103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB3380

 

Introduced 2/8/2024, by Sen. Sara Feigenholtz

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5.2

    Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions requiring the Department of Healthcare and Family Services to make certain per diem add-on payments to nursing facilities that meet specified staffing levels indicated by the STRIVE study, provides that whenever the federal Centers for Medicare and Medicaid Services no longer updates the STRIVE study, the Department of Healthcare and Family Services shall use the last quarter STRIVE numbers for add-on calculations and shall not decrease the payment amounts until a replacement staff time measurement study is incorporated by law.


LRB103 38150 KTG 68283 b

 

 

A BILL FOR

 

SB3380LRB103 38150 KTG 68283 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5.2 as follows:
 
6    (305 ILCS 5/5-5.2)
7    Sec. 5-5.2. Payment.
8    (a) All nursing facilities that are grouped pursuant to
9Section 5-5.1 of this Act shall receive the same rate of
10payment for similar services.
11    (b) It shall be a matter of State policy that the Illinois
12Department shall utilize a uniform billing cycle throughout
13the State for the long-term care providers.
14    (c) (Blank).
15    (c-1) Notwithstanding any other provisions of this Code,
16the methodologies for reimbursement of nursing services as
17provided under this Article shall no longer be applicable for
18bills payable for nursing services rendered on or after a new
19reimbursement system based on the Patient Driven Payment Model
20(PDPM) has been fully operationalized, which shall take effect
21for services provided on or after the implementation of the
22PDPM reimbursement system begins. For the purposes of Public
23Act 102-1035 this amendatory Act of the 102nd General

 

 

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1Assembly, the implementation date of the PDPM reimbursement
2system and all related provisions shall be July 1, 2022 if the
3following conditions are met: (i) the Centers for Medicare and
4Medicaid Services has approved corresponding changes in the
5reimbursement system and bed assessment; and (ii) the
6Department has filed rules to implement these changes no later
7than June 1, 2022. Failure of the Department to file rules to
8implement the changes provided in Public Act 102-1035 this
9amendatory Act of the 102nd General Assembly no later than
10June 1, 2022 shall result in the implementation date being
11delayed to October 1, 2022.
12    (d) The new nursing services reimbursement methodology
13utilizing the Patient Driven Payment Model, which shall be
14referred to as the PDPM reimbursement system, taking effect
15July 1, 2022, upon federal approval by the Centers for
16Medicare and Medicaid Services, shall be based on the
17following:
18        (1) The methodology shall be resident-centered,
19    facility-specific, cost-based, and based on guidance from
20    the Centers for Medicare and Medicaid Services.
21        (2) Costs shall be annually rebased and case mix index
22    quarterly updated. The nursing services methodology will
23    be assigned to the Medicaid enrolled residents on record
24    as of 30 days prior to the beginning of the rate period in
25    the Department's Medicaid Management Information System
26    (MMIS) as present on the last day of the second quarter

 

 

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1    preceding the rate period based upon the Assessment
2    Reference Date of the Minimum Data Set (MDS).
3        (3) Regional wage adjustors based on the Health
4    Service Areas (HSA) groupings and adjusters in effect on
5    April 30, 2012 shall be included, except no adjuster shall
6    be lower than 1.06.
7        (4) PDPM nursing case mix indices in effect on March
8    1, 2022 shall be assigned to each resident class at no less
9    than 0.7858 of the Centers for Medicare and Medicaid
10    Services PDPM unadjusted case mix values, in effect on
11    March 1, 2022.
12        (5) The pool of funds available for distribution by
13    case mix and the base facility rate shall be determined
14    using the formula contained in subsection (d-1).
15        (6) The Department shall establish a variable per diem
16    staffing add-on in accordance with the most recent
17    available federal staffing report, currently the Payroll
18    Based Journal, for the same period of time, and if
19    applicable adjusted for acuity using the same quarter's
20    MDS. The Department shall rely on Payroll Based Journals
21    provided to the Department of Public Health to make a
22    determination of non-submission. If the Department is
23    notified by a facility of missing or inaccurate Payroll
24    Based Journal data or an incorrect calculation of
25    staffing, the Department must make a correction as soon as
26    the error is verified for the applicable quarter.

