Bill Text: IL HB4543 | 2019-2020 | 101st General Assembly | Introduced

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Bill Title: Amends the Illinois Public Aid Code. Provides that for State Fiscal Years 2021 through 2024, an annual assessment on inpatient and outpatient services is imposed on each hospital provider, subject to other specified provisions. Contains provisions concerning a hospital's non-Medicaid gross revenue for State Fiscal Years 2021 and 2022. Contains provisions concerning the assignment of a pool allocation percentage for certain hospitals designated as a Level II trauma center; increased capitation payments to managed care organizations; the extension of certain assessments to July 1, 2022 (rather than July 1, 2020); reimbursements for inpatient general acute care services to non-publicly owned safety net hospitals, non-publicly owned critical access hospitals, hospital providers in high-need communities, and other facilities; the allocation of funds from the transitional access hospital pool; administrative rules for data collection and payment from the health disparities pay-for-collection pool; and other matters. Amends the Illinois Administrative Procedure Act. Provides that the Department of Healthcare and Family Services shall have emergency rulemaking authority to implement the provisions of the amendatory Act concerning assessments. Amends the Emergency Medical Services (EMS) Systems Act. Removes provisions requiring the Department of Public Health to issue a Freestanding Emergency Center license to a facility that has discontinued inpatient hospital services and meets other requirements. Effective immediately.

Spectrum: Partisan Bill (Democrat 19-0)

Status: (Introduced - Dead) 2020-06-23 - Rule 19(b) / Re-referred to Rules Committee [HB4543 Detail]

Download: Illinois-2019-HB4543-Introduced.html

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101ST GENERAL ASSEMBLY State of Illinois 2019 and 2020 HB4543 Introduced , by Rep. Emanuel Chris Welch SYNOPSIS AS INTRODUCED:
See Index
Amends the Illinois Public Aid Code. Provides that for State Fiscal Years 2021 through 2024, an annual assessment on inpatient and outpatient services is imposed on each hospital provider, subject to other specified provisions. Contains provisions concerning a hospital's non-Medicaid gross revenue for State Fiscal Years 2021 and 2022. Contains provisions concerning the assignment of a pool allocation percentage for certain hospitals designated as a Level II trauma center; increased capitation payments to managed care organizations; the extension of certain assessments to July 1, 2022 (rather than July 1, 2020); reimbursements for inpatient general acute care services to non-publicly owned safety net hospitals, non-publicly owned critical access hospitals, hospital providers in high-need communities, and other facilities; the allocation of funds from the transitional access hospital pool; administrative rules for data collection and payment from the health disparities pay-for-collection pool; and other matters. Amends the Illinois Administrative Procedure Act. Provides that the Department of Healthcare and Family Services shall have emergency rulemaking authority to implement the provisions of the amendatory Act concerning assessments. Amends the Emergency Medical Services (EMS) Systems Act. Removes provisions requiring the Department of Public Health to issue a Freestanding Emergency Center license to a facility that has discontinued inpatient hospital services and meets other requirements. Effective immediately.
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FISCAL NOTE ACT MAY APPLY
A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. Legislative intent. The General Assembly finds
that, in order to improve equitable access to hospital services
for all Illinoisans, the hospital provider assessment and
associated payments to hospitals from the Hospital Provider
Fund must be reoriented toward the support of hospitals that
are located in areas with the greatest health needs and most
adversely affected by health disparities.
Section 5. The Illinois Administrative Procedure Act is
amended by adding Section 5-45.1 as follows:
(5 ILCS 100/5-45.1 new)
Sec. 5-45.1. Emergency rulemaking; Department of
Healthcare and Family Services. To provide for the expeditious
and timely implementation of changes made by this amendatory
Act of the 101st General Assembly to Sections 5A-2, 5A-12.6,
5A-14, and 14-12 of the Illinois Public Aid Code, emergency
rules may be adopted in accordance with Section 5-45 by the
Department of Healthcare and Family Services. The adoption of
emergency rules authorized by Section 5-45 and this Section is
deemed to be necessary for the public interest, safety, and

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welfare. This Section is repealed on January 1, 2026.
Section 10. The Emergency Medical Services (EMS) Systems
Act is amended by changing Section 32.5 as follows:
(210 ILCS 50/32.5)
Sec. 32.5. Freestanding Emergency Center.
(a) The Department shall issue an annual Freestanding
Emergency Center (FEC) license to any facility that has
received a permit from the Health Facilities and Services
Review Board to establish a Freestanding Emergency Center by
January 1, 2015, and:
(1) is located: (A) in a municipality with a population
of 50,000 or fewer inhabitants; (B) within 50 miles of the
hospital that owns or controls the FEC; and (C) within 50
miles of the Resource Hospital affiliated with the FEC as
part of the EMS System;
(2) is wholly owned or controlled by an Associate or
Resource Hospital, but is not a part of the hospital's
physical plant;
(3) meets the standards for licensed FECs, adopted by
rule of the Department, including, but not limited to:
(A) facility design, specification, operation, and
maintenance standards;
(B) equipment standards; and
(C) the number and qualifications of emergency

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medical personnel and other staff, which must include
at least one board certified emergency physician
present at the FEC 24 hours per day.
(4) limits its participation in the EMS System strictly
to receiving a limited number of patients by ambulance: (A)
according to the FEC's 24-hour capabilities; (B) according
to protocols developed by the Resource Hospital within the
FEC's designated EMS System; and (C) as pre-approved by
both the EMS Medical Director and the Department;
(5) provides comprehensive emergency treatment
services, as defined in the rules adopted by the Department
pursuant to the Hospital Licensing Act, 24 hours per day,
on an outpatient basis;
(6) provides an ambulance and maintains on site
ambulance services staffed with paramedics 24 hours per
day;
(7) (blank);
(8) complies with all State and federal patient rights
provisions, including, but not limited to, the Emergency
Medical Treatment Act and the federal Emergency Medical
Treatment and Active Labor Act;
(9) maintains a communications system that is fully
integrated with its Resource Hospital within the FEC's
designated EMS System;
(10) reports to the Department any patient transfers
from the FEC to a hospital within 48 hours of the transfer

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plus any other data determined to be relevant by the
Department;
(11) submits to the Department, on a quarterly basis,
the FEC's morbidity and mortality rates for patients
treated at the FEC and other data determined to be relevant
by the Department;
(12) does not describe itself or hold itself out to the
general public as a full service hospital or hospital
emergency department in its advertising or marketing
activities;
(13) complies with any other rules adopted by the
Department under this Act that relate to FECs;
(14) passes the Department's site inspection for
compliance with the FEC requirements of this Act;
(15) submits a copy of the permit issued by the Health
Facilities and Services Review Board indicating that the
facility has complied with the Illinois Health Facilities
Planning Act with respect to the health services to be
provided at the facility;
(16) submits an application for designation as an FEC
in a manner and form prescribed by the Department by rule;
and
(17) pays the annual license fee as determined by the
Department by rule.
(a-5) Notwithstanding any other provision of this Section,
the Department may issue an annual FEC license to a facility

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that is located in a county that does not have a licensed
general acute care hospital if the facility's application for a
permit from the Illinois Health Facilities Planning Board has
been deemed complete by the Department of Public Health by
January 1, 2014 and if the facility complies with the
requirements set forth in paragraphs (1) through (17) of
subsection (a).
(a-10) Notwithstanding any other provision of this
Section, the Department may issue an annual FEC license to a
facility if the facility has, by January 1, 2014, filed a
letter of intent to establish an FEC and if the facility
complies with the requirements set forth in paragraphs (1)
through (17) of subsection (a).
(a-15) Notwithstanding any other provision of this
Section, the Department shall issue an annual FEC license to a
facility if the facility: (i) discontinues operation as a
hospital within 180 days after December 4, 2015 (the effective
date of Public Act 99-490) this amendatory Act of the 99th
General Assembly with a Health Facilities and Services Review
Board project number of E-017-15; (ii) has an application for a
permit to establish an FEC from the Health Facilities and
Services Review Board that is deemed complete by January 1,
2017; and (iii) complies with the requirements set forth in
paragraphs (1) through (17) of subsection (a) of this Section.
(a-20) (Blank). Notwithstanding any other provision of
this Section, the Department shall issue an annual FEC license

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to a facility if:
(1) the facility is a hospital that has discontinued
inpatient hospital services;
(2) the Department of Healthcare and Family Services
has certified the conversion to an FEC was approved by the
Hospital Transformation Review Committee as a project
subject to the hospital's transformation under subsection
(d-5) of Section 14-12 of the Illinois Public Aid Code;
(3) the facility complies with the requirements set
forth in paragraphs (1) through (17), provided however that
the FEC may be located in a municipality with a population
greater than 50,000 inhabitants and shall not be subject to
the requirements of the Illinois Health Facilities
Planning Act that are applicable to the conversion to an
FEC if the Department of Healthcare and Family Service has
certified the conversion to an FEC was approved by the
Hospital Transformation Review Committee as a project
subject to the hospital's transformation under subsection
(d-5) of Section 14-12 of the Illinois Public Aid Code; and
(4) the facility is located at the same physical
location where the facility served as a hospital.
(b) The Department shall:
(1) annually inspect facilities of initial FEC
applicants and licensed FECs, and issue annual licenses to
or annually relicense FECs that satisfy the Department's
licensure requirements as set forth in subsection (a);

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(2) suspend, revoke, refuse to issue, or refuse to
renew the license of any FEC, after notice and an
opportunity for a hearing, when the Department finds that
the FEC has failed to comply with the standards and
requirements of the Act or rules adopted by the Department
under the Act;
(3) issue an Emergency Suspension Order for any FEC
when the Director or his or her designee has determined
that the continued operation of the FEC poses an immediate
and serious danger to the public health, safety, and
welfare. An opportunity for a hearing shall be promptly
initiated after an Emergency Suspension Order has been
issued; and
(4) adopt rules as needed to implement this Section.
(Source: P.A. 99-490, eff. 12-4-15; 99-710, eff. 8-5-16;
100-581, eff. 3-12-18; revised 7-23-19.)
Section 15. The Illinois Public Aid Code is amended by
changing Sections 5A-2, 5A-12.6, 5A-13, 5A-14, and 14-12 as
follows:
(305 ILCS 5/5A-2) (from Ch. 23, par. 5A-2)
(Section scheduled to be repealed on July 1, 2020)
Sec. 5A-2. Assessment.
(a)(1) Subject to Sections 5A-3 and 5A-10, for State fiscal
years 2009 through 2018, or as long as continued under Section

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5A-16, an annual assessment on inpatient services is imposed on
each hospital provider in an amount equal to $218.38 multiplied
by the difference of the hospital's occupied bed days less the
hospital's Medicare bed days, provided, however, that the
amount of $218.38 shall be increased by a uniform percentage to
generate an amount equal to 75% of the State share of the
payments authorized under Section 5A-12.5, with such increase
only taking effect upon the date that a State share for such
payments is required under federal law. For the period of April
through June 2015, the amount of $218.38 used to calculate the
assessment under this paragraph shall, by emergency rule under
subsection (s) of Section 5-45 of the Illinois Administrative
Procedure Act, be increased by a uniform percentage to generate
$20,250,000 in the aggregate for that period from all hospitals
subject to the annual assessment under this paragraph.
(2) In addition to any other assessments imposed under this
Article, effective July 1, 2016 and semi-annually thereafter
through June 2018, or as provided in Section 5A-16, in addition
to any federally required State share as authorized under
paragraph (1), the amount of $218.38 shall be increased by a
uniform percentage to generate an amount equal to 75% of the
ACA Assessment Adjustment, as defined in subsection (b-6) of
this Section.
For State fiscal years 2009 through 2018, or as provided in
Section 5A-16, a hospital's occupied bed days and Medicare bed
days shall be determined using the most recent data available

