Sen. Sara Feigenholtz

Filed: 5/16/2024

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 3380

2    AMENDMENT NO. ______. Amend Senate Bill 3380 by replacing
3everything after the enacting clause with the following:
 
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

 

 

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1provided under this Article shall no longer be applicable for
2bills payable for nursing services rendered on or after a new
3reimbursement system based on the Patient Driven Payment Model
4(PDPM) has been fully operationalized, which shall take effect
5for services provided on or after the implementation of the
6PDPM reimbursement system begins. For the purposes of Public
7Act 102-1035 this amendatory Act of the 102nd General
8Assembly, the implementation date of the PDPM reimbursement
9system and all related provisions shall be July 1, 2022 if the
10following conditions are met: (i) the Centers for Medicare and
11Medicaid Services has approved corresponding changes in the
12reimbursement system and bed assessment; and (ii) the
13Department has filed rules to implement these changes no later
14than June 1, 2022. Failure of the Department to file rules to
15implement the changes provided in Public Act 102-1035 this
16amendatory Act of the 102nd General Assembly no later than
17June 1, 2022 shall result in the implementation date being
18delayed to October 1, 2022.
19    (d) The new nursing services reimbursement methodology
20utilizing the Patient Driven Payment Model, which shall be
21referred to as the PDPM reimbursement system, taking effect
22July 1, 2022, upon federal approval by the Centers for
23Medicare and Medicaid Services, shall be based on the
24following:
25        (1) The methodology shall be resident-centered,
26    facility-specific, cost-based, and based on guidance from

 

 

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1    the Centers for Medicare and Medicaid Services.
2        (2) Costs shall be annually rebased and case mix index
3    quarterly updated. The nursing services methodology will
4    be assigned to the Medicaid enrolled residents on record
5    as of 30 days prior to the beginning of the rate period in
6    the Department's Medicaid Management Information System
7    (MMIS) as present on the last day of the second quarter
8    preceding the rate period based upon the Assessment
9    Reference Date of the Minimum Data Set (MDS).
10        (3) Regional wage adjustors based on the Health
11    Service Areas (HSA) groupings and adjusters in effect on
12    April 30, 2012 shall be included, except no adjuster shall
13    be lower than 1.06.
14        (4) PDPM nursing case mix indices in effect on March
15    1, 2022 shall be assigned to each resident class at no less
16    than 0.7858 of the Centers for Medicare and Medicaid
17    Services PDPM unadjusted case mix values, in effect on
18    March 1, 2022.
19        (5) The pool of funds available for distribution by
20    case mix and the base facility rate shall be determined
21    using the formula contained in subsection (d-1).
22        (6) The Department shall establish a variable per diem
23    staffing add-on in accordance with the most recent
24    available federal staffing report, currently the Payroll
25    Based Journal, for the same period of time, and if
26    applicable adjusted for acuity using the same quarter's

 

 

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1    MDS. The Department shall rely on Payroll Based Journals
2    provided to the Department of Public Health to make a
3    determination of non-submission. If the Department is
4    notified by a facility of missing or inaccurate Payroll
5    Based Journal data or an incorrect calculation of
6    staffing, the Department must make a correction as soon as
7    the error is verified for the applicable quarter.
8        Facilities with at least 70% of the staffing indicated
9    by the STRIVE study shall be paid a per diem add-on of $9,
10    increasing by equivalent steps for each whole percentage
11    point until the facilities reach a per diem of $14.88.
12    Facilities with at least 80% of the staffing indicated by
13    the STRIVE study shall be paid a per diem add-on of $14.88,
14    increasing by equivalent steps for each whole percentage
15    point until the facilities reach a per diem add-on of
16    $23.80. Facilities with at least 92% of the staffing
17    indicated by the STRIVE study shall be paid a per diem
18    add-on of $23.80, increasing by equivalent steps for each
19    whole percentage point until the facilities reach a per
20    diem add-on of $29.75. Facilities with at least 100% of
21    the staffing indicated by the STRIVE study shall be paid a
22    per diem add-on of $29.75, increasing by equivalent steps
23    for each whole percentage point until the facilities reach
24    a per diem add-on of $35.70. Facilities with at least 110%
25    of the staffing indicated by the STRIVE study shall be
26    paid a per diem add-on of $35.70, increasing by equivalent