 

 

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1        Facilities with at least 70% of the staffing indicated
2    by the STRIVE study shall be paid a per diem add-on of $9,
3    increasing by equivalent steps for each whole percentage
4    point until the facilities reach a per diem of $14.88.
5    Facilities with at least 80% of the staffing indicated by
6    the STRIVE study shall be paid a per diem add-on of $14.88,
7    increasing by equivalent steps for each whole percentage
8    point until the facilities reach a per diem add-on of
9    $23.80. Facilities with at least 92% of the staffing
10    indicated by the STRIVE study shall be paid a per diem
11    add-on of $23.80, increasing by equivalent steps for each
12    whole percentage point until the facilities reach a per
13    diem add-on of $29.75. Facilities with at least 100% of
14    the staffing indicated by the STRIVE study shall be paid a
15    per diem add-on of $29.75, increasing by equivalent steps
16    for each whole percentage point until the facilities reach
17    a per diem add-on of $35.70. Facilities with at least 110%
18    of the staffing indicated by the STRIVE study shall be
19    paid a per diem add-on of $35.70, increasing by equivalent
20    steps for each whole percentage point until the facilities
21    reach a per diem add-on of $38.68. Facilities with at
22    least 125% or higher of the staffing indicated by the
23    STRIVE study shall be paid a per diem add-on of $38.68.
24    Beginning April 1, 2023, no nursing facility's variable
25    staffing per diem add-on shall be reduced by more than 5%
26    in 2 consecutive quarters. For the quarters beginning July

 

 

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1    1, 2022 and October 1, 2022, no facility's variable per
2    diem staffing add-on shall be calculated at a rate lower
3    than 85% of the staffing indicated by the STRIVE study. No
4    facility below 70% of the staffing indicated by the STRIVE
5    study shall receive a variable per diem staffing add-on
6    after December 31, 2022.
7        Whenever the federal Centers for Medicare and Medicaid
8    Services no longer updates the STRIVE study, the
9    Department shall use the last quarter STRIVE numbers for
10    add-on calculations and shall not decrease the payment
11    amounts until a replacement staff time measurement study
12    is incorporated into this Section by law.
13        (7) For dates of services beginning July 1, 2022, the
14    PDPM nursing component per diem for each nursing facility
15    shall be the product of the facility's (i) statewide PDPM
16    nursing base per diem rate, $92.25, adjusted for the
17    facility average PDPM case mix index calculated quarterly
18    and (ii) the regional wage adjuster, and then add the
19    Medicaid access adjustment as defined in (e-3) of this
20    Section. Transition rates for services provided between
21    July 1, 2022 and October 1, 2023 shall be the greater of
22    the PDPM nursing component per diem or:
23            (A) for the quarter beginning July 1, 2022, the
24        RUG-IV nursing component per diem;
25            (B) for the quarter beginning October 1, 2022, the
26        sum of the RUG-IV nursing component per diem

 

 

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1        multiplied by 0.80 and the PDPM nursing component per
2        diem multiplied by 0.20;
3            (C) for the quarter beginning January 1, 2023, the
4        sum of the RUG-IV nursing component per diem
5        multiplied by 0.60 and the PDPM nursing component per
6        diem multiplied by 0.40;
7            (D) for the quarter beginning April 1, 2023, the
8        sum of the RUG-IV nursing component per diem
9        multiplied by 0.40 and the PDPM nursing component per
10        diem multiplied by 0.60;
11            (E) for the quarter beginning July 1, 2023, the
12        sum of the RUG-IV nursing component per diem
13        multiplied by 0.20 and the PDPM nursing component per
14        diem multiplied by 0.80; or
15            (F) for the quarter beginning October 1, 2023 and
16        each subsequent quarter, the transition rate shall end
17        and a nursing facility shall be paid 100% of the PDPM
18        nursing component per diem.
19    (d-1) Calculation of base year Statewide RUG-IV nursing
20base per diem rate.
21        (1) Base rate spending pool shall be:
22            (A) The base year resident days which are
23        calculated by multiplying the number of Medicaid
24        residents in each nursing home as indicated in the MDS
25        data defined in paragraph (4) by 365.
26            (B) Each facility's nursing component per diem in

 

 