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from each hospital's 2005 Medicare cost report as contained in
the Healthcare Cost Report Information System file, for the
quarter ending on December 31, 2006, without regard to any
subsequent adjustments or changes to such data. If a hospital's
2005 Medicare cost report is not contained in the Healthcare
Cost Report Information System, then the Illinois Department
may obtain the hospital provider's occupied bed days and
Medicare bed days from any source available, including, but not
limited to, records maintained by the hospital provider, which
may be inspected at all times during business hours of the day
by the Illinois Department or its duly authorized agents and
employees.
(3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
fiscal years 2019 and 2020, an annual assessment on inpatient
services is imposed on each hospital provider in an amount
equal to $197.19 multiplied by the difference of the hospital's
occupied bed days less the hospital's Medicare bed days;
however, for State fiscal year 2021, the amount of $197.19
shall be increased by a uniform percentage to generate an
additional $6,250,000 in the aggregate for that period from all
hospitals subject to the annual assessment under this
paragraph. For State fiscal years 2019 and 2020, a hospital's
occupied bed days and Medicare bed days shall be determined
using the most recent data available from each hospital's 2015
Medicare cost report as contained in the Healthcare Cost Report
Information System file, for the quarter ending on March 31,

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2017, without regard to any subsequent adjustments or changes
to such data. If a hospital's 2015 Medicare cost report is not
contained in the Healthcare Cost Report Information System,
then the Illinois Department may obtain the hospital provider's
occupied bed days and Medicare bed days from any source
available, including, but not limited to, records maintained by
the hospital provider, which may be inspected at all times
during business hours of the day by the Illinois Department or
its duly authorized agents and employees. Notwithstanding any
other provision in this Article, for a hospital provider that
did not have a 2015 Medicare cost report, but paid an
assessment in State fiscal year 2018 on the basis of
hypothetical data, that assessment amount shall be used for
State fiscal years 2019 and 2020; however, for State fiscal
year 2021, the assessment amount shall be increased by the
proportion that it represents of the total annual assessment
that is generated from all hospitals in order to generate
$6,250,000 in the aggregate for that period from all hospitals
subject to the annual assessment under this paragraph.
Subject to Sections 5A-3 and 5A-10, for State fiscal years
2021 through 2024, an annual assessment on inpatient services
is imposed on each hospital provider in an amount equal to
$197.19 multiplied by the difference of the hospital's occupied
bed days less the hospital's Medicare bed days, provided
however, that the amount of $197.19 used to calculate the
assessment under this paragraph shall, by rule, be adjusted by

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a uniform percentage to generate the same total annual
assessment that was generated in State fiscal year 2020 from
all hospitals subject to the annual assessment under this
paragraph plus $6,250,000. For State fiscal years 2021 and
2022, a hospital's occupied bed days and Medicare bed days
shall be determined using the most recent data available from
each hospital's 2017 Medicare cost report as contained in the
Healthcare Cost Report Information System file, for the quarter
ending on March 31, 2019, without regard to any subsequent
adjustments or changes to such data. For State fiscal years
2023 and 2024, a hospital's occupied bed days and Medicare bed
days shall be determined using the most recent data available
from each hospital's 2019 Medicare cost report as contained in
the Healthcare Cost Report Information System file, for the
quarter ending on March 31, 2021, without regard to any
subsequent adjustments or changes to such data.
(b) (Blank).
(b-5)(1) Subject to Sections 5A-3 and 5A-10, for the
portion of State fiscal year 2012, beginning June 10, 2012
through June 30, 2012, and for State fiscal years 2013 through
2018, or as provided in Section 5A-16, an annual assessment on
outpatient services is imposed on each hospital provider in an
amount equal to .008766 multiplied by the hospital's outpatient
gross revenue, provided, however, that the amount of .008766
shall be increased by a uniform percentage to generate an
amount equal to 25% of the State share of the payments

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authorized under Section 5A-12.5, with such increase only
taking effect upon the date that a State share for such
payments is required under federal law. For the period
beginning June 10, 2012 through June 30, 2012, the annual
assessment on outpatient services shall be prorated by
multiplying the assessment amount by a fraction, the numerator
of which is 21 days and the denominator of which is 365 days.
For the period of April through June 2015, the amount of
.008766 used to calculate the assessment under this paragraph
shall, by emergency rule under subsection (s) of Section 5-45
of the Illinois Administrative Procedure Act, be increased by a
uniform percentage to generate $6,750,000 in the aggregate for
that period from all hospitals subject to the annual assessment
under this paragraph.
(2) In addition to any other assessments imposed under this
Article, effective July 1, 2016 and semi-annually thereafter
through June 2018, in addition to any federally required State
share as authorized under paragraph (1), the amount of .008766
shall be increased by a uniform percentage to generate an
amount equal to 25% of the ACA Assessment Adjustment, as
defined in subsection (b-6) of this Section.
For the portion of State fiscal year 2012, beginning June
10, 2012 through June 30, 2012, and State fiscal years 2013
through 2018, or as provided in Section 5A-16, a hospital's
outpatient gross revenue shall be determined using the most
recent data available from each hospital's 2009 Medicare cost

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report as contained in the Healthcare Cost Report Information
System file, for the quarter ending on June 30, 2011, without
regard to any subsequent adjustments or changes to such data.
If a hospital's 2009 Medicare cost report is not contained in
the Healthcare Cost Report Information System, then the
Department may obtain the hospital provider's outpatient gross
revenue from any source available, including, but not limited
to, records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Department or its duly authorized agents and employees.
(3) Subject to Sections 5A-3, 5A-10, and 5A-16, for State
fiscal years 2019 and 2020, an annual assessment on outpatient
services is imposed on each hospital provider in an amount
equal to .01358 multiplied by the hospital's outpatient gross
revenue; however, for State fiscal year 2021, the amount of
.01358 shall be increased by a uniform percentage to generate
an additional $6,250,000 in the aggregate for that period from
all hospitals subject to the annual assessment under this
paragraph. For State fiscal years 2019 and 2020, a hospital's
outpatient gross revenue shall be determined using the most
recent data available from each hospital's 2015 Medicare cost
report as contained in the Healthcare Cost Report Information
System file, for the quarter ending on March 31, 2017, without
regard to any subsequent adjustments or changes to such data.
If a hospital's 2015 Medicare cost report is not contained in
the Healthcare Cost Report Information System, then the

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Department may obtain the hospital provider's outpatient gross
revenue from any source available, including, but not limited
to, records maintained by the hospital provider, which may be
inspected at all times during business hours of the day by the
Department or its duly authorized agents and employees.
Notwithstanding any other provision in this Article, for a
hospital provider that did not have a 2015 Medicare cost
report, but paid an assessment in State fiscal year 2018 on the
basis of hypothetical data, that assessment amount shall be
used for State fiscal years 2019 and 2020; however, for State
fiscal year 2021, the assessment amount shall be increased by
the proportion that it represents of the total annual
assessment that is generated from all hospitals in order to
generate $6,250,000 in the aggregate for that period from all
hospitals subject to the annual assessment under this
paragraph.
Subject to Sections 5A-3 and 5A-10, for State fiscal years
2021 through 2024, an annual assessment on outpatient services
is imposed on each hospital provider in an amount equal to
.01358 multiplied by the hospital's outpatient gross revenue,
provided however, that the amount of .01358 used to calculate
the assessment under this paragraph shall, by rule, be adjusted
by a uniform percentage to generate the same total annual
assessment that was generated in State fiscal year 2020 from
all hospitals subject to the annual assessment under this
paragraph plus $6,250,000. For State fiscal years 2021 and

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2022, a hospital's outpatient gross revenue shall be determined
using the most recent data available from each hospital's 2017
Medicare cost report as contained in the Healthcare Cost Report
Information System file, for the quarter ending on March 31,
2019, without regard to any subsequent adjustments or changes
to such data. For State fiscal years 2023 and 2024, a
hospital's outpatient gross revenue shall be determined using
the most recent data available from each hospital's 2019
Medicare cost report as contained in the Healthcare Cost Report
Information System file, for the quarter ending on March 31,
2021, without regard to any subsequent adjustments or changes
to such data.
(b-6)(1) As used in this Section, "ACA Assessment
Adjustment" means:
(A) For the period of July 1, 2016 through December 31,
2016, the product of .19125 multiplied by the sum of the
fee-for-service payments to hospitals as authorized under
Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of April 2016 multiplied by 6.
(B) For the period of January 1, 2017 through June 30,
2017, the product of .19125 multiplied by the sum of the
fee-for-service payments to hospitals as authorized under
Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care

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organizations for hospital services due and payable in the
month of October 2016 multiplied by 6, except that the
amount calculated under this subparagraph (B) shall be
adjusted, either positively or negatively, to account for
the difference between the actual payments issued under
Section 5A-12.5 for the period beginning July 1, 2016
through December 31, 2016 and the estimated payments due
and payable in the month of April 2016 multiplied by 6 as
described in subparagraph (A).
(C) For the period of July 1, 2017 through December 31,
2017, the product of .19125 multiplied by the sum of the
fee-for-service payments to hospitals as authorized under
Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of April 2017 multiplied by 6, except that the amount
calculated under this subparagraph (C) shall be adjusted,
either positively or negatively, to account for the
difference between the actual payments issued under
Section 5A-12.5 for the period beginning January 1, 2017
through June 30, 2017 and the estimated payments due and
payable in the month of October 2016 multiplied by 6 as
described in subparagraph (B).
(D) For the period of January 1, 2018 through June 30,
2018, the product of .19125 multiplied by the sum of the
fee-for-service payments to hospitals as authorized under

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Section 5A-12.5 and the adjustments authorized under
subsection (t) of Section 5A-12.2 to managed care
organizations for hospital services due and payable in the
month of October 2017 multiplied by 6, except that:
(i) the amount calculated under this subparagraph
(D) shall be adjusted, either positively or
negatively, to account for the difference between the
actual payments issued under Section 5A-12.5 for the
period of July 1, 2017 through December 31, 2017 and
the estimated payments due and payable in the month of
April 2017 multiplied by 6 as described in subparagraph
(C); and
(ii) the amount calculated under this subparagraph
(D) shall be adjusted to include the product of .19125
multiplied by the sum of the fee-for-service payments,
if any, estimated to be paid to hospitals under
subsection (b) of Section 5A-12.5.
(2) The Department shall complete and apply a final
reconciliation of the ACA Assessment Adjustment prior to June
30, 2018 to account for:
(A) any differences between the actual payments issued
or scheduled to be issued prior to June 30, 2018 as
authorized in Section 5A-12.5 for the period of January 1,
2018 through June 30, 2018 and the estimated payments due
and payable in the month of October 2017 multiplied by 6 as
described in subparagraph (D); and