 

 

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1    steps for each whole percentage point until the facilities
2    reach a per diem add-on of $38.68. Facilities with at
3    least 125% or higher of the staffing indicated by the
4    STRIVE study shall be paid a per diem add-on of $38.68.
5    Beginning April 1, 2023, no nursing facility's variable
6    staffing per diem add-on shall be reduced by more than 5%
7    in 2 consecutive quarters. For the quarters beginning July
8    1, 2022 and October 1, 2022, no facility's variable per
9    diem staffing add-on shall be calculated at a rate lower
10    than 85% of the staffing indicated by the STRIVE study. No
11    facility below 70% of the staffing indicated by the STRIVE
12    study shall receive a variable per diem staffing add-on
13    after December 31, 2022.
14        Because the federal Centers for Medicare and Medicaid
15    Services no longer allows updates to the STRIVE staffing
16    referenced in the preceding paragraph using data from the
17    Resource Utilization Group Version IV, the Department
18    shall pay, beginning July 1, 2024, the staffing per diem
19    add-on computed for the quarter beginning April 1, 2024.
20    The payment shall remain the same until a replacement
21    methodology is incorporated into this Section by law
22    unless the facility does not meet the maintenance of
23    effort as described in this Section.
24        For the purposes of this Section, "maintenance of
25    effort" refers to a requirement that if any facility's per
26    diem staffing hours, as computed from the data reported in

 

 

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1    the federal Payroll Based Journal for any quarter during
2    the period in which no replacement methodology has been
3    enacted into law, falls 15% or more from the reported per
4    diem staffing hours used to compute the staffing per diem
5    add-on for the quarter beginning April 1, 2024, the
6    facility shall have a 5% reduction in the per diem paid
7    staffing add-on for that quarter. The percentage below the
8    April 1, 2024 staffing shall be computed by subtracting
9    the April 1, 2024 reported staffing hours from the current
10    quarter's reported staffing hours and dividing the result
11    by the April 1, 2024 quarter's reported staffing hours. An
12    additional 5% reduction in the staffing incentive shall be
13    assessed for every additional 5% reduction in the per diem
14    staffing hours for that quarter. Each quarter's staffing
15    per diem hours shall be compared independently to the per
16    diem staffing hours used to compute the staffing per diem
17    add-on for the quarter beginning April 1, 2024, for any
18    reduction in payment of the staffing per diem add-on.
19        (7) For dates of services beginning July 1, 2022, the
20    PDPM nursing component per diem for each nursing facility
21    shall be the product of the facility's (i) statewide PDPM
22    nursing base per diem rate, $92.25, adjusted for the
23    facility average PDPM case mix index calculated quarterly
24    and (ii) the regional wage adjuster, and then add the
25    Medicaid access adjustment as defined in (e-3) of this
26    Section. Transition rates for services provided between

 

 

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1    July 1, 2022 and October 1, 2023 shall be the greater of
2    the PDPM nursing component per diem or:
3            (A) for the quarter beginning July 1, 2022, the
4        RUG-IV nursing component per diem;
5            (B) for the quarter beginning October 1, 2022, the
6        sum of the RUG-IV nursing component per diem
7        multiplied by 0.80 and the PDPM nursing component per
8        diem multiplied by 0.20;
9            (C) for the quarter beginning January 1, 2023, the
10        sum of the RUG-IV nursing component per diem
11        multiplied by 0.60 and the PDPM nursing component per
12        diem multiplied by 0.40;
13            (D) for the quarter beginning April 1, 2023, the
14        sum of the RUG-IV nursing component per diem
15        multiplied by 0.40 and the PDPM nursing component per
16        diem multiplied by 0.60;
17            (E) for the quarter beginning July 1, 2023, the
18        sum of the RUG-IV nursing component per diem
19        multiplied by 0.20 and the PDPM nursing component per
20        diem multiplied by 0.80; or
21            (F) for the quarter beginning October 1, 2023 and
22        each subsequent quarter, the transition rate shall end
23        and a nursing facility shall be paid 100% of the PDPM
24        nursing component per diem.
25    (d-1) Calculation of base year Statewide RUG-IV nursing
26base per diem rate.