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1        effect on July 1, 2012 shall be multiplied by
2        subsection (A).
3            (C) Thirteen million is added to the product of
4        subparagraph (A) and subparagraph (B) to adjust for
5        the exclusion of nursing homes defined in paragraph
6        (5).
7        (2) For each nursing home with Medicaid residents as
8    indicated by the MDS data defined in paragraph (4),
9    weighted days adjusted for case mix and regional wage
10    adjustment shall be calculated. For each home this
11    calculation is the product of:
12            (A) Base year resident days as calculated in
13        subparagraph (A) of paragraph (1).
14            (B) The nursing home's regional wage adjustor
15        based on the Health Service Areas (HSA) groupings and
16        adjustors in effect on April 30, 2012.
17            (C) Facility weighted case mix which is the number
18        of Medicaid residents as indicated by the MDS data
19        defined in paragraph (4) multiplied by the associated
20        case weight for the RUG-IV 48 grouper model using
21        standard RUG-IV procedures for index maximization.
22            (D) The sum of the products calculated for each
23        nursing home in subparagraphs (A) through (C) above
24        shall be the base year case mix, rate adjusted
25        weighted days.
26        (3) The Statewide RUG-IV nursing base per diem rate:

 

 

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1            (A) on January 1, 2014 shall be the quotient of the
2        paragraph (1) divided by the sum calculated under
3        subparagraph (D) of paragraph (2);
4            (B) on and after July 1, 2014 and until July 1,
5        2022, shall be the amount calculated under
6        subparagraph (A) of this paragraph (3) plus $1.76; and
7            (C) beginning July 1, 2022 and thereafter, $7
8        shall be added to the amount calculated under
9        subparagraph (B) of this paragraph (3) of this
10        Section.
11        (4) Minimum Data Set (MDS) comprehensive assessments
12    for Medicaid residents on the last day of the quarter used
13    to establish the base rate.
14        (5) Nursing facilities designated as of July 1, 2012
15    by the Department as "Institutions for Mental Disease"
16    shall be excluded from all calculations under this
17    subsection. The data from these facilities shall not be
18    used in the computations described in paragraphs (1)
19    through (4) above to establish the base rate.
20    (e) Beginning July 1, 2014, the Department shall allocate
21funding in the amount up to $10,000,000 for per diem add-ons to
22the RUGS methodology for dates of service on and after July 1,
232014:
24        (1) $0.63 for each resident who scores in I4200
25    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
26        (2) $2.67 for each resident who scores either a "1" or

 

 

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1    "2" in any items S1200A through S1200I and also scores in
2    RUG groups PA1, PA2, BA1, or BA2.
3    (e-1) (Blank).
4    (e-2) For dates of services beginning January 1, 2014 and
5ending September 30, 2023, the RUG-IV nursing component per
6diem for a nursing home shall be the product of the statewide
7RUG-IV nursing base per diem rate, the facility average case
8mix index, and the regional wage adjustor. For dates of
9service beginning July 1, 2022 and ending September 30, 2023,
10the Medicaid access adjustment described in subsection (e-3)
11shall be added to the product.
12    (e-3) A Medicaid Access Adjustment of $4 adjusted for the
13facility average PDPM case mix index calculated quarterly
14shall be added to the statewide PDPM nursing per diem for all
15facilities with annual Medicaid bed days of at least 70% of all
16occupied bed days adjusted quarterly. For each new calendar
17year and for the 6-month period beginning July 1, 2022, the
18percentage of a facility's occupied bed days comprised of
19Medicaid bed days shall be determined by the Department
20quarterly. For dates of service beginning January 1, 2023, the
21Medicaid Access Adjustment shall be increased to $4.75. This
22subsection shall be inoperative on and after January 1, 2028.
23    (e-4) Subject to federal approval, on and after January 1,
242024, the Department shall increase the rate add-on at
25paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
26for ventilator services from $208 per day to $481 per day.

 

 

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1Payment is subject to the criteria and requirements under 89
2Ill. Adm. Code 147.335.
3    (f) (Blank).
4    (g) Notwithstanding any other provision of this Code, on
5and after July 1, 2012, for facilities not designated by the
6Department of Healthcare and Family Services as "Institutions
7for Mental Disease", rates effective May 1, 2011 shall be
8adjusted as follows:
9        (1) (Blank);
10        (2) (Blank);
11        (3) Facility rates for the capital and support
12    components shall be reduced by 1.7%.
13    (h) Notwithstanding any other provision of this Code, on
14and after July 1, 2012, nursing facilities designated by the
15Department of Healthcare and Family Services as "Institutions
16for Mental Disease" and "Institutions for Mental Disease" that
17are facilities licensed under the Specialized Mental Health
18Rehabilitation Act of 2013 shall have the nursing,
19socio-developmental, capital, and support components of their
20reimbursement rate effective May 1, 2011 reduced in total by
212.7%.
22    (i) On and after July 1, 2014, the reimbursement rates for
23the support component of the nursing facility rate for
24facilities licensed under the Nursing Home Care Act as skilled
25or intermediate care facilities shall be the rate in effect on
26June 30, 2014 increased by 8.17%.