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(B) any difference between the estimated
fee-for-service payments under subsection (b) of Section
5A-12.5 and the amount of such payments that are actually
scheduled to be paid.
The Department shall notify hospitals of any additional
amounts owed or reduction credits to be applied to the June
2018 ACA Assessment Adjustment. This is to be considered the
final reconciliation for the ACA Assessment Adjustment.
(3) Notwithstanding any other provision of this Section, if
for any reason the scheduled payments under subsection (b) of
Section 5A-12.5 are not issued in full by the final day of the
period authorized under subsection (b) of Section 5A-12.5,
funds collected from each hospital pursuant to subparagraph (D)
of paragraph (1) and pursuant to paragraph (2), attributable to
the scheduled payments authorized under subsection (b) of
Section 5A-12.5 that are not issued in full by the final day of
the period attributable to each payment authorized under
subsection (b) of Section 5A-12.5, shall be refunded.
(4) The increases authorized under paragraph (2) of
subsection (a) and paragraph (2) of subsection (b-5) shall be
limited to the federally required State share of the total
payments authorized under Section 5A-12.5 if the sum of such
payments yields an annualized amount equal to or less than
$450,000,000, or if the adjustments authorized under
subsection (t) of Section 5A-12.2 are found not to be
actuarially sound; however, this limitation shall not apply to

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the fee-for-service payments described in subsection (b) of
Section 5A-12.5.
(c) (Blank).
(c-5)(1) Subject to Sections 5A-3 and 5A-10, for State
Fiscal Years 2021 through 2024, an annual assessment on
inpatient and outpatient services is imposed on each hospital
provider. The assessment shall be as described in paragraph (2)
of this subsection.
(2)(A) The "total assessment" shall be equal to the sum of
the following 2 numbers:
(B) The assessment imposed on each hospital provider shall
be equal to a rate multiplied by the sum of their non-Medicaid
inpatient gross revenue and non-Medicaid outpatient gross
revenue. The Department shall determine the rate so that it is
uniform for all hospital providers subject to the assessment
and the funds generated by the assessment are equivalent to the
total assessment.
For State Fiscal Years 2021 and 2022, a hospital's
non-Medicaid gross revenue shall be determined using the most
recent data available from each hospital's 2017 Medicare cost
report as contained in the Healthcare Cost Report Information
System file, for the quarter ending on March 31, 2019, without
regard to any subsequent adjustments or changes to such data.
For State Fiscal Years 2023 and 2024, a hospital's non-Medicaid
gross revenue shall be determined using the most recent data
available from each hospital's 2019 Medicare cost report as

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contained in the Healthcare Cost Report Information System
file, for the quarter ending on March 31, 2021, without regard
to any subsequent adjustments or changes to such data. If a
hospital's Medicare cost report is not contained in the
Healthcare Cost Report Information System or the hospital's
Medicare cost report contains insufficient information to
determine gross non-Medicaid inpatient or outpatient revenue,
then the Department may obtain the hospital provider's gross
non-Medicaid revenue from any source available, including, but
not limited to, records maintained by the hospital provider,
which may be inspected at all times during business hours of
the day by the Department or its duly authorized agents and
employees. The Department may also set any additional reporting
requirements for Medicare cost reports as deemed necessary to
determine non-Medicaid gross revenue inpatient and outpatient
revenue for future fiscal years.
(d) Notwithstanding any of the other provisions of this
Section, the Department is authorized to adopt rules to reduce
the rate of any annual assessment imposed under this Section,
as authorized by Section 5-46.2 of the Illinois Administrative
Procedure Act.
(e) Notwithstanding any other provision of this Section,
any plan providing for an assessment on a hospital provider as
a permissible tax under Title XIX of the federal Social
Security Act and Medicaid-eligible payments to hospital
providers from the revenues derived from that assessment shall

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be reviewed by the Illinois Department of Healthcare and Family
Services, as the Single State Medicaid Agency required by
federal law, to determine whether those assessments and
hospital provider payments meet federal Medicaid standards. If
the Department determines that the elements of the plan may
meet federal Medicaid standards and a related State Medicaid
Plan Amendment is prepared in a manner and form suitable for
submission, that State Plan Amendment shall be submitted in a
timely manner for review by the Centers for Medicare and
Medicaid Services of the United States Department of Health and
Human Services and subject to approval by the Centers for
Medicare and Medicaid Services of the United States Department
of Health and Human Services. No such plan shall become
effective without approval by the Illinois General Assembly by
the enactment into law of related legislation. Notwithstanding
any other provision of this Section, the Department is
authorized to adopt rules to reduce the rate of any annual
assessment imposed under this Section. Any such rules may be
adopted by the Department under Section 5-50 of the Illinois
Administrative Procedure Act.
(Source: P.A. 100-581, eff. 3-12-18; 101-10, eff. 6-5-19.)
(305 ILCS 5/5A-12.6)
(Section scheduled to be repealed on July 1, 2020)
Sec. 5A-12.6. Continuation of hospital access payments on
or after July 1, 2018.

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(a) To preserve and improve access to hospital services,
for hospital services rendered on or after July 1, 2018 the
Department shall, except for hospitals described in subsection
(b) of Section 5A-3, make payments to hospitals as set forth in
this Section. Payments under this Section are not due and
payable, however, until (i) the methodologies described in this
Section are approved by the federal government in an
appropriate State Plan amendment and (ii) the assessment
imposed under this Article is determined to be a permissible
tax under Title XIX of the Social Security Act. In determining
the hospital access payments authorized under subsections (f)
through (n) of this Section, unless otherwise specified, only
Illinois hospitals shall be eligible for a payment and total
Medicaid utilization statistics shall be used to determine the
payment amount. In determining the hospital access payments
authorized under subsection (d) and subsections (f) through (l)
of this Section, if a hospital ceases to receive payments from
the pool, the payments for all hospitals continuing to receive
payments from such pool shall be uniformly adjusted to fully
expend the aggregate amount of the pool, with such adjustment
being effective on the first day of the second month following
the date the hospital ceases to receive payments from such
pool.
(b) Phase in of funds to claims-based payments and updates.
To ensure access to hospital services, the Department may only
use funds financed by the assessment authorized under Section

HB4543 - 23 - LRB101 19021 KTG 68481 b
5A-2 to increase claims-based payment rates, including
applicable policy add-on payments or adjusters, in accordance
with this subsection. Starting in State Fiscal Year 2021, to To
increase the claims-based payment rates up to the amounts
specified in this subsection, the hospital access payments
authorized in paragraphs (3) through (5) of subsection (g),
paragraph (3) of subsection (h), paragraph (2) of subsection
(i), paragraph (1) of subsection (j), subsection (k), and
subsection (n) of this Section shall be reduced to zero.
Following this, the remaining hospital access payments
authorized in subsection (d) and subsections (g) through (l) of
this Section shall be uniformly reduced.
(1) For State fiscal years 2019 and 2020, up to
$635,000,000 of the total spending financed from the
assessment authorized under Section 5A-2 that is intended
to pay for hospital services and the hospital supplemental
access payments authorized under subsections (d) and (f) of
Section 14-12 for payment in State fiscal year 2018 may be
used to increase claims-based hospital payment rates as
specified under Section 14-12.
(2) For State fiscal years 2021 and 2022, up to
$1,696,000,000 $1,164,000,000 of the total spending
financed from the assessment authorized under Section 5A-2
that is intended to pay for hospital services and the
hospital supplemental access payments authorized under
subsections (d) and (f) of Section 14-12 for payment in

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State Fiscal Year 2018 may be used to increase claims-based
hospital payment rates as specified under Section 14-12.
(3) (Blank). For State fiscal years 2023, up to
$1,397,000,000 of the total spending financed from the
assessment authorized under Section 5A-2 that is intended
to pay for hospital services and the hospital supplemental
access payments authorized under subsections (d) and (f) of
Section 14-12 for payment in State Fiscal Year 2018 may be
used to increase claims-based hospital payment rates as
specified under Section 14-12.
(4) (Blank). For State fiscal years 2024, up to
$1,663,000,000 of the total spending financed from the
assessment authorized under Section 5A-2 that is intended
to pay for hospital services and the hospital supplemental
access payments authorized under subsections (d) and (f) of
Section 14-12 for payment in State Fiscal Year 2018 may be
used to increase claims-based hospital payment rates as
specified under Section 14-12.
(5) Beginning in State fiscal year 2021, and at least
every 24 months thereafter, the Department shall, by rule,
update the hospital access payments authorized under this
Section to take into account the amount of funds being used
to increase claims-based hospital payment rates under
Section 14-12 and to apply the most recently available data
and information, including data from the most recent base
year and qualifying criteria which shall correlate to the

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updated base year data, to determine a hospital's
eligibility for each payment and the amount of the payment
authorized under this Section. Any updates of the hospital
access payment methodologies shall not result in any
diminishment of the aggregate amount of hospital access
payment expenditures, except for reductions attributable
to the use of such funds to increase claims-based hospital
payment rates as authorized by this Section. Nothing in
this Section shall be construed as precluding variations in
the amount of any individual hospital's access payments.
The Department shall publish the proposed rules to update
the hospital access payments at least 90 days before their
proposed effective date. The proposed rules shall not be
adopted using emergency rulemaking authority. The
Department shall notify each hospital, in writing, of the
impact of these updates on the hospital at least 30
calendar days prior to their effective date.
(c) The hospital access payments authorized under
subsections (d) through (n) of this Section shall be paid in 12
equal installments on or before the seventh State business day
of each month, except that no payment shall be due within 100
days after the later of the date of notification of federal
approval of the payment methodologies required under this
Section or any waiver required under 42 CFR 433.68, at which
time the sum of amounts required under this Section prior to
the date of notification is due and payable. Payments under

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this Section are not due and payable, however, until (i) the
methodologies described in this Section are approved by the
federal government in an appropriate State Plan amendment and
(ii) the assessment imposed under this Article is determined to
be a permissible tax under Title XIX of the Social Security
Act. The Department may, when practicable, accelerate the
schedule upon which payments authorized under this Section are
made.
(d) Rate increase-based adjustment.
(1) From the funds financed by the assessment
authorized under Section 5A-2, individual funding pools by
category of service shall be established, for Inpatient
General Acute Care services in the amount of $268,051,572,
Inpatient Rehab Care services in the amount of $24,500,610,
Inpatient Psychiatric Care service in the amount of
$94,617,812, and Outpatient Care Services in the amount of
$328,828,641.
(2) Each Illinois hospital and other hospitals
authorized under this subsection, except for long-term
acute care hospitals and public hospitals, shall be
assigned a pool allocation percentage for each category of
service that is equal to the ratio of the hospital's
estimated FY2019 claims-based payments including all
applicable FY2019 policy adjusters, multiplied by the
applicable service credit factor for the hospital, divided
by the total of the FY2019 claims-based payments including

HB4543 - 27 - LRB101 19021 KTG 68481 b
all FY2019 policy adjusters for each category of service
adjusted by each hospital's applicable service credit
factor for all qualified hospitals. For each category of
service, a hospital shall receive a supplemental payment
equal to its pool allocation percentage multiplied by the
total pool amount.
(3) Effective July 1, 2018, for purposes of determining
for State fiscal years 2019 and 2020 the hospitals eligible
for the payments authorized under this subsection, the
Department shall include children's hospitals located in
St. Louis that are designated a Level III perinatal center
by the Department of Public Health and also designated a
Level I pediatric trauma center by the Department of Public
Health as of December 1, 2017.
(4) As used in this subsection, "service credit factor"
is determined based on a hospital's Rate Year 2017 Medicaid
inpatient utilization rate ("MIUR") rounded to the nearest
whole percentage, as follows:
(A) Tier 1: A hospital with a MIUR equal to or
greater than 60% shall have a service credit factor of
200%.
(B) Tier 2: A hospital with a MIUR equal to or
greater than 33% but less than 60% shall have a service
credit factor of 100%.
(C) Tier 3: A hospital with a MIUR equal to or
greater than 20% but less than 33% shall have a service

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credit factor of 50%.
(D) Tier 4: A hospital with a MIUR less than 20%
shall have a service credit factor of 10%.
(e) Graduate medical education.
(1) The calculation of graduate medical education
payments shall be based on the hospital's Medicare cost
report ending in Calendar Year 2015, as reported in
Medicare cost reports released on October 19, 2016 with
data through September 30, 2016. An Illinois hospital
reporting intern and resident cost on its Medicare cost
report shall be eligible for graduate medical education
payments.
(2) Each hospital's annualized Medicaid Intern
Resident Cost is calculated using annualized intern and
resident total costs obtained from Worksheet B Part I,
Column 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
96-98, and 105-112 multiplied by the percentage that the
hospital's Medicaid days (Worksheet S3 Part I, Column 7,
Lines 14 and 16-18) comprise of the hospital's total days
(Worksheet S3 Part I, Column 8, Lines 14 and 16-18).
(3) An annualized Medicaid indirect medical education
(IME) payment is calculated for each hospital using its IME
payments (Worksheet E Part A, Line 29, Col 1) multiplied by
the percentage that its Medicaid days (Worksheet S3 Part I,
Column 7, Lines 14 and 16-18) comprise of its Medicare days
(Worksheet S3 Part I, Column 6, Lines 14 and 16-18).

