AUTHORITY: Implementing and authorized by Articles III, IV, V and VI and Section 12-13 of the Illinois Public Aid Code [305 ILCS 5/Arts. III, IV, V and VI and 12-13].

SOURCE: Adopted at 36 Ill. Reg. 4875, effective March 15, 2012.

SUBPART A: GENERAL PROVISIONS

 

Section 150.5  Incorporation by Reference

 

a)         Any rules or regulations of an agency of the United States or of a nationally recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified and do not include any later amendments or editions.

 

b)         To the extent that they are not inconsistent with this Part, the provisions of 42 CFR 495 (2011) are incorporated in this Part.

 

Section 150.10  Definitions

 

For the purposes of this Part, the following definitions apply:

 

"Acute care hospital" means a hospital that has been assigned a CCN with the last four digits in the series 0001-0879 or 1300-1399 and has an average length of a patient stay of 25 or fewer days.  Multiple hospitals operating under a single CCN are, for purposes of this Part, considered as a single hospital.

 

"Children's hospital" means a hospital that predominately treats individuals under the age of 21 and has been assigned a CMS certification number with the last four digits in the series 3300-3399 or, in the instance of a hospital that does not participate in Medicare, is licensed as a pediatric hospital by the Illinois Department of Public Health.

 

"Coordinated care participating hospital" means a hospital that is located in a geographic area of the State in which HFS mandates some or all of the beneficiaries of the Medical Assistance Program residing in the area to enroll in a care coordination program, as defined in 305 ILCS 5/5-30, that has entered into a contract to provide hospital services to enrollees of the care coordination program; has not been offered a contract by a care coordination plan that pays no less than HFS would have paid on a fee-for-service (FFS) basis, but excluding disproportionate share hospital adjustment payments or any other supplemental payment that HFS pays directly; or is not licensed to serve the population mandated to enroll in the care coordination program.

 

"CCN" means CMMS certification number, a six character identification number assigned to CMMS Medicare and Medicaid providers (formerly known as the Medicare/Medicaid provider number, the online survey, certification and reporting (OSCAR) number, or the Medicare identification number).

 

"CMMS" means the Centers for Medicare and Medicaid Services, the organizational unit within the U.S. Department of Health and Human Services responsible for overseeing the Medicaid program.

 

"Department" means the Department of Healthcare and Family Services.

 

"Hospital" means any institution, place, building or agency, public or private, whether organized for profit or not-for-profit, that is:

 

located in Illinois and is subject to licensure by the Illinois Department of Public Health under the Hospital Licensing Act [210 ILCS 85] or the University of Illinois Hospital Act [110 ILCS 330]; or

 

located in another state and meets all comparable conditions and requirements of the Hospital Licensing Act in effect for the state in which it is located.

 

"Medicaid" means medical assistance provided pursuant to Title XIX of the federal Social Security Act, as implemented pursuant to Article V of the Illinois Public Aid Code or a comparable law in another state.

 

"Medicaid Managed Care Entity (MMCE) participating hospitals" means a hospital that is located in a geographic area of the State in which HFS offers enrollment with an MMCE as a voluntary option to beneficiaries of the Medical Assistance Program and that has entered into a contract to provide hospital services to enrollees of an MMCE.

 

"Medicare" means health insurance provided pursuant to Title XVIII of the federal Social Security Act.

 

Section 150.15  Applicability

 

a)         Should any rule, subdivision, clause, phrase or provision of this Part be held unconstitutional or invalid for any reason whatsoever, those holdings shall not affect the validity of the remaining portions of this Part.

 

b)         This Part shall be operative only to the extent that it does not conflict with any federal law or regulation governing federal grants for the funding of, or reimbursement of public expenditures for, the development and use of health information technology.

 

Section 150.20  Legislative Basis

 

a)         The Illinois Health Information Exchange and Technology Act (P.A. 96-1331) established the Illinois Health Information Exchange to promote and facilitate the sharing of health information among health care providers within Illinois and in other states.

 

b)         The American Recovery and Reinvestment Act of 2009 (P. L. 111-5) offers funding to states to promote and facilitate the sharing of health information among health care providers.

SUBPART B: PROVIDER INCENTIVE PROGRAM

 

Section 150.100  Provider Eligibility

 

a)         General Requirements.  A provider must:

 

1)         Be within one of the classes of eligible professionals enumerated in subsection (b).

 

2)         Be enrolled, and in good standing, with the Department to participate in the Illinois Medical Assistance Program.

 

3)         Be a registered user of the Department's Medical Electronic Data Interchange System.

 

b)         Eligible Professionals (EP).

 

1)         The health practitioners that may be eligible for incentive payments are limited to the following:

 

A)        A certified nurse-midwife.

 

B)        A dentist.

 

C)        A nurse practitioner.

 

D)        A physician.

 

E)        An optometrist.

 

F)         A physician assistant (PA) practicing in a federally qualified health center (FQHC) or a rural health clinic (RHC) that is led by a PA.

 

2)         Eligible Hospitals (EH).  The hospitals that may be eligible for incentive payments are limited to the following hospitals:

 

A)        Acute care hospitals.

 

B)        Children's hospitals.

 

c)         Eligibility Requirements for EP.  For each year for which the practitioner seeks an incentive payment, the practitioner must:

 

1)         Have a minimum 30 percent patient volume attributable to individuals receiving Medicaid, except in the instance of a practitioner:

 

A)        that is a pediatrician, with a minimum 20 percent patient volume attributable to individuals receiving Medicaid.