 

 

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1        (1) Base rate spending pool shall be:
2            (A) The base year resident days which are
3        calculated by multiplying the number of Medicaid
4        residents in each nursing home as indicated in the MDS
5        data defined in paragraph (4) by 365.
6            (B) Each facility's nursing component per diem in
7        effect on July 1, 2012 shall be multiplied by
8        subsection (A).
9            (C) Thirteen million is added to the product of
10        subparagraph (A) and subparagraph (B) to adjust for
11        the exclusion of nursing homes defined in paragraph
12        (5).
13        (2) For each nursing home with Medicaid residents as
14    indicated by the MDS data defined in paragraph (4),
15    weighted days adjusted for case mix and regional wage
16    adjustment shall be calculated. For each home this
17    calculation is the product of:
18            (A) Base year resident days as calculated in
19        subparagraph (A) of paragraph (1).
20            (B) The nursing home's regional wage adjustor
21        based on the Health Service Areas (HSA) groupings and
22        adjustors in effect on April 30, 2012.
23            (C) Facility weighted case mix which is the number
24        of Medicaid residents as indicated by the MDS data
25        defined in paragraph (4) multiplied by the associated
26        case weight for the RUG-IV 48 grouper model using

 

 

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1        standard RUG-IV procedures for index maximization.
2            (D) The sum of the products calculated for each
3        nursing home in subparagraphs (A) through (C) above
4        shall be the base year case mix, rate adjusted
5        weighted days.
6        (3) The Statewide RUG-IV nursing base per diem rate:
7            (A) on January 1, 2014 shall be the quotient of the
8        paragraph (1) divided by the sum calculated under
9        subparagraph (D) of paragraph (2);
10            (B) on and after July 1, 2014 and until July 1,
11        2022, shall be the amount calculated under
12        subparagraph (A) of this paragraph (3) plus $1.76; and
13            (C) beginning July 1, 2022 and thereafter, $7
14        shall be added to the amount calculated under
15        subparagraph (B) of this paragraph (3) of this
16        Section.
17        (4) Minimum Data Set (MDS) comprehensive assessments
18    for Medicaid residents on the last day of the quarter used
19    to establish the base rate.
20        (5) Nursing facilities designated as of July 1, 2012
21    by the Department as "Institutions for Mental Disease"
22    shall be excluded from all calculations under this
23    subsection. The data from these facilities shall not be
24    used in the computations described in paragraphs (1)
25    through (4) above to establish the base rate.
26    (e) Beginning July 1, 2014, the Department shall allocate

 

 

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1funding in the amount up to $10,000,000 for per diem add-ons to
2the RUGS methodology for dates of service on and after July 1,
32014:
4        (1) $0.63 for each resident who scores in I4200
5    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
6        (2) $2.67 for each resident who scores either a "1" or
7    "2" in any items S1200A through S1200I and also scores in
8    RUG groups PA1, PA2, BA1, or BA2.
9    (e-1) (Blank).
10    (e-2) For dates of services beginning January 1, 2014 and
11ending September 30, 2023, the RUG-IV nursing component per
12diem for a nursing home shall be the product of the statewide
13RUG-IV nursing base per diem rate, the facility average case
14mix index, and the regional wage adjustor. For dates of
15service beginning July 1, 2022 and ending September 30, 2023,
16the Medicaid access adjustment described in subsection (e-3)
17shall be added to the product.
18    (e-3) A Medicaid Access Adjustment of $4 adjusted for the
19facility average PDPM case mix index calculated quarterly
20shall be added to the statewide PDPM nursing per diem for all
21facilities with annual Medicaid bed days of at least 70% of all
22occupied bed days adjusted quarterly. For each new calendar
23year and for the 6-month period beginning July 1, 2022, the
24percentage of a facility's occupied bed days comprised of
25Medicaid bed days shall be determined by the Department
26quarterly. For dates of service beginning January 1, 2023, the

 

 