HB4543 - 29 - LRB101 19021 KTG 68481 b
(4) For each hospital, its annualized Medicaid Intern
Resident Cost and its annualized Medicaid IME payment are
summed and multiplied by 33% to determine the hospital's
final graduate medical education payment.
(f) Alzheimer's treatment access payment. Each Illinois
academic medical center or teaching hospital, as defined in
Section 5-5e.2 of this Code, that is identified as the primary
hospital affiliate of one of the Regional Alzheimer's Disease
Assistance Centers, as designated by the Alzheimer's Disease
Assistance Act and identified in the Department of Public
Health's Alzheimer's Disease State Plan dated December 2016,
shall be paid an Alzheimer's treatment access payment equal to
the product of $10,000,000 multiplied by a fraction, the
numerator of which is the qualifying hospital's Fiscal Year
2015 total admissions and the denominator of which is the
Fiscal Year 2015 total admissions for all hospitals eligible
for the payment.
(g) Safety-net hospital, private critical access hospital,
and outpatient high volume access payment.
(1) Each safety-net hospital, as defined in Section
5-5e.1 of this Code, for Rate Year 2017 that is not
publicly owned shall be paid an outpatient high volume
access payment equal to $40,000,000 multiplied by a
fraction, the numerator of which is the hospital's Fiscal
Year 2015 outpatient services and the denominator of which
is the Fiscal Year 2015 outpatient services for all

HB4543 - 30 - LRB101 19021 KTG 68481 b
hospitals eligible under this paragraph for this payment.
(2) Each critical access hospital that is not publicly
owned shall be paid an outpatient high volume access
payment equal to $55,000,000 multiplied by a fraction, the
numerator of which is the hospital's Fiscal Year 2015
outpatient services and the denominator of which is the
Fiscal Year 2015 outpatient services for all hospitals
eligible under this paragraph for this payment.
(3) Each tier 1 hospital that is not publicly owned
shall be paid an outpatient high volume access payment
equal to $25,000,000 multiplied by a fraction, the
numerator of which is the hospital's Fiscal Year 2015
outpatient services and the denominator of which is the
Fiscal Year 2015 outpatient services for all hospitals
eligible under this paragraph for this payment. A tier 1
outpatient high volume hospital means one of the following:
(i) a non-publicly owned hospital, excluding a safety net
hospital as defined in Section 5-5e.1 of this Code for Rate
Year 2017, with total outpatient services, equal to or
greater than the regional mean plus one standard deviation
for all hospitals in the region but less than the mean plus
1.5 standard deviation; (ii) an Illinois non-publicly
owned hospital with total outpatient service units equal to
or greater than the statewide mean plus one standard
deviation; or (iii) a non-publicly owned safety net
hospital as defined in Section 5-5e.1 of this Code for Rate

HB4543 - 31 - LRB101 19021 KTG 68481 b
Year 2017, with total outpatient services, equal to or
greater than the regional mean plus one standard deviation
for all hospitals in the region.
(4) Each tier 2 hospital that is not publicly owned
shall be paid an outpatient high volume access payment
equal to $25,000,000 multiplied by a fraction, the
numerator of which is the hospital's Fiscal Year 2015
outpatient services and the denominator of which is the
Fiscal Year 2015 outpatient services for all hospitals
eligible under this paragraph for this payment. A tier 2
outpatient high volume hospital means a non-publicly owned
hospital, excluding a safety-net hospital as defined in
Section 5-5e.1 of this Code for Rate Year 2017, with total
outpatient services equal to or greater than the regional
mean plus 1.5 standard deviations for all hospitals in the
region but less than the mean plus 2 standard deviations.
(5) Each tier 3 hospital that is not publicly owned
shall be paid an outpatient high volume access payment
equal to $58,000,000 multiplied by a fraction, the
numerator of which is the hospital's Fiscal Year 2015
outpatient services and the denominator of which is the
Fiscal Year 2015 outpatient services for all hospitals
eligible under this paragraph for this payment. A tier 3
outpatient high volume hospital means a non-publicly owned
hospital, excluding a safety-net hospital as defined in
Section 5-5e.1 of this Code for Rate Year 2017, with total

HB4543 - 32 - LRB101 19021 KTG 68481 b
outpatient services equal to or greater than the regional
mean plus 2 standard deviations for all hospitals in the
region.
(h) Medicaid dependent or high volume hospital access
payment.
(1) To qualify for a Medicaid dependent hospital access
payment, a hospital shall meet one of the following
criteria:
(A) Be a non-publicly owned general acute care
hospital that is a safety-net hospital, as defined in
Section 5-5e.1 of this Code, for Rate Year 2017.
(B) Be a pediatric hospital that is a safety net
hospital, as defined in Section 5-5e.1 of this Code,
for Rate Year 2017 and have a Medicaid inpatient
utilization rate equal to or greater than 50%.
(C) Be a general acute care hospital with a
Medicaid inpatient utilization rate equal to or
greater than 50% in Rate Year 2017.
(2) The Medicaid dependent hospital access payment
shall be determined as follows:
(A) Each tier 1 hospital shall be paid a Medicaid
dependent hospital access payment equal to $23,000,000
multiplied by a fraction, the numerator of which is the
hospital's Fiscal Year 2015 total days and the
denominator of which is the Fiscal Year 2015 total days
for all hospitals eligible under this subparagraph for

HB4543 - 33 - LRB101 19021 KTG 68481 b
this payment. A tier 1 Medicaid dependent hospital
means a qualifying hospital with a Rate Year 2017
Medicaid inpatient utilization rate equal to or
greater than the statewide mean but less than the
statewide mean plus 0.5 standard deviation.
(B) Each tier 2 hospital shall be paid a Medicaid
dependent hospital access payment equal to $15,000,000
multiplied by a fraction, the numerator of which is the
hospital's Fiscal Year 2015 total days and the
denominator of which is the Fiscal Year 2015 total days
for all hospitals eligible under this subparagraph for
this payment. A tier 2 Medicaid dependent hospital
means a qualifying hospital with a Rate Year 2017
Medicaid inpatient utilization rate equal to or
greater than the statewide mean plus 0.5 standard
deviations but less than the statewide mean plus one
standard deviation.
(C) Each tier 3 hospital shall be paid a Medicaid
dependent hospital access payment equal to $15,000,000
multiplied by a fraction, the numerator of which is the
hospital's Fiscal Year 2015 total days and the
denominator of which is the Fiscal Year 2015 total days
for all hospitals eligible under this subparagraph for
this payment. A tier 3 Medicaid dependent hospital
means a qualifying hospital with a Rate Year 2017
Medicaid inpatient utilization rate equal to or

HB4543 - 34 - LRB101 19021 KTG 68481 b
greater than the statewide mean plus one standard
deviation but less than the statewide mean plus 1.5
standard deviations.
(D) Each tier 4 hospital shall be paid a Medicaid
dependent hospital access payment equal to $53,000,000
multiplied by a fraction, the numerator of which is the
hospital's Fiscal Year 2015 total days and the
denominator of which is the Fiscal Year 2015 total days
for all hospitals eligible under this subparagraph for
this payment. A tier 4 Medicaid dependent hospital
means a qualifying hospital with a Rate Year 2017
Medicaid inpatient utilization rate equal to or
greater than the statewide mean plus 1.5 standard
deviations but less than the statewide mean plus 2
standard deviations.
(E) Each tier 5 hospital shall be paid a Medicaid
dependent hospital access payment equal to $75,000,000
multiplied by a fraction, the numerator of which is the
hospital's Fiscal Year 2015 total days and the
denominator of which is the Fiscal Year 2015 total days
for all hospitals eligible under this subparagraph for
this payment. A tier 5 Medicaid dependent hospital
means a qualifying hospital with a Rate Year 2017
Medicaid inpatient utilization rate equal to or
greater than the statewide mean plus 2 standard
deviations.

HB4543 - 35 - LRB101 19021 KTG 68481 b
(3) Each Medicaid high volume hospital shall be paid a
Medicaid high volume access payment equal to $300,000,000
multiplied by a fraction, the numerator of which is the
hospital's Fiscal Year 2015 total admissions and the
denominator of which is the Fiscal Year 2015 total
admissions for all hospitals eligible under this paragraph
for this payment. A Medicaid high volume hospital means the
Illinois general acute care hospitals with the highest
number of Fiscal Year 2015 total admissions that when
ranked in descending order from the highest Fiscal Year
2015 total admissions to the lowest Fiscal Year 2015 total
admissions, in the aggregate, sum to at least 50% of the
total admissions for all such hospitals in Fiscal Year
2015; however, any hospital which has qualified as a
Medicaid dependent hospital shall not also be considered a
Medicaid high volume hospital.
(i) Perinatal care access payment.
(1) Each Illinois non-publicly owned hospital
designated a Level II or II+ perinatal center by the
Department of Public Health as of December 1, 2017 shall be
assigned a pool allocation percentage equal to a fraction,
the numerator of which is the hospital's Fiscal Year 2015
total admissions multiplied by the hospital's Medicaid
utilization factor and the denominator of which is the sum
of Fiscal Year 2015 admissions multiplied by Medicaid
utilization factor for all hospitals authorized for

HB4543 - 36 - LRB101 19021 KTG 68481 b
payment under this paragraph. Each qualifying hospital
will be paid an access payment equal to $200,000,000
multiplied by its pool allocation percentage. a fraction,
the numerator of which is the hospital's Fiscal Year 2015
total admissions and the denominator of which is the Fiscal
Year 2015 total admissions for all hospitals eligible under
this paragraph for this payment.
(2) Each Illinois non-publicly owned hospital
designated a Level III perinatal center by the Department
of Public Health as of December 1, 2017 shall be paid an
access payment equal to $100,000,000 multiplied by a
fraction, the numerator of which is the hospital's Fiscal
Year 2015 total admissions and the denominator of which is
the Fiscal Year 2015 total admissions for all hospitals
eligible under this paragraph for this payment.
(3) As used in this subsection, "Medicaid utilization
factor" is equal to the square of the sum of 0.5 and the
hospital's rate year 2017 Medicaid inpatient utilization
rate.
(j) Trauma care access payment.
(1) Each Illinois non-publicly owned hospital
designated a Level I trauma center by the Department of
Public Health as of December 1, 2017 shall be paid an
access payment equal to $160,000,000 multiplied by a
fraction, the numerator of which is the hospital's Fiscal
Year 2015 total admissions and the denominator of which is

