by the Illinois Department

of Public Health in accordance with 42 CFR 485 Subpart F) for outpatient

discharges occurring in SFY 2019 for which the outpatient claims were priced

and paid under the methodology in subsection (d)(3)(A). The amount of the

supplemental payment will be equal to the difference of:

1)         The

payment amount of each claim calculated using the critical access hospital EAPG

standardized amount set to equal a 23% increase in simulated EAPG payments

using base period paid claims data set forth in subsection (d)(3)(B); and

2)         The

payment amount of each claim calculated using the critical access hospital EAPG

standardized amount in effect on July 1, 2018.