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1Medicaid Access Adjustment shall be increased to $4.75. This
2subsection shall be inoperative on and after January 1, 2028.
3    (e-4) Subject to federal approval, on and after January 1,
42024, the Department shall increase the rate add-on at
5paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
6for ventilator services from $208 per day to $481 per day.
7Payment is subject to the criteria and requirements under 89
8Ill. Adm. Code 147.335.
9    (f) (Blank).
10    (g) Notwithstanding any other provision of this Code, on
11and after July 1, 2012, for facilities not designated by the
12Department of Healthcare and Family Services as "Institutions
13for Mental Disease", rates effective May 1, 2011 shall be
14adjusted as follows:
15        (1) (Blank);
16        (2) (Blank);
17        (3) Facility rates for the capital and support
18    components shall be reduced by 1.7%.
19    (h) Notwithstanding any other provision of this Code, on
20and after July 1, 2012, nursing facilities designated by the
21Department of Healthcare and Family Services as "Institutions
22for Mental Disease" and "Institutions for Mental Disease" that
23are facilities licensed under the Specialized Mental Health
24Rehabilitation Act of 2013 shall have the nursing,
25socio-developmental, capital, and support components of their
26reimbursement rate effective May 1, 2011 reduced in total by

 

 

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12.7%.
2    (i) On and after July 1, 2014, the reimbursement rates for
3the support component of the nursing facility rate for
4facilities licensed under the Nursing Home Care Act as skilled
5or intermediate care facilities shall be the rate in effect on
6June 30, 2014 increased by 8.17%.
7    (i-1) Subject to federal approval, on and after January 1,
82024, the reimbursement rates for the support component of the
9nursing facility rate for facilities licensed under the
10Nursing Home Care Act as skilled or intermediate care
11facilities shall be the rate in effect on June 30, 2023
12increased by 12%.
13    (j) Notwithstanding any other provision of law, subject to
14federal approval, effective July 1, 2019, sufficient funds
15shall be allocated for changes to rates for facilities
16licensed under the Nursing Home Care Act as skilled nursing
17facilities or intermediate care facilities for dates of
18services on and after July 1, 2019: (i) to establish, through
19June 30, 2022 a per diem add-on to the direct care per diem
20rate not to exceed $70,000,000 annually in the aggregate
21taking into account federal matching funds for the purpose of
22addressing the facility's unique staffing needs, adjusted
23quarterly and distributed by a weighted formula based on
24Medicaid bed days on the last day of the second quarter
25preceding the quarter for which the rate is being adjusted.
26Beginning July 1, 2022, the annual $70,000,000 described in

 

 

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1the preceding sentence shall be dedicated to the variable per
2diem add-on for staffing under paragraph (6) of subsection
3(d); and (ii) in an amount not to exceed $170,000,000 annually
4in the aggregate taking into account federal matching funds to
5permit the support component of the nursing facility rate to
6be updated as follows:
7        (1) 80%, or $136,000,000, of the funds shall be used
8    to update each facility's rate in effect on June 30, 2019
9    using the most recent cost reports on file, which have had
10    a limited review conducted by the Department of Healthcare
11    and Family Services and will not hold up enacting the rate
12    increase, with the Department of Healthcare and Family
13    Services.
14        (2) After completing the calculation in paragraph (1),
15    any facility whose rate is less than the rate in effect on
16    June 30, 2019 shall have its rate restored to the rate in
17    effect on June 30, 2019 from the 20% of the funds set
18    aside.
19        (3) The remainder of the 20%, or $34,000,000, shall be
20    used to increase each facility's rate by an equal
21    percentage.
22    (k) During the first quarter of State Fiscal Year 2020,
23the Department of Healthcare of Family Services must convene a
24technical advisory group consisting of members of all trade
25associations representing Illinois skilled nursing providers
26to discuss changes necessary with federal implementation of

 

 

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1Medicare's Patient-Driven Payment Model. Implementation of
2Medicare's Patient-Driven Payment Model shall, by September 1,
32020, end the collection of the MDS data that is necessary to
4maintain the current RUG-IV Medicaid payment methodology. The
5technical advisory group must consider a revised reimbursement
6methodology that takes into account transparency,
7accountability, actual staffing as reported under the
8federally required Payroll Based Journal system, changes to
9the minimum wage, adequacy in coverage of the cost of care, and
10a quality component that rewards quality improvements.
11    (l) The Department shall establish per diem add-on
12payments to improve the quality of care delivered by
13facilities, including:
14        (1) Incentive payments determined by facility
15    performance on specified quality measures in an initial
16    amount of $70,000,000. Nothing in this subsection shall be
17    construed to limit the quality of care payments in the
18    aggregate statewide to $70,000,000, and, if quality of
19    care has improved across nursing facilities, the
20    Department shall adjust those add-on payments accordingly.
21    The quality payment methodology described in this
22    subsection must be used for at least State Fiscal Year
23    2023. Beginning with the quarter starting July 1, 2023,
24    the Department may add, remove, or change quality metrics
25    and make associated changes to the quality payment
26    methodology as outlined in subparagraph (E). Facilities