HB4543 - 37 - LRB101 19021 KTG 68481 b
the Fiscal Year 2015 total admissions for all hospitals
eligible under this paragraph for this payment.
(2) Each Illinois non-publicly owned hospital
designated a Level II trauma center by the Department of
Public Health as of December 1, 2017 shall be assigned a
pool allocation percentage equal to a fraction, the
numerator of which is the hospital's Fiscal Year 2015 total
admissions multiplied by the hospital's Medicaid
utilization factor and the denominator of which is the sum
of Fiscal Year 2015 admissions multiplied by Medicaid
utilization factor for all hospitals authorized for
payment under this paragraph. Each qualifying hospital
will be paid an access payment equal to $200,000,000
multiplied by its pool allocation percentage. a fraction,
the numerator of which is the hospital's Fiscal Year 2015
total admissions and the denominator of which is the Fiscal
Year 2015 total admissions for all hospitals eligible under
this paragraph for this payment.
(3) As used in this subsection, "Medicaid utilization
factor" is equal to the square of the sum of 0.5 and the
hospital's rate year 2017 Medicaid inpatient utilization
rate.
(k) Perinatal and trauma center access payment.
(1) Each Illinois non-publicly owned hospital
designated a Level III perinatal center and a Level I or II
trauma center by the Department of Public Health as of

HB4543 - 38 - LRB101 19021 KTG 68481 b
December 1, 2017, and that has a Rate Year 2017 Medicaid
inpatient utilization rate equal to or greater than 20% and
a calendar year 2015 occupancy ratio equal to or greater
than 50%, shall be paid an access payment equal to
$160,000,000 multiplied by a fraction, the numerator of
which is the hospital's Fiscal Year 2015 total admissions
and the denominator of which is the Fiscal Year 2015 total
admissions for all hospitals eligible under this paragraph
for this payment.
(2) Each Illinois non-publicly owned hospital
designated a Level II or II+ perinatal center and a Level I
or II trauma center by the Department of Public Health as
of December 1, 2017, and that has a Rate Year 2017 Medicaid
inpatient utilization rate equal to or greater than 20% and
a calendar year 2015 occupancy ratio equal to or greater
than 50%, shall be paid an access payment equal to
$200,000,000 multiplied by a fraction, the numerator of
which is the hospital's Fiscal Year 2015 total admissions
and the denominator of which is the Fiscal Year 2015 total
admissions for all hospitals eligible under this paragraph
for this payment.
(l) Long-term acute care access payment. Each Illinois
non-publicly owned long-term acute care hospital that has a
Rate Year 2017 Medicaid inpatient utilization rate equal to or
greater than 25% and a calendar year 2015 occupancy ratio equal
to or greater than 60% shall be paid an access payment equal to

HB4543 - 39 - LRB101 19021 KTG 68481 b
$19,000,000 multiplied by a fraction, the numerator of which is
the hospital's Fiscal Year 2015 general acute care admissions
and the denominator of which is the Fiscal Year 2015 general
acute care admissions for all hospitals eligible under this
subsection for this payment.
(m) Small public hospital access payment.
(1) As used in this subsection, "small public hospital"
means any Illinois publicly owned hospital which is not a
"large public hospital" as described in 89 Ill. Adm. Code
148.25(a).
(2) Each small public hospital shall be paid an
inpatient access payment equal to $2,825,000 multiplied by
a fraction, the numerator of which is the hospital's Fiscal
Year 2015 total days and the denominator of which is the
Fiscal Year 2015 total days for all hospitals under this
paragraph for this payment.
(3) Each small public hospital shall be paid an
outpatient access payment equal to $24,000,000 multiplied
by a fraction, the numerator of which is the hospital's
Fiscal Year 2015 outpatient services and the denominator of
which is the Fiscal Year 2015 outpatient services for all
hospitals eligible under this paragraph for this payment.
(n) Psychiatric care access payment. In addition to rates
paid for inpatient psychiatric services, the Illinois
Department shall, by rule, establish an access payment for
inpatient hospital psychiatric services that shall, in the

HB4543 - 40 - LRB101 19021 KTG 68481 b
aggregate, spend approximately $61,141,188 annually. In
consultation with the hospital community, the Department may,
by rule, incorporate the funds used for this access payment to
increase the payment rates for inpatient psychiatric services,
except that such changes shall not take effect before July 1,
2019. Upon incorporation into the claims payment rates, this
access payment shall be repealed. Beginning July 1, 2018, for
purposes of determining for State fiscal years 2019 and 2020
the hospitals eligible for the payments authorized under this
subsection, the Department shall include out-of-state
hospitals that are designated a Level I pediatric trauma center
or a Level I trauma center by the Department of Public Health
as of December 1, 2017.
(o) For purposes of this Section, a hospital that is
enrolled to provide Medicaid services during State fiscal year
2015 shall have its utilization and associated reimbursements
annualized prior to the payment calculations being performed
under this Section.
(p) Definitions. As used in this Section, unless the
context requires otherwise:
"General acute care admissions" means, for a given
hospital, the sum of inpatient hospital admissions provided to
recipients of medical assistance under Title XIX of the Social
Security Act for general acute care, excluding admissions for
individuals eligible for Medicare under Title XVIII of the
Social Security Act (Medicaid/Medicare crossover admissions),

HB4543 - 41 - LRB101 19021 KTG 68481 b
as tabulated from the Department's paid claims data for general
acute care admissions occurring during State fiscal year 2015
that was adjudicated by the Department through October 28,
2016.
"Occupancy ratio" is determined utilizing the IDPH
Hospital Profile CY15 - Facility Utilization Data - Source 2015
Annual Hospital Questionnaire. Utilizes all beds and days
including observation days but excludes Long Term Care and
Swing bed and their associated beds and days.
"Outpatient services" means, for a given hospital, the sum
of the number of outpatient encounters identified as unique
services provided to recipients of medical assistance under
Title XIX of the Social Security Act for general acute care,
psychiatric care, and rehabilitation care, excluding
outpatient services for individuals eligible for Medicare
under Title XVIII of the Social Security Act (Medicaid/Medicare
crossover services), as tabulated from the Department's paid
claims data for outpatient services occurring during State
fiscal year 2015 that was adjudicated by the Department through
October 28, 2016.
"Total days" means, for a given hospital, the sum of
inpatient hospital days provided to recipients of medical
assistance under Title XIX of the Social Security Act for
general acute care, psychiatric care, and rehabilitation care,
excluding days for individuals eligible for Medicare under
Title XVIII of the Social Security Act (Medicaid/Medicare

HB4543 - 42 - LRB101 19021 KTG 68481 b
crossover days), as tabulated from the Department's paid claims
data for total days occurring during State fiscal year 2015
that was adjudicated by the Department through October 28,
2016.
"Total admissions" means, for a given hospital, the sum of
inpatient hospital admissions provided to recipients of
medical assistance under Title XIX of the Social Security Act
for general acute care, psychiatric care, and rehabilitation
care, excluding admissions for individuals eligible for
Medicare under Title XVIII of that Act (Medicaid/Medicare
crossover admissions), as tabulated from the Department's paid
claims data for admissions occurring during State fiscal year
2015 that was adjudicated by the Department through October 28,
2016.
(q) Notwithstanding any of the other provisions of this
Section, the Department is authorized to adopt rules that
change the hospital access payments specified in this Section,
but only to the extent necessary to conform to any federally
approved amendment to the Title XIX State Plan. Any such rules
shall be adopted by the Department as authorized by Section
5-50 of the Illinois Administrative Procedure Act.
Notwithstanding any other provision of law, any changes
implemented as a result of this subsection (q) shall be given
retroactive effect so that they shall be deemed to have taken
effect as of the effective date of this amendatory Act of the
100th General Assembly.

HB4543 - 43 - LRB101 19021 KTG 68481 b
(r)(1) On or after July 1, 2018, and no less than annually
thereafter, the Department shall calculate increased increase
capitation payments to capitated managed care organizations
(MCOs) to equal the aggregate reduction of payments made in
this Section to preserve access to hospital services for
recipients under the Medical Assistance Program. The
calculated aggregate amount of all increased capitation
payments to all MCOs for a fiscal year shall at least be the
amount needed to avoid reduction in payments authorized under
Section 5A-15.
(2) On or after July 1, 2018, and no less than annually
thereafter until the changes described in paragraph (3) are
implemented, the Department shall increase capitation payments
to MCOs by the amount calculated under paragraph (1). Payments
to MCOs under this Section shall be consistent with actuarial
certification and shall be published by the Department each
year. Managed care organizations and hospitals (including
through their representative organizations), shall develop and
implement methodologies and rates for payments that will
preserve and improve access to hospital services for recipients
in furtherance of the State's public policy to ensure equal
access to covered services to recipients under the Medical
Assistance Program. The Department shall make available, on a
monthly basis, a report of the capitation payments that are
made to each MCO, including the number of enrollees for which
such payment is made, the per enrollee amount of the payment,

HB4543 - 44 - LRB101 19021 KTG 68481 b
and any adjustments that have been made. Following the
effective date of this amendatory Act of the 101st General
Assembly, each MCO shall expend at least an amount equivalent
to the increased capitation payments it receives under this
Section to support the availability of hospital services and to
ensure access to hospital services in furtherance of the
State's public policy. Each MCO shall submit to the Department
and the Department shall make available, on a monthly basis, a
report of each payment to a hospital in accordance with
methodologies and rates to preserve and improve access to
hospital services. Payments to MCOs that would be paid
consistent with actuarial certification and enrollment in the
absence of the increased capitation payments under this Section
shall not be reduced as a consequence of payments made under
this subsection.
(3) Following the effective date of this amendatory Act of
the 101st General Assembly, contracts between the Department
and MCOs for subsequent plan years shall require MCOs to pass
through the payment amounts in accordance with this Section
reduced and added up to the aggregate amount calculated under
paragraph (1), in conformance with 42 CFR 438.6. Each MCO shall
submit to the Department and the Department shall make
available, on a quarterly basis, a report of each payment to a
hospital in accordance with this paragraph.
(4) As used in this subsection, "MCO" means an entity which
contracts with the Department to provide services where payment

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for medical services is made on a capitated basis.
(Source: P.A. 100-581, eff. 3-12-18.)
(305 ILCS 5/5A-13)
Sec. 5A-13. Emergency rulemaking.
(a) The Department of Healthcare and Family Services
(formerly Department of Public Aid) may adopt rules necessary
to implement this amendatory Act of the 94th General Assembly
through the use of emergency rulemaking in accordance with
Section 5-45 of the Illinois Administrative Procedure Act. For
purposes of that Act, the General Assembly finds that the
adoption of rules to implement this amendatory Act of the 94th
General Assembly is deemed an emergency and necessary for the
public interest, safety, and welfare.
(b) The Department of Healthcare and Family Services may
adopt rules necessary to implement this amendatory Act of the
97th General Assembly through the use of emergency rulemaking
in accordance with Section 5-45 of the Illinois Administrative
Procedure Act. For purposes of that Act, the General Assembly
finds that the adoption of rules to implement this amendatory
Act of the 97th General Assembly is deemed an emergency and
necessary for the public interest, safety, and welfare.
(c) The Department of Healthcare and Family Services may
adopt rules necessary to initially implement the changes to
Articles 5, 5A, 12, and 14 of this Code under this amendatory
Act of the 100th General Assembly through the use of emergency