 

 

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1    (i-1) Subject to federal approval, on and after January 1,
22024, the reimbursement rates for the support component of the
3nursing facility rate for facilities licensed under the
4Nursing Home Care Act as skilled or intermediate care
5facilities shall be the rate in effect on June 30, 2023
6increased by 12%.
7    (j) Notwithstanding any other provision of law, subject to
8federal approval, effective July 1, 2019, sufficient funds
9shall be allocated for changes to rates for facilities
10licensed under the Nursing Home Care Act as skilled nursing
11facilities or intermediate care facilities for dates of
12services on and after July 1, 2019: (i) to establish, through
13June 30, 2022 a per diem add-on to the direct care per diem
14rate not to exceed $70,000,000 annually in the aggregate
15taking into account federal matching funds for the purpose of
16addressing the facility's unique staffing needs, adjusted
17quarterly and distributed by a weighted formula based on
18Medicaid bed days on the last day of the second quarter
19preceding the quarter for which the rate is being adjusted.
20Beginning July 1, 2022, the annual $70,000,000 described in
21the preceding sentence shall be dedicated to the variable per
22diem add-on for staffing under paragraph (6) of subsection
23(d); and (ii) in an amount not to exceed $170,000,000 annually
24in the aggregate taking into account federal matching funds to
25permit the support component of the nursing facility rate to
26be updated as follows:

 

 

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1        (1) 80%, or $136,000,000, of the funds shall be used
2    to update each facility's rate in effect on June 30, 2019
3    using the most recent cost reports on file, which have had
4    a limited review conducted by the Department of Healthcare
5    and Family Services and will not hold up enacting the rate
6    increase, with the Department of Healthcare and Family
7    Services.
8        (2) After completing the calculation in paragraph (1),
9    any facility whose rate is less than the rate in effect on
10    June 30, 2019 shall have its rate restored to the rate in
11    effect on June 30, 2019 from the 20% of the funds set
12    aside.
13        (3) The remainder of the 20%, or $34,000,000, shall be
14    used to increase each facility's rate by an equal
15    percentage.
16    (k) During the first quarter of State Fiscal Year 2020,
17the Department of Healthcare of Family Services must convene a
18technical advisory group consisting of members of all trade
19associations representing Illinois skilled nursing providers
20to discuss changes necessary with federal implementation of
21Medicare's Patient-Driven Payment Model. Implementation of
22Medicare's Patient-Driven Payment Model shall, by September 1,
232020, end the collection of the MDS data that is necessary to
24maintain the current RUG-IV Medicaid payment methodology. The
25technical advisory group must consider a revised reimbursement
26methodology that takes into account transparency,

 

 

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1accountability, actual staffing as reported under the
2federally required Payroll Based Journal system, changes to
3the minimum wage, adequacy in coverage of the cost of care, and
4a quality component that rewards quality improvements.
5    (l) The Department shall establish per diem add-on
6payments to improve the quality of care delivered by
7facilities, including:
8        (1) Incentive payments determined by facility
9    performance on specified quality measures in an initial
10    amount of $70,000,000. Nothing in this subsection shall be
11    construed to limit the quality of care payments in the
12    aggregate statewide to $70,000,000, and, if quality of
13    care has improved across nursing facilities, the
14    Department shall adjust those add-on payments accordingly.
15    The quality payment methodology described in this
16    subsection must be used for at least State Fiscal Year
17    2023. Beginning with the quarter starting July 1, 2023,
18    the Department may add, remove, or change quality metrics
19    and make associated changes to the quality payment
20    methodology as outlined in subparagraph (E). Facilities
21    designated by the Centers for Medicare and Medicaid
22    Services as a special focus facility or a hospital-based
23    nursing home do not qualify for quality payments.
24            (A) Each quality pool must be distributed by
25        assigning a quality weighted score for each nursing
26        home which is calculated by multiplying the nursing

 

 

