Section 153.126 Long Term Care Facility Medicaid Per Diem Adjustments

a) Notwithstanding the provisions set forth in Section 153.100, the socio‑development component for facilities that are federally defined as Institutions for Mental Disease (see 89 Ill. Adm. Code 145.30) shall be increased by 253 percent beginning with services provided on and after March 1, 2008.

b) Notwithstanding the provisions set forth in Section 153.100, daily residential rates effective on March 1, 2008, for intermediate care facilities for persons with developmental disabilities (ICF/DD), including skilled nursing facilities for persons under 22 years of age (SNF/Ped), for which a patient contribution is required, shall be increased by 2.2 percent.

c) Notwithstanding the provisions set forth in Section 153.100, developmental training rates effective on March 1, 2008 shall be increased by 2.5 percent.

d) Notwithstanding the provisions set forth in Sections 153.100 and 153.125, for dates of services provided on or after July 1, 2012, the $10 per day per individual payment for individuals with developmental disabilities in nursing facilities, described in 89 Ill. Adm. Code 147.350, shall be eliminated.

e) Notwithstanding the provisions set forth in Sections 153.100 and 153.125, on or after July 1, 2012, nursing facilities not designated as Institutions for Mental Disease shall have rates effective May 1, 2011 (see Section 153.125) adjusted as follows:

1) Individual nursing rates for residents classified in Resource Utilization Groups IV (RUG-IV) PA1, PA2, BA1 and BA2, during the quarter ending March 31, 2012, shall be reduced by 10 percent;

2) Individual nursing rates for residents classified in all other RUG-IV groups shall be reduced by 1.0 percent; and

3) Facility rates for the support and capital components shall be reduced by 1.7 percent.

f) Notwithstanding the provisions set forth in Sections 153.100 and 153.125, on or after July 1, 2012, nursing facilities designated as Institutions for Mental Disease and facilities licensed under the Specialized Mental Health Rehabilitation Act shall have the nursing, socio-development, capital and support components of their reimbursement rate effective May 1, 2011 (see Section 153.125), reduced in total by 2.7 percent.

g) Notwithstanding the provisions set forth in Sections 153.100 and 153.125, on or after July 1, 2012, supported living facilities, as defined in 89 Ill. Adm. Code 146.205, shall have rates reduced by 2.7 percent.

h) Notwithstanding the provisions set forth in Sections 153.100 and 153.125 and 89 Ill. Adm. Code 140.560 and 140.561, for services provided on or after July 1, 2014, the support component of a nursing facility's rate for facilities licensed under the Nursing Home Care Act as skilled or intermediate care facilities (SNF/ICF) shall be the rate in effect on June 30, 2014, increased by 8.17%.

i) Long Term Care Facilities for Persons under 22 Years of Age Serving Clinically Complex Residents

1) Effective for dates of service on or after July 1, 2013, long term care facilities for persons under 22 years of age serving clinically complex residents means facilities licensed by the Department of Public Health as long term care facilities for persons under 22 years of age that serve severely and chronically ill pediatric patients requiring exceptional care, if the facility has 30% or more of its patients receiving ventilator care.

2) For dates of services starting July 1, 2013, long term care facilities for persons under 22 years of age serving clinically complex residents shall receive Medicaid reimbursement on 30-day expedited schedule.

3) Effective for dates of service on or after July 1, 2014, for purposes of this Section, a person under 22 years of age is considered clinically complex if the person requires at least one of the following medical services:

A) Tracheostomy care with dependence on mechanical ventilation for a minimum of six hours each day.

B) Tracheostomy care requiring suctioning at least every six hours, room air mist or oxygen as needed, and dependence on one of the treatment procedures listed under subsection (i)(4), excluding the procedure listed in subsection (i)(4)(B).

C) Total parenteral nutrition or other intravenous nutritional support and one of the treatment procedures listed under subsection (i)(4).

4) The following treatment procedures apply to the conditions in subsections (i)(3)(B) and (C):

A) Intermittent suctioning at least every eight hours and room air mist or oxygen as needed.

B) Continuous intravenous therapy, including administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals; or intravenous pharmaceutical administration of more than one agent via a peripheral or central line, without continuous infusion.

C) Peritoneal dialysis treatments requiring at least four exchanges every 24 hours.

D) Tube feeding via nasogastric or gastrostomy tube.

E) Other medical technologies required continuously, which in the opinion of the attending physician require the services of a professional nurse.

5) Reimbursement

A) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 140, 144 and 147, and subject to federal approval of changes to the Title XIX State Plan, for dates of service starting July 1, 2014 through implementation of a new reimbursement system, long term care facilities for persons under 22 years of age serving clinically complex residents shall receive a per diem rate of $304 for clinically complex residents.

B) Notwithstanding the provisions set forth in 89 Ill. Adm. Code 140, 144 and 147, and subject to federal approval of changes to the Title XIX State Plan, for dates of service starting July 1, 2014, long term care facilities for persons under 22 years of age serving clinically complex residents that have a policy documenting their method of routine assessment of a resident's potential for being weaned from a ventilator, with interventions implemented noted in the resident's record, shall receive a per diem rate of $669 for clinically complex residents on a ventilator.

(Source: Amended at 38 Ill. Reg. 23799, effective December 2, 2014)