HB4543 - 46 - LRB101 19021 KTG 68481 b
rulemaking in accordance with subsection (aa) of Section 5-45
of the Illinois Administrative Procedure Act. For purposes of
that Act, the General Assembly finds that the adoption of rules
to implement the changes to Articles 5, 5A, 12, and 14 of this
Code under this amendatory Act of the 100th General Assembly is
deemed an emergency and necessary for the public interest,
safety, and welfare. The 24-month limitation on the adoption of
emergency rules does not apply to rules adopted to initially
implement the changes to Articles 5, 5A, 12, and 14 of this
Code under this amendatory Act of the 100th General Assembly.
For purposes of this subsection, "initially" means any
emergency rules necessary to immediately implement the changes
authorized to Articles 5, 5A, 12, and 14 of this Code under
this amendatory Act of the 100th General Assembly; however,
emergency rulemaking authority shall not be used to make
changes that could otherwise be made following the process
established in the Illinois Administrative Procedure Act.
(d) The Department of Healthcare and Family Services may on
a one-time-only basis adopt rules necessary to initially
implement the changes to Articles 5A and 14 of this Code under
this amendatory Act of the 100th General Assembly through the
use of emergency rulemaking in accordance with subsection (ee)
of Section 5-45 of the Illinois Administrative Procedure Act.
For purposes of that Act, the General Assembly finds that the
adoption of rules on a one-time-only basis to implement the
changes to Articles 5A and 14 of this Code under this

HB4543 - 47 - LRB101 19021 KTG 68481 b
amendatory Act of the 100th General Assembly is deemed an
emergency and necessary for the public interest, safety, and
welfare. The 24-month limitation on the adoption of emergency
rules does not apply to rules adopted to initially implement
the changes to Articles 5A and 14 of this Code under this
amendatory Act of the 100th General Assembly.
(e) The Department of Healthcare and Family Services may
adopt rules necessary to initially implement the changes made
by this amendatory Act of the 101st General Assembly to
Sections 5A-2, 5A-12.6, 5A-14, and 14-12 of this Code through
the use of emergency rulemaking in accordance with the Illinois
Administrative Procedure Act. For purposes of the Illinois
Administrative Procedure Act Act, the General Assembly finds
that the adoption of rules to implement the changes made by
this amendatory Act of the 101st General Assembly to Sections
5A-2, 5A-12.6, 5A-14, and 14-12 of this Code is deemed an
emergency and necessary for the public interest, safety, and
welfare. The 24-month limitation on the adoption of emergency
rules does not apply to rules adopted to initially implement
the changes made by this amendatory Act of the 101st General
Assembly to Sections 5A-2, 5A-12.6, 5A-14, and 14-12 of this
Code. As used in this subsection, "initially" means any
emergency rules necessary to immediately implement the changes
made by this amendatory Act of the 101st General Assembly to
Sections 5A-2, 5A-12.6, 5A-14, and 14-12 of this Code. However,
emergency rulemaking authority shall not be used to make

HB4543 - 48 - LRB101 19021 KTG 68481 b
changes that could otherwise be made following the process
established in the Illinois Administrative Procedure Act.
(Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19.)
(305 ILCS 5/5A-14)
Sec. 5A-14. Repeal of assessments and disbursements.
(a) Section 5A-2 is repealed on July 1, 2022 2020.
(b) Section 5A-12 is repealed on July 1, 2005.
(c) Section 5A-12.1 is repealed on July 1, 2008.
(d) Section 5A-12.2 and Section 5A-12.4 are repealed on
July 1, 2018, subject to Section 5A-16.
(e) Section 5A-12.3 is repealed on July 1, 2011.
(f) Section 5A-12.6 is repealed on July 1, 2022 2020.
(Source: P.A. 100-581, eff. 3-12-18.)
(305 ILCS 5/14-12)
Sec. 14-12. Hospital rate reform payment system. The
hospital payment system pursuant to Section 14-11 of this
Article shall be as follows:
(a) Inpatient hospital services. Effective for discharges
on and after July 1, 2014, reimbursement for inpatient general
acute care services shall utilize the All Patient Refined
Diagnosis Related Grouping (APR-DRG) software, version 30,
distributed by 3MTM Health Information System.
(1) The Department shall establish Medicaid weighting
factors to be used in the reimbursement system established

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under this subsection. Initial weighting factors shall be
the weighting factors as published by 3M Health Information
System, associated with Version 30.0 adjusted for the
Illinois experience.
(2) The Department shall establish a
statewide-standardized amount to be used in the inpatient
reimbursement system. The Department shall publish these
amounts on its website no later than 10 calendar days prior
to their effective date.
(3) In addition to the statewide-standardized amount,
the Department shall develop adjusters to adjust the rate
of reimbursement for critical Medicaid providers or
services for trauma, transplantation services, perinatal
care, and Graduate Medical Education (GME).
(4) The Department shall develop add-on payments to
account for exceptionally costly inpatient stays,
consistent with Medicare outlier principles. Outlier fixed
loss thresholds may be updated to control for excessive
growth in outlier payments no more frequently than on an
annual basis, but at least triennially. Upon updating the
fixed loss thresholds, the Department shall be required to
update base rates within 12 months.
(5) The Department shall define those hospitals or
distinct parts of hospitals that shall be exempt from the
APR-DRG reimbursement system established under this
Section. The Department shall publish these hospitals'

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inpatient rates on its website no later than 10 calendar
days prior to their effective date.
(6) Beginning July 1, 2014 and ending on June 30, 2024,
in addition to the statewide-standardized amount, the
Department shall develop an adjustor to adjust the rate of
reimbursement for safety-net hospitals defined in Section
5-5e.1 of this Code excluding pediatric hospitals.
(7) Beginning July 1, 2014 and ending on June 30, 2020,
or upon implementation of inpatient psychiatric rate
increases as described in subsection (n) of Section
5A-12.6, in addition to the statewide-standardized amount,
the Department shall develop an adjustor to adjust the rate
of reimbursement for Illinois freestanding inpatient
psychiatric hospitals that are not designated as
children's hospitals by the Department but are primarily
treating patients under the age of 21.
(7.5) (Blank). Beginning July 1, 2020, the
reimbursement for inpatient psychiatric services shall be
so that base claims projected reimbursement is increased by
an amount equal to the funds allocated in paragraph (2) of
subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8) and (9) of this subsection
and paragraphs (3) and (4) of subsection (b) multiplied by
13%. Beginning July 1, 2022, the reimbursement for
inpatient psychiatric services shall be so that base claims
projected reimbursement is increased by an amount equal to

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the funds allocated in paragraph (3) of subsection (b) of
Section 5A-12.6, less the amount allocated under
paragraphs (8) and (9) of this subsection and paragraphs
(3) and (4) of subsection (b) multiplied by 13%. Beginning
July 1, 2024, the reimbursement for inpatient psychiatric
services shall be so that base claims projected
reimbursement is increased by an amount equal to the funds
allocated in paragraph (4) of subsection (b) of Section
5A-12.6, less the amount allocated under paragraphs (8) and
(9) of this subsection and paragraphs (3) and (4) of
subsection (b) multiplied by 13%.
(8) Beginning July 1, 2018, in addition to the
statewide-standardized amount, the Department shall adjust
the rate of reimbursement for hospitals designated by the
Department of Public Health as a Perinatal Level II or II+
center by applying the same adjustor that is applied to
Perinatal and Obstetrical care cases for Perinatal Level
III centers, as of December 31, 2017.
(9) Beginning July 1, 2018, in addition to the
statewide-standardized amount, the Department shall apply
the same adjustor that is applied to trauma cases as of
December 31, 2017 to inpatient claims to treat patients
with burns, including, but not limited to, APR-DRGs 841,
842, 843, and 844.
(10) Beginning July 1, 2018, the
statewide-standardized amount for inpatient general acute

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care services shall be uniformly increased by a uniform
dollar amount so that base claims projected reimbursement
is increased by an amount equal to the funds allocated in
paragraph (1) of subsection (b) of Section 5A-12.6, less
the amount allocated under paragraphs (8), (9), and (12)
through (15) and (9) of this subsection and paragraphs (3)
and (4) of subsection (b) multiplied by 40%. Beginning July
1, 2020, the statewide-standardized amount for inpatient
general acute care services shall be uniformly increased so
that base claims projected reimbursement is increased by an
amount equal to the funds allocated in paragraph (2) of
subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8) and (9) of this subsection
and paragraphs (3) and (4) of subsection (b) multiplied by
40%. Beginning July 1, 2022, the statewide-standardized
amount for inpatient general acute care services shall be
uniformly increased so that base claims projected
reimbursement is increased by an amount equal to the funds
allocated in paragraph (3) of subsection (b) of Section
5A-12.6, less the amount allocated under paragraphs (8) and
(9) of this subsection and paragraphs (3) and (4) of
subsection (b) multiplied by 40%. Beginning July 1, 2023
the statewide-standardized amount for inpatient general
acute care services shall be uniformly increased so that
base claims projected reimbursement is increased by an
amount equal to the funds allocated in paragraph (4) of

HB4543 - 53 - LRB101 19021 KTG 68481 b
subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8) and (9) of this subsection
and paragraphs (3) and (4) of subsection (b) multiplied by
40%.
(11) Beginning July 1, 2018, the reimbursement for
inpatient rehabilitation services shall be increased by
the addition of a $96 per day add-on.
Beginning July 1, 2020, the reimbursement for
inpatient rehabilitation services shall be uniformly
increased so that the $96 per day add-on is increased by an
amount equal to the funds allocated in paragraph (2) of
subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8) and (9) of this subsection
and paragraphs (3) and (4) of subsection (b) multiplied by
0.9%.
Beginning July 1, 2022, the reimbursement for
inpatient rehabilitation services shall be uniformly
increased so that the $96 per day add-on as adjusted by the
July 1, 2020 increase, is increased by an amount equal to
the funds allocated in paragraph (3) of subsection (b) of
Section 5A-12.6, less the amount allocated under
paragraphs (8) and (9) of this subsection and paragraphs
(3) and (4) of subsection (b) multiplied by 0.9%.
Beginning July 1, 2023, the reimbursement for
inpatient rehabilitation services shall be uniformly
increased so that the $96 per day add-on as adjusted by the

HB4543 - 54 - LRB101 19021 KTG 68481 b
July 1, 2022 increase, is increased by an amount equal to
the funds allocated in paragraph (4) of subsection (b) of
Section 5A-12.6, less the amount allocated under
paragraphs (8) and (9) of this subsection and paragraphs
(3) and (4) of subsection (b) multiplied by 0.9%.
(12) Beginning July 1, 2020, the reimbursement for
inpatient general acute care services to non-publicly
owned safety net hospitals, as defined in Section 5-5e.1 of
this Code for Rate Year 2017, shall be increased by a
uniform dollar amount so that base claims projected
reimbursement is increased by an amount equal to
$400,000,000 of the funds allocated in paragraph (2) of
subsection (b) of Section 5A-12.6.
(13) Beginning July 1, 2020, the reimbursement for
inpatient general acute care services to non-publicly
owned critical access hospitals shall be increased by a
uniform dollar amount so that base claims projected
reimbursement is increased by an amount equal to
$100,000,000 of the funds allocated in paragraph (2) of
subsection (b) of Section 5A-12.6.
(14) Beginning July 1, 2020, the reimbursement for
inpatient general acute care services to hospital
providers in high-need communities shall be increased by a
uniform dollar amount so that base claims projected
reimbursement is increased by an amount equal to
$500,000,000 of the funds allocated in paragraph (2) of