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1        home's quality base period Medicaid days by the
2        nursing home's star rating weight in that period.
3            (B) Star rating weights are assigned based on the
4        nursing home's star rating for the LTS quality star
5        rating. As used in this subparagraph, "LTS quality
6        star rating" means the long-term stay quality rating
7        for each nursing facility, as assigned by the Centers
8        for Medicare and Medicaid Services under the Five-Star
9        Quality Rating System. The rating is a number ranging
10        from 0 (lowest) to 5 (highest).
11                (i) Zero-star or one-star rating has a weight
12            of 0.
13                (ii) Two-star rating has a weight of 0.75.
14                (iii) Three-star rating has a weight of 1.5.
15                (iv) Four-star rating has a weight of 2.5.
16                (v) Five-star rating has a weight of 3.5.
17            (C) Each nursing home's quality weight score is
18        divided by the sum of all quality weight scores for
19        qualifying nursing homes to determine the proportion
20        of the quality pool to be paid to the nursing home.
21            (D) The quality pool is no less than $70,000,000
22        annually or $17,500,000 per quarter. The Department
23        shall publish on its website the estimated payments
24        and the associated weights for each facility 45 days
25        prior to when the initial payments for the quarter are
26        to be paid. The Department shall assign each facility

 

 

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1        the most recent and applicable quarter's STAR value
2        unless the facility notifies the Department within 15
3        days of an issue and the facility provides reasonable
4        evidence demonstrating its timely compliance with
5        federal data submission requirements for the quarter
6        of record. If such evidence cannot be provided to the
7        Department, the STAR rating assigned to the facility
8        shall be reduced by one from the prior quarter.
9            (E) The Department shall review quality metrics
10        used for payment of the quality pool and make
11        recommendations for any associated changes to the
12        methodology for distributing quality pool payments in
13        consultation with associations representing long-term
14        care providers, consumer advocates, organizations
15        representing workers of long-term care facilities, and
16        payors. The Department may establish, by rule, changes
17        to the methodology for distributing quality pool
18        payments.
19            (F) The Department shall disburse quality pool
20        payments from the Long-Term Care Provider Fund on a
21        monthly basis in amounts proportional to the total
22        quality pool payment determined for the quarter.
23            (G) The Department shall publish any changes in
24        the methodology for distributing quality pool payments
25        prior to the beginning of the measurement period or
26        quality base period for any metric added to the

 

 

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1        distribution's methodology.
2        (2) Payments based on CNA tenure, promotion, and CNA
3    training for the purpose of increasing CNA compensation.
4    It is the intent of this subsection that payments made in
5    accordance with this paragraph be directly incorporated
6    into increased compensation for CNAs. As used in this
7    paragraph, "CNA" means a certified nursing assistant as
8    that term is described in Section 3-206 of the Nursing
9    Home Care Act, Section 3-206 of the ID/DD Community Care
10    Act, and Section 3-206 of the MC/DD Act. The Department
11    shall establish, by rule, payments to nursing facilities
12    equal to Medicaid's share of the tenure wage increments
13    specified in this paragraph for all reported CNA employee
14    hours compensated according to a posted schedule
15    consisting of increments at least as large as those
16    specified in this paragraph. The increments are as
17    follows: an additional $1.50 per hour for CNAs with at
18    least one and less than 2 years' experience plus another
19    $1 per hour for each additional year of experience up to a
20    maximum of $6.50 for CNAs with at least 6 years of
21    experience. For purposes of this paragraph, Medicaid's
22    share shall be the ratio determined by paid Medicaid bed
23    days divided by total bed days for the applicable time
24    period used in the calculation. In addition, and additive
25    to any tenure increments paid as specified in this
26    paragraph, the Department shall establish, by rule,

 

 

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1    payments supporting Medicaid's share of the
2    promotion-based wage increments for CNA employee hours
3    compensated for that promotion with at least a $1.50
4    hourly increase. Medicaid's share shall be established as
5    it is for the tenure increments described in this
6    paragraph. Qualifying promotions shall be defined by the
7    Department in rules for an expected 10-15% subset of CNAs
8    assigned intermediate, specialized, or added roles such as
9    CNA trainers, CNA scheduling "captains", and CNA
10    specialists for resident conditions like dementia or
11    memory care or behavioral health.
12    (m) The Department shall work with nursing facility
13industry representatives to design policies and procedures to
14permit facilities to address the integrity of data from
15federal reporting sites used by the Department in setting
16facility rates.
17(Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
18102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
19Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
20Section 50-5, eff. 1-1-24; revised 12-15-23.)