 

B)        that practices predominately in an FQHC or RHC with a minimum 30 percent patient volume attributable to needy individuals, as defined at 42 CFR 495.302.

 

2)         Not be a "hospital-based EP" as defined at 42 CFR 495.4, except this provision does not apply to a practitioner practicing predominately at an FQHC or RHC.

 

d)         Eligibility Requirements for EH.  For each year for which the hospital seeks an incentive payment, an acute care hospital must have at least a 10 percent volume attributable to individuals receiving Medicaid.  A children's hospital is exempt from meeting a patient volume threshold.

 

Section 150.110  Provider Registration and Attestation

 

a)         Providers must register to receive the incentive payment at the federal CMMS registration website.

 

b)         CMMS transmits files from the registration system to the Department containing information necessary to process the provider incentive payment registrations.

 

c)         Providers that meet the prerequisite criteria established by CMMS will be notified by the Department that they must provide additional information, via attestation to the Department.

 

d)         Providers must complete the attestation on the Department's Medical Electronic Data Interchange System.

 

1)         The attestation for all providers must include the following:

 

A)        A valid National Provider Identifier number;

 

B)        The provider is not sanctioned;

 

C)        No Electronic Health Record Provider Incentive Payment (EHR PIP) has been received in the payment year;

 

D)        Illinois is the only state selected to request an incentive payment in the payment year;

 

E)        The provider meets the patient volume requirements for the Medicaid PIP program as defined in Section 150.100(c) and (d);

 

F)         The provider has adopted, implemented or upgraded to a certified Electronic Health Record System;

 

G)        The provider has not received State or local government funding that is directly attributable to the cost of EHR technology; and

 

H)        The provider agrees to the assignment of the PIP Program payment and that the Taxpayer Identification Number of the assignee is correct.

 

2)         The following provider specific attestation requirements must be completed as appropriate:

 

A)        The provider is not a hospital-based professional who furnishes 90 percent or more of his or her professional services in an inpatient hospital or emergency room;

 

B)        The provider is a pediatrician with a Medicaid patient volume between 20 and 30 percent and is either a board certified pediatrician or 90 percent of the patient volume is under the age of 21 at the time the service is rendered;

 

C)        The provider is a physician assistant practicing in an FQHC or RHC if the FQHC or RHC:

 

i)          is led by a PA as the primary provider;

 

ii)         has a clinical or medical director that is a PA; or

 

iii)        the owner is a PA;

 

D)        The provider practices predominately in an FQHC or RHC.

 

e)         The Department will evaluate the attestation information submitted by providers.  The Department will approve or deny provider registration based on the evaluation of the information.

 

1)         Providers who are approved will be scheduled for the incentive payment.

 

2)         Providers who are determined by the Department to be ineligible will be notified of the decision and their right to appeal.

 

Section 150.120  Incentive Payment

 

a)         The Department will make the incentive payment to EP, as defined in Section 150.100(b)(1), in accordance with the guidelines defined at 42 CFR 495.310.

 

b)         The Department will base the incentive payment to EH, as defined in Section 150.100(b)(2), on the hospital aggregate incentive amount as calculated under 42 CFR 495.310.

 

1)         Pediatric specialty hospitals, critical access hospitals, hospitals operated by the Cook County Health and Hospitals System, hospitals operated by the University of Illinois at Chicago and coordinated care participating hospitals and MMCE hospitals with the exception of those identified in subsection (b)(2) will receive the incentive payment based on the following schedule:

 

A)        Year 1: 50 percent of the aggregate payment amount.

 

B)        Year 2: 40 percent of the aggregate payment amount.

 

C)        Year 3: 10 percent of the aggregate payment amount.

 

D)        Year 4: 0 percent of the aggregate payment amount.

 

E)        Year 5: 0 percent of the aggregate payment amount.

 

2)         Hospitals that are either coordinated care participating hospitals or MMCE participating hospitals, but not both, located in an area in which both an MMCE and a mandatory coordinated care program operate, or hospitals that are in areas where neither a mandatory coordinated care program nor an MMCE operate, will receive the incentive payment on the following schedule:

 

A)        Year 1:  40 percent of the aggregate payment amount.

 

B)        Year 2:  30 percent of the aggregate payment amount.

 

C)        Year 3:  20 percent of the aggregate payment amount.

 

D)        Year 4:  10 percent of the aggregate payment amount.

 

E)        Year 5:  0 percent of the aggregate payment amount.

 

3)         Hospitals that do not meet the qualifications outlined in subsections (b)(1) and (b)(2) will receive the incentive payment on the following schedule:

 

A)        Year 1:  25 percent of the aggregate payment amount.

 

B)        Year 2:  25 percent of the aggregate payment amount.

 

C)        Year 3:  20 percent of the aggregate payment amount.

 

D)        Year 4:  15 percent of the aggregate payment amount.

 

E)        Year 5:  15 percent of the aggregate payment amount.

 

Section 150.130  Appeals

 

Providers will be eligible to appeal any of the issues defined at 42 CFR 495.370.  All appeals will be processed in accordance with 89 Ill. Adm. Code 104.Subpart C.

 

Section 150.140  Audits

 

All audits will be processed in accordance with 89 Ill. Adm. Code 140.30.