HB4543 - 55 - LRB101 19021 KTG 68481 b
subsection (b) of Section 5A-12.6. A hospital shall qualify
as a hospital in a high-need community if it is located in
a census tract with median household income below the
statewide median household income, is located in a census
tract with life expectancy below the statewide average, and
has a Medicaid inpatient utilization rate at or above the
statewide median.
(15) Beginning July 1, 2020, the reimbursement for
inpatient psychiatric services to non-publicly owned
general acute care hospitals shall be increased by a
uniform dollar amount so that base claims projected
reimbursement is increased by an amount equal to
$61,000,000 of the funds allocated in paragraph (2) of
subsection (b) of Section 5A-12.6.
(b) Outpatient hospital services. Effective for dates of
service on and after July 1, 2014, reimbursement for outpatient
services shall utilize the Enhanced Ambulatory Procedure
Grouping (EAPG) software, version 3.7 distributed by 3MTM
Health Information System.
(1) The Department shall establish Medicaid weighting
factors to be used in the reimbursement system established
under this subsection. The initial weighting factors shall
be the weighting factors as published by 3M Health
Information System, associated with Version 3.7.
(2) The Department shall establish service specific
statewide-standardized amounts to be used in the

HB4543 - 56 - LRB101 19021 KTG 68481 b
reimbursement system.
(A) The initial statewide standardized amounts,
with the labor portion adjusted by the Calendar Year
2013 Medicare Outpatient Prospective Payment System
wage index with reclassifications, shall be published
by the Department on its website no later than 10
calendar days prior to their effective date.
(B) The Department shall establish adjustments to
the statewide-standardized amounts for each Critical
Access Hospital, as designated by the Department of
Public Health in accordance with 42 CFR 485, Subpart F.
For outpatient services provided on or before June 30,
2018, 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 under Section 5A-12.4 of
this Code net of the associated tax costs are equal to
the estimated costs of outpatient base period claims
data with a rate year cost inflation factor applied.
(3) In addition to the statewide-standardized amounts,
the Department shall develop adjusters to adjust the rate
of reimbursement for critical Medicaid hospital outpatient
providers or services, including outpatient high volume or
safety-net hospitals. Beginning July 1, 2018, the
outpatient high volume adjustor shall be increased to
increase annual expenditures associated with this adjustor

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by $79,200,000, based on the State Fiscal Year 2015 base
year data and this adjustor shall apply to public
hospitals, except for large public hospitals, as defined
under 89 Ill. Adm. Code 148.25(a).
(4) Beginning July 1, 2018, in addition to the
statewide standardized amounts, the Department shall make
an add-on payment for outpatient expensive devices and
drugs. This add-on payment shall at least apply to claim
lines that: (i) are assigned with one of the following
EAPGs: 490, 1001 to 1020, and coded with one of the
following revenue codes: 0274 to 0276, 0278; or (ii) are
assigned with one of the following EAPGs: 430 to 441, 443,
444, 460 to 465, 495, 496, 1090. The add-on payment shall
be calculated as follows: the claim line's covered charges
multiplied by the hospital's total acute cost to charge
ratio, less the claim line's EAPG payment plus $1,000,
multiplied by 0.8.
(5) Beginning July 1, 2018, the statewide-standardized
amounts for outpatient services shall be increased by a
uniform dollar amount percentage so that base claims
projected reimbursement is increased by an amount equal to
no less than the funds allocated in paragraph (1) of
subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8), (9), and (12) through (15)
and (9) of subsection (a) and paragraphs (3) and (4) of
this subsection multiplied by 46%. Beginning July 1, 2020,

HB4543 - 58 - LRB101 19021 KTG 68481 b
the statewide-standardized amounts for outpatient services
shall be increased by a uniform percentage so that base
claims projected reimbursement is increased by an amount
equal to no less than the funds allocated in paragraph (2)
of subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8) and (9) of subsection (a)
and paragraphs (3) and (4) of this subsection multiplied by
46%. Beginning July 1, 2022, the statewide-standardized
amounts for outpatient services shall be increased by a
uniform percentage so that base claims projected
reimbursement is increased by an amount equal to the funds
allocated in paragraph (3) of subsection (b) of Section
5A-12.6, less the amount allocated under paragraphs (8) and
(9) of subsection (a) and paragraphs (3) and (4) of this
subsection multiplied by 46%. Beginning July 1, 2023, the
statewide-standardized amounts for outpatient services
shall be increased by a uniform percentage so that base
claims projected reimbursement is increased by an amount
equal to no less than the funds allocated in paragraph (4)
of subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8) and (9) of subsection (a)
and paragraphs (3) and (4) of this subsection multiplied by
46%.
(6) Effective for dates of service on or after July 1,
2018, the Department shall establish adjustments to the
statewide-standardized amounts for each Critical Access

HB4543 - 59 - LRB101 19021 KTG 68481 b
Hospital, as designated by the Department of Public Health
in accordance with 42 CFR 485, Subpart F, such that each
Critical Access Hospital's standardized amount for
outpatient services shall be increased by the applicable
uniform dollar amount percentage determined pursuant to
paragraph (5) of this subsection. It is the intent of the
General Assembly that the adjustments required under this
paragraph (6) by Public Act 100-1181 this amendatory Act of
the 100th General Assembly shall be applied retroactively
to claims for dates of service provided on or after July 1,
2018.
(7) Effective for dates of service on or after March 8,
2019 (the effective date of Public Act 100-1181) this
amendatory Act of the 100th General Assembly, the
Department shall recalculate and implement an updated
statewide-standardized amount for outpatient services
provided by hospitals that are not Critical Access
Hospitals to reflect the applicable uniform dollar amount
percentage determined pursuant to paragraph (5).
(1) Any recalculation to the
statewide-standardized amounts for outpatient services
provided by hospitals that are not Critical Access
Hospitals shall be the amount necessary to achieve the
increase in the statewide-standardized amounts for
outpatient services increased by a uniform dollar
amount percentage, so that base claims projected

HB4543 - 60 - LRB101 19021 KTG 68481 b
reimbursement is increased by an amount equal to no
less than the funds allocated in paragraph (1) of
subsection (b) of Section 5A-12.6, less the amount
allocated under paragraphs (8), (9), and (12) through
(15) and (9) of subsection (a) and paragraphs (3) and
(4) of this subsection, for all hospitals that are not
Critical Access Hospitals, multiplied by 46%.
(2) It is the intent of the General Assembly that
the recalculations required under this paragraph (7)
by Public Act 100-1181 this amendatory Act of the 100th
General Assembly shall be applied prospectively to
claims for dates of service provided on or after March
8, 2019 (the effective date of Public Act 100-1181)
this amendatory Act of the 100th General Assembly and
that no recoupment or repayment by the Department or an
MCO of payments attributable to recalculation under
this paragraph (7), issued to the hospital for dates of
service on or after July 1, 2018 and before March 8,
2019 (the effective date of Public Act 100-1181) this
amendatory Act of the 100th General Assembly, shall be
permitted.
(8) The Department shall ensure that all necessary
adjustments to the managed care organization capitation
base rates necessitated by the adjustments under
subparagraph (6) or (7) of this subsection are completed
and applied retroactively in accordance with Section

HB4543 - 61 - LRB101 19021 KTG 68481 b
5-30.8 of this Code within 90 days of March 8, 2019 (the
effective date of Public Act 100-1181) this amendatory Act
of the 100th General Assembly.
(c) In consultation with the hospital community, the
Department is authorized to replace 89 Ill. Admin. Code 152.150
as published in 38 Ill. Reg. 4980 through 4986 within 12 months
of June 16, 2014 (the effective date of Public Act 98-651). If
the Department does not replace these rules within 12 months of
June 16, 2014 (the effective date of Public Act 98-651), the
rules in effect for 152.150 as published in 38 Ill. Reg. 4980
through 4986 shall remain in effect until modified by rule by
the Department. Nothing in this subsection shall be construed
to mandate that the Department file a replacement rule.
(d) Transition period. There shall be a transition period
to the reimbursement systems authorized under this Section that
shall begin on the effective date of these systems and continue
until June 30, 2018, unless extended by rule by the Department.
To help provide an orderly and predictable transition to the
new reimbursement systems and to preserve and enhance access to
the hospital services during this transition, the Department
shall allocate a transitional hospital access pool of at least
$290,000,000 annually so that transitional hospital access
payments are made to hospitals.
(1) After the transition period, the Department may
begin incorporating the transitional hospital access pool
into the base rate structure; however, the transitional

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hospital access payments in effect on June 30, 2018 shall
continue to be paid, if continued under Section 5A-16.
(2) After the transition period, if the Department
reduces payments from the transitional hospital access
pool, it shall increase base rates, develop new adjustors,
adjust current adjustors, develop new hospital access
payments based on updated information, or any combination
thereof by an amount equal to the decreases proposed in the
transitional hospital access pool payments, ensuring that
the entire transitional hospital access pool amount shall
continue to be used for hospital payments.
(d-5) Hospital transformation program. The Department, in
conjunction with the Hospital Transformation Review Committee
created under subsection (d-5), shall develop a hospital
transformation program to provide financial assistance to
hospitals in areas of greatest health need and areas most
adversely affected by health disparities that require such
assistance to transform or expand in transforming their
services and care models to better meet align with the needs of
the communities they serve. The payments authorized in this
Section shall be subject to approval by the federal government.
(1) Phase 1. In State fiscal years 2019 through 2020,
the Department shall allocate funds from the transitional
access hospital pool to create a hospital transformation
pool of at least $262,906,870 annually and make hospital
transformation payments to hospitals. Subject to Section

HB4543 - 63 - LRB101 19021 KTG 68481 b
5A-16, in State fiscal years 2019 and 2020, an Illinois
hospital that received either a transitional hospital
access payment under subsection (d) or a supplemental
payment under subsection (f) of this Section in State
fiscal year 2018, shall receive a hospital transformation
payment as follows:
(A) If the hospital's Rate Year 2017 Medicaid
inpatient utilization rate is equal to or greater than
45%, the hospital transformation payment shall be
equal to 100% of the sum of its transitional hospital
access payment authorized under subsection (d) and any
supplemental payment authorized under subsection (f).
(B) If the hospital's Rate Year 2017 Medicaid
inpatient utilization rate is equal to or greater than
25% but less than 45%, the hospital transformation
payment shall be equal to 75% of the sum of its
transitional hospital access payment authorized under
subsection (d) and any supplemental payment authorized
under subsection (f).
(C) If the hospital's Rate Year 2017 Medicaid
inpatient utilization rate is less than 25%, the
hospital transformation payment shall be equal to 50%
of the sum of its transitional hospital access payment
authorized under subsection (d) and any supplemental
payment authorized under subsection (f).
(2) Phase 2. In State Fiscal Year 2021, the Department

