Section 148.290  Adjustments and Reductions to Total Payments

Effective for dates of outpatient services on or after July 1, 2014 and inpatient discharges on or after July 1, 2014:

a)         The adjustments described in this Section, as applicable, shall be made to reimbursement amounts calculated pursuant to Sections 148.105, 148.110, 148.115, 148.140, 148.160, 148.170, 148.330 and 89 Ill. Adm. Code 149.100 prior to payment.  The adjustments are to be applied in the order in which they are listed in this Section.

b)         Adjustments to base rates made pursuant to 89 Ill. Adm. Code 152.150.

c)         Increases in Payments.  Supplemental payments pursuant to the Long Term Acute Care Hospital Quality Improvement Transfer Program Act [210 ILCS 155] in accordance with Section 148.115(f).

d)         Reductions in Payments.  The Department's payment obligation shall be reduced  by:

1)         Charges.  Except for reimbursement calculated under Sections 148.140, 148.160 and 148.170, payment shall not exceed the lesser of:

A)        The reimbursement amount determined pursuant to subsections (a) and (b).

B)        The allowable charges billed to the Department on the claim.

2)         Hospital Rate Reductions. Payment shall be reduced pursuant to the provisions of 89 Ill. Adm. Code 152.100.

3)         Third-party Liability.  Hospitals shall determine whether services are covered, in whole or in part, under any program or under any other private group indemnification or insurance program or managed care entity.  To the extent that coverage is available, the Department's payment obligation shall be reduced.

4)         Copayments. Copayments are assessed in accordance with Section 148.190.

e)         Increases in Payments.  The Department's payments obligations shall be increased, if applicable, by:

1)         Medicaid high volume adjustment payments pursuant to Section 148.112.

2)         Medicaid percentage adjustment payments pursuant to Section 148.122.

3)         DSH adjustment payments pursuant to Section 148.120.

(Source:  Amended at 38 Ill. Reg. 15165, effective July 2, 2014)