Section 146.225  Reimbursement for Medicaid Residents

SLFs shall accept the reimbursement provided in this Section as payment in full for all services provided to Medicaid residents.

a)         The Department shall establish its portion of the reimbursement for Medicaid residents by calculating 60 percent of the weighted average (weighted by Medicaid patient days) nursing facility rates for the geographic grouping as defined in Section 146.290.  Each SLF shall be paid 60 percent of the weighted average nursing facility geographic group rate, based upon the nursing facility geographic group in which it is located.  The rates paid to SLFs shall be updated semi-annually on April 1 and on October 1 to assure that the rates coincide with 60 percent of weighted average nursing facility geographic group rates.  Effective October 1, 2002, SLF rates shall remain at a minimum of the rate in effect as of September 30, 2002.

b)         The payment rate received by the SLF from the Department for services, with the exception of meals, provided in accordance with Section 146.230 shall constitute the full and complete charge for services rendered.  Additional payment, other than patient credits authorized by the Department, may not be accepted.  Meals are included in the room and board amount paid by the resident.

c)         Single Occupancy:  Each Medicaid resident of an SLF shall be allotted a minimum of $90 per month as a deduction from his or her income as a protected amount for personal use.  The SLF may charge each Medicaid resident no more than the current SSI rate for a single individual less a minimum of $90 for room and board charges.  Any income remaining after deduction of the protected minimum of $90 and room and board charges shall be applied first towards medical expenses not covered under the Department's Medical Assistance Program.  Any income remaining after that shall be applied to the charges for SLF services paid by the Department.

d)         Double Occupancy: In the event a Medicaid eligible resident chooses to share an apartment, the Medicaid resident of an SLF shall be allotted a minimum of $90 per month as a deduction from his or her income as a protected amount for personal use.  The SLF may charge each Medicaid resident no more than the resident's share of the current SSI rate for a couple less a minimum of $90 for room and board charges.  The room and board rate for two Medicaid eligible individuals sharing an apartment cannot exceed the SSI rate for a married couple even if the two individuals sharing an apartment are unrelated.  Any income of an individual remaining after deduction of the protected minimum of $90 and room and board charges shall be applied first towards that individual's medical expenses not covered under the Department's Medical Assistance Program.  Any income of an individual remaining after that shall be applied to that individual's charges for SLF services paid by the Department.  If one, or both, of the individuals sharing an apartment is not Medicaid eligible, the SLF may negotiate its own rate with the non-Medicaid individual or individuals.

e)         The room and board charge for Medicaid residents shall only be increased when the SSI amount is increased.  Any room and board charge increase shall not exceed the amount of the SSI increase.

f)          Payment shall be made by the Department for up to 30 days per State fiscal year during a Medicaid resident's temporary absence from the SLF when the absence is due to situations such as hospitalizations or vacations.  The resident shall continue to be responsible for room and board charges during any absence.  Involuntary discharge criteria relating to temporary absence are found at Section 146.255(b) and (d)(7).  Nursing facilities that have a distinct part certified as an SLF shall consider converted beds in the nursing facility's licensed capacity when calculating the 93 percent occupancy level for bed reserve payments pursuant to 89 Ill. Adm. Code 140.523.

1)         The day a resident is transferred to the hospital is the first day of the temporary absence.

2)         For all other temporary absences, except a long-term care admission, the day after resident leaves the SLF is the first day of the temporary absence.

3)         The day before resident returns to the SLF is the last day of the temporary absence.

4)         The Department does not pay for temporary absence due to admission to a long-term care facility.  In this instance, an SLF shall discharge the resident from the Department's database.  An SLF may choose to hold an apartment while a resident is in a long-term care facility.

5)         By agreement between the SLF and a resident, an SLF may continue to hold an apartment when a resident has exceeded the 30 days payable by the Department.

(Source:  Amended at 31 Ill. Reg. 11681, effective August 1, 2007)