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shall allocate the funds from the transitional access
hospital pool in the same manner as for Phase 1 as
described in paragraph (1). In addition, during State
Fiscal Year 2021 the Department shall prepare and make
available to hospitals data on health disparities for their
use in planning improvements by which they can address
negative impacts of health disparities in communities they
serve. If necessary an amount not to exceed $20,000,000
shall be available from the Hospital Provider Fund for the
Department as a health disparities pay-for-collection pool
to pay health care providers for collection of
patient-level data, such as on race and ethnicity,
sufficient to serve as the baseline year for measuring
improvement or lack of improvement in health disparities
and for adjustment of payments based on health disparities
in future years. In addition, during State Fiscal Year
2021, the Department, in conjunction with the Hospital
Transformation Review Committee, shall complete a
stakeholder process to determine the priorities of the
hospital transformation program, including at a minimum
the following:
(A) The Department, in conjunction with the
Hospital Transformation Review Committee, shall
provide an opportunity for public input and formal
mechanism for stakeholder participation in identifying
priority delivery system reform and improvement

HB4543 - 65 - LRB101 19021 KTG 68481 b
purposes for the transformation program based on
community health needs.
(B) The Department, in conjunction with the
Hospital Transformation Review Committee, shall
conduct no fewer than 6 hearings for this purpose. No
fewer than 2 of these hearings shall be held in the
City of Chicago, and at least one additional hearing
shall be held in another location in Cook County.
(C) The Department shall publish a report with the
results of this process on its website.
(3) Phase 3. During State fiscal years 2021 and 2022
and thereafter, the Department shall allocate funds from
the transitional access hospital pool to create a hospital
transformation pool annually and make hospital
transformation payments from the hospital transformation
pool to hospitals participating in the transformation
program. Hospitals in areas of greatest health need and
areas most adversely affected by health disparities that
require assistance to transform or expand their services to
better meet the needs of communities they serve, as defined
in rules adopted in accordance with subparagraph (B) of
paragraph 4, Any hospital may seek transformation funding
in Phase 3, however, that priority shall be given to
Disproportionate Share Hospitals and Critical Access
Hospitals 2. Any hospital that seeks transformation
funding in Phase 3 2 to update or repurpose the hospital's

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physical structure to transition to a new delivery model,
must submit to the Department in writing a transformation
plan, based on the Department's guidelines, that describes
the changes or service expansions it seeks to make and
selects process and outcome measures, from a set developed
by the Department, the hospital will meet through the
course of the transformation project; a timeline for the
transformation plan; as well as financial information
sufficient to allow the Department to determine whether the
changes or service expansions could occur but for
transformation program funding. desired delivery model
with projections of patient volumes by service lines and
projected revenues, expenses, and net income that
correspond to the new delivery model. In Phase 3 2, subject
to the approval of rules, the Department may use the
hospital transformation pool to increase base rates,
develop new adjustors, or adjust current adjustors, or
develop new access payments in order to support and
incentivize hospitals pursuing to pursue such
transformation. In developing such methodologies, the
Department shall ensure that the entire hospital
transformation pool continues to be expended to ensure
access to hospital services. If necessary an amount not to
exceed $20,000,000 per year shall be available from the
Hospital Provider Fund for the Department as a disparities
pay-for-collection pool to pay health care providers for

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collection of patient-level data, such as on race and
ethnicity, sufficient to serve as the baseline year for
measuring improvement or lack of improvement in health
disparities and for adjustment of payments based on health
disparities in future years. The Department annually shall
allocate to the hospital transformation pool funds from the
transitional access hospital pool; any unused amount from
the $20,000,000 health disparities pay-for-collection
pool; and $120,000,000 from the Hospital Provider Fund. or
to support organizations that had received hospital
transformation payments under this Section.
(A) Any hospital participating in the hospital
transformation program shall provide an opportunity
for public input by local community groups, hospital
workers, and healthcare professionals and assist in
facilitating discussions about any transformations or
changes to the hospital.
(A-5) Any hospital that seeks to commit
transformation funding to capital spending shall
submit to the Department in writing a transformation
plan, based on the Department's guidelines, that
describes the proposed changes to the hospital's
physical facilities with projections of patient
volumes by service lines and projected revenues,
expenses, and net income.
(B) As provided in paragraph (9) of Section 3 of

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the Illinois Health Facilities Planning Act, any
hospital seeking to expand services through
participating in the transformation program may be
excluded from the requirements of the Illinois Health
Facilities Planning Act for those projects related to
the hospital's transformation. To be eligible, the
hospital must submit to the Health Facilities and
Services Review Board certification from the
Department, approved by the Hospital Transformation
Review Committee, that the project is a part of the
hospital's transformation.
(C) (Blank). As provided in subsection (a-20) of
Section 32.5 of the Emergency Medical Services (EMS)
Systems Act, a hospital that received hospital
transformation payments under this Section may convert
to a freestanding emergency center. To be eligible for
such a conversion, the hospital must submit to the
Department of Public Health certification from the
Department, approved by the Hospital Transformation
Review Committee, that the project is a part of the
hospital's transformation.
(4)(A) By August 1, 2020 the Department, in conjunction
with the Hospital Transformation Review Committee, shall
develop and file administrative rules with the Secretary of
State setting forth processes for data collection and
payment from the health disparities pay-for-collection

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pool.
(B) By March 1, 2021 (3) By April 1, 2019 March 12,
2018 (Public Act 100-581) the Department, in conjunction
with the Hospital Transformation Review Committee, shall
develop and file as an administrative rule with the
Secretary of State the goals, objectives, policies,
standards, payment models, process and outcome measures,
or criteria to be applied in Phase 3 2 of the program to
allocate the hospital transformation funds. The goals,
objectives, and policies to be considered may include, but
are not limited to, reducing health disparities; achieving
unmet needs of a community that a hospital serves such as
behavioral health services, outpatient services, or drug
rehabilitation services; attaining certain quality or
patient safety benchmarks for health care services; or
improving the coordination, effectiveness, and efficiency
of care delivery. The rulemaking shall direct managed care
organizations (MCOs) to make payments under this
subsection (d-5) in a manner conforming with 42 CFR 438.6
regarding payments directed to be made by MCOs as part of a
delivery system reform and improvement initiatives.
Notwithstanding any other provision of law, any rule
adopted in accordance with this subsection (d-5) may be
submitted to the Joint Committee on Administrative Rules
for approval only if the rule has first been approved by 9
of the 14 members of the Hospital Transformation Review

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Committee.
(5) (4) Hospital Transformation Review Committee.
There is created the Hospital Transformation Review
Committee. The Committee shall consist of 14 members. No
later than 30 days after March 12, 2018 (the effective date
of Public Act 100-581), the 4 legislative leaders shall
each appoint 3 members; the Governor shall appoint the
Director of Healthcare and Family Services, or his or her
designee, as a member; and the Director of Healthcare and
Family Services shall appoint one member. Any vacancy shall
be filled by the applicable appointing authority within 15
calendar days. The members of the Committee shall select a
Chair and a Vice-Chair from among its members, provided
that the Chair and Vice-Chair cannot be appointed by the
same appointing authority and must be from different
political parties. The Chair shall have the authority to
establish a meeting schedule and convene meetings of the
Committee, and the Vice-Chair shall have the authority to
convene meetings in the absence of the Chair. The Committee
may establish its own rules with respect to meeting
schedule, notice of meetings, and the disclosure of
documents; however, the Committee shall not have the power
to subpoena individuals or documents and any rules must be
approved by 9 of the 14 members. The Committee shall
perform the functions described in this Section and advise
and consult with the Director in the administration of this

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Section. In addition to reviewing and approving the
policies, procedures, and rules for the hospital
transformation program, the Committee shall consider and
make recommendations related to qualifying criteria and
payment methodologies related to safety-net hospitals and
children's hospitals. Members of the Committee appointed
by the legislative leaders shall be subject to the
jurisdiction of the Legislative Ethics Commission, not the
Executive Ethics Commission, and all requests under the
Freedom of Information Act shall be directed to the
applicable Freedom of Information officer for the General
Assembly. The Department shall provide operational support
to the Committee as necessary. The Committee is dissolved
on April 1, 2019.
(6) Definitions. As used in this Section:
"Managed care organization" or "MCO" means an entity
which contracts with the Department to provide services
where payment for medical services is made on a capitated
basis.
"Health disparities" mean preventable differences in
the burden of disease, injury, violence, or opportunities
to achieve optimal health that are experienced by socially
disadvantaged populations.
(e) Beginning 36 months after initial implementation, the
Department shall update the reimbursement components in

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subsections (a) and (b), including standardized amounts and
weighting factors, and at least triennially and no more
frequently than annually thereafter. The Department shall
publish these updates on its website no later than 30 calendar
days prior to their effective date.
(f) Continuation of supplemental payments. Any
supplemental payments authorized under Illinois Administrative
Code 148 effective January 1, 2014 and that continue during the
period of July 1, 2014 through December 31, 2014 shall remain
in effect as long as the assessment imposed by Section 5A-2
that is in effect on December 31, 2017 remains in effect.
(g) Notwithstanding subsections (a) through (f) of this
Section and notwithstanding the changes authorized under
Section 5-5b.1, any updates to the system shall not result in
any diminishment of the overall effective rates of
reimbursement as of the implementation date of the new system
(July 1, 2014). These updates shall not preclude variations in
any individual component of the system or hospital rate
variations. Nothing in this Section shall prohibit the
Department from increasing the rates of reimbursement or
developing payments to ensure access to hospital services.
Nothing in this Section shall be construed to guarantee a
minimum amount of spending in the aggregate or per hospital as
spending may be impacted by factors, including, but not limited
to, the number of individuals in the medical assistance program
and the severity of illness of the individuals.

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(h)(1) The Department shall have the authority to modify by
rulemaking any changes to the rates or methodologies in this
Section as required by the federal government to obtain federal
financial participation for expenditures made under this
Section.
(2) The Department shall have the authority to adjust by
rulemaking payment methodologies in this Section if such
adjustments are required by the federal government to conform
with 42 CFR 438.6 regarding payments directed to be made by
MCOs.
(i) Except for subsections (g) and (h) of this Section, the
Department shall, pursuant to subsection (c) of Section 5-40 of
the Illinois Administrative Procedure Act, provide for
presentation at the June 2014 hearing of the Joint Committee on
Administrative Rules (JCAR) additional written notice to JCAR
of the following rules in order to commence the second notice
period for the following rules: rules published in the Illinois
Register, rule dated February 21, 2014 at 38 Ill. Reg. 4559
(Medical Payment), 4628 (Specialized Health Care Delivery
Systems), 4640 (Hospital Services), 4932 (Diagnostic Related
Grouping (DRG) Prospective Payment System (PPS)), and 4977
(Hospital Reimbursement Changes), and published in the
Illinois Register dated March 21, 2014 at 38 Ill. Reg. 6499
(Specialized Health Care Delivery Systems) and 6505 (Hospital
Services).
(j) Out-of-state hospitals. Beginning July 1, 2018, for

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purposes of determining for State fiscal years 2019 and 2020
the hospitals eligible for the payments authorized under
subsections (a) and (b) of this Section, the Department shall
include out-of-state hospitals that are designated a Level I
pediatric trauma center or a Level I trauma center by the
Department of Public Health as of December 1, 2017.
(k) The Department shall notify each hospital and managed
care organization, in writing, of the impact of the updates
under this Section at least 30 calendar days prior to their
effective date.
(Source: P.A. 100-581, eff. 3-12-18; 100-1181, eff. 3-8-19;
101-81, eff. 7-12-19; revised 7-29-19.)
Section 99. Effective date. This Act takes effect upon
becoming law.
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INDEX
Statutes amended in order of appearance