 

 

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1    designated by the Centers for Medicare and Medicaid
2    Services as a special focus facility or a hospital-based
3    nursing home do not qualify for quality payments.
4            (A) Each quality pool must be distributed by
5        assigning a quality weighted score for each nursing
6        home which is calculated by multiplying the nursing
7        home's quality base period Medicaid days by the
8        nursing home's star rating weight in that period.
9            (B) Star rating weights are assigned based on the
10        nursing home's star rating for the LTS quality star
11        rating. As used in this subparagraph, "LTS quality
12        star rating" means the long-term stay quality rating
13        for each nursing facility, as assigned by the Centers
14        for Medicare and Medicaid Services under the Five-Star
15        Quality Rating System. The rating is a number ranging
16        from 0 (lowest) to 5 (highest).
17                (i) Zero-star or one-star rating has a weight
18            of 0.
19                (ii) Two-star rating has a weight of 0.75.
20                (iii) Three-star rating has a weight of 1.5.
21                (iv) Four-star rating has a weight of 2.5.
22                (v) Five-star rating has a weight of 3.5.
23            (C) Each nursing home's quality weight score is
24        divided by the sum of all quality weight scores for
25        qualifying nursing homes to determine the proportion
26        of the quality pool to be paid to the nursing home.

 

 

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1            (D) The quality pool is no less than $70,000,000
2        annually or $17,500,000 per quarter. The Department
3        shall publish on its website the estimated payments
4        and the associated weights for each facility 45 days
5        prior to when the initial payments for the quarter are
6        to be paid. The Department shall assign each facility
7        the most recent and applicable quarter's STAR value
8        unless the facility notifies the Department within 15
9        days of an issue and the facility provides reasonable
10        evidence demonstrating its timely compliance with
11        federal data submission requirements for the quarter
12        of record. If such evidence cannot be provided to the
13        Department, the STAR rating assigned to the facility
14        shall be reduced by one from the prior quarter.
15            (E) The Department shall review quality metrics
16        used for payment of the quality pool and make
17        recommendations for any associated changes to the
18        methodology for distributing quality pool payments in
19        consultation with associations representing long-term
20        care providers, consumer advocates, organizations
21        representing workers of long-term care facilities, and
22        payors. The Department may establish, by rule, changes
23        to the methodology for distributing quality pool
24        payments.
25            (F) The Department shall disburse quality pool
26        payments from the Long-Term Care Provider Fund on a

 

 

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

 

 

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1    experience. For purposes of this paragraph, Medicaid's
2    share shall be the ratio determined by paid Medicaid bed
3    days divided by total bed days for the applicable time
4    period used in the calculation. In addition, and additive
5    to any tenure increments paid as specified in this
6    paragraph, the Department shall establish, by rule,
7    payments supporting Medicaid's share of the
8    promotion-based wage increments for CNA employee hours
9    compensated for that promotion with at least a $1.50
10    hourly increase. Medicaid's share shall be established as
11    it is for the tenure increments described in this
12    paragraph. Qualifying promotions shall be defined by the
13    Department in rules for an expected 10-15% subset of CNAs
14    assigned intermediate, specialized, or added roles such as
15    CNA trainers, CNA scheduling "captains", and CNA
16    specialists for resident conditions like dementia or
17    memory care or behavioral health.
18    (m) The Department shall work with nursing facility
19industry representatives to design policies and procedures to
20permit facilities to address the integrity of data from
21federal reporting sites used by the Department in setting
22facility rates.
23(Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
24102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
25Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
26Section 50-5, eff. 1-1-24; revised 12-15-23.)
 

 

 

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1    Section 99. Effective date. This Act takes effect July 1,
22024.".