Sen. Donne E. Trotter

Filed: 3/26/2014

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 741

2    AMENDMENT NO. ______. Amend Senate Bill 741 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)  (from Ch. 23, par. 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 the
13State for the long-term care providers.
14    (c) Notwithstanding any other provisions of this Code, the
15methodologies for reimbursement of nursing services as
16provided under this Article shall no longer be applicable for

 

 

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1bills payable for nursing services rendered on or after a new
2reimbursement system based on the Resource Utilization Groups
3(RUGs) has been fully operationalized, which shall take effect
4for services provided on or after January 1, 2014.
5    (d) The new nursing services reimbursement methodology
6utilizing RUG-IV 48 grouper model, which shall be referred to
7as the RUGs reimbursement system, taking effect January 1,
82014, shall be based on the following:
9        (1) The methodology shall be resident-driven,
10    facility-specific, and cost-based.
11        (2) Costs shall be annually rebased and case mix index
12    quarterly updated. The nursing services methodology will
13    be assigned to the Medicaid enrolled residents on record as
14    of 30 days prior to the beginning of the rate period in the
15    Department's Medicaid Management Information System (MMIS)
16    as present on the last day of the second quarter preceding
17    the rate period.
18        (3) Regional wage adjustors based on the Health Service
19    Areas (HSA) groupings and adjusters in effect on April 30,
20    2012 shall be included.
21        (4) Case mix index shall be assigned to each resident
22    class based on the Centers for Medicare and Medicaid
23    Services staff time measurement study in effect on July 1,
24    2013, utilizing an index maximization approach.
25        (5) The pool of funds available for distribution by
26    case mix and the base facility rate shall be determined

 

 

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

 

 

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1        defined in paragraph (4) multiplied by the associated
2        case weight for the RUG-IV 48 grouper model using
3        standard RUG-IV procedures for index maximization.
4            (D) The sum of the products calculated for each
5        nursing home in subparagraphs (A) through (C) above
6        shall be the base year case mix, rate adjusted weighted
7        days.
8        (3) The Statewide RUG-IV nursing base per diem rate on
9    January 1, 2014 shall be the quotient of the paragraph (1)
10    divided by the sum calculated under subparagraph (D) of
11    paragraph (2).
12        (3-1) Beginning January 1, 2015 and every quarter
13    thereafter, the base per diem rate set by the calculations
14    contained in this Section, which is $83.49, shall be
15    adjusted by the addition of the quotient of $32,000,000 set
16    aside for this purpose and any additional moneys as
17    provided in paragraph (4) of subsection (e) and subsection
18    (e-3) divided by the sum calculated under subparagraph (D)
19    of paragraph (2).
20        (4) Minimum Data Set (MDS) comprehensive assessments
21    for Medicaid residents on March 31, 2012 the last day of
22    the quarter used to establish the base rate.
23        (5) Nursing facilities designated as of July 1, 2012 by
24    the Department as "Institutions for Mental Disease" shall
25    be excluded from all calculations under this subsection.
26    The data from these facilities shall not be used in the

 

 

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1    computations described in paragraphs (1) through (4) above
2    to establish the base rate.
3    (e) Notwithstanding any other provision of this Code, the
4Department shall by rule develop a reimbursement methodology
5reflective of the intensity of care and services requirements
6of low need residents in the lowest RUG IV groupers and
7corresponding regulations. Only that portion of the RUGs
8Reimbursement System spending pool described in subsection
9(d-1) attributed to the groupers as of July 1, 2013 for which
10the methodology in this Section is developed may be diverted
11for this purpose. The Department shall submit the rules no
12later than January 1, 2014 for an implementation date no later
13than January 1, 2015 which shall establish at a minimum the
14following add-on adjustments to the facility's RUG-IV rate: .
15        (1) at a minimum a $208 per day add-on for each
16    resident qualifying for ventilator care adjustment as
17    outlined in the administrative rules of the Department of
18    Healthcare and Family Services;
19        (2) at a minimum a $5 per day add-on for each resident
20    residing in a dedicated Alzheimer's unit with an
21    Alzheimer's or a non-Alzheimer's dementia diagnosis as
22    scored on the MDS 3.0;
23        (3) at a minimum a $2.50 per day add-on for each
24    resident falling in the bottom 4 RUG-IV groupers with an
25    Alzheimer's or a non-Alzheimer's dementia diagnosis not
26    residing in a dedicated Alzheimer's unit as scored on the

 

 

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1    MDS 3.0; and
2        (4) at a minimum a $3.00 per day add-on for each
3    resident with a diagnosis of a serious mental illness. If
4    for any quarter the amount needed for the serious mental
5    illness add-on is less than $2,000,000, the difference
6    shall be added to the base rate adjustment as provided in
7    paragraph (3-1) of subsection (d-1).
8    For the purpose of the add-on calculations, a dedicated
9Alzheimer's unit must meet the criteria set forth in Subpart U
10of Title 77, Part 300 of the Illinois Administrative Code.
11"Serious mental illness" means a primary or secondary SMI
12diagnosis in one of MDS 3.0 items S1200 A through I.
13"Alzheimer's" and "non-Alzheimer's dementia" means a diagnosis
14in MDS 3.0 item I4200 or I4800.
15    If the Department does not implement this reimbursement
16methodology by the required date, the nursing component per
17diem on January 1, 2015 for residents classified in RUG-IV
18groups PA1, PA2, BA1, and BA2 shall be the blended rate of the
19calculated RUG-IV nursing component per diem and the nursing
20component per diem in effect on July 1, 2012. This blended rate
21shall be applied only to nursing homes whose resident
22population is greater than or equal to 70% of the total
23residents served and whose RUG-IV nursing component per diem
24rate is less than the nursing component per diem in effect on
25July 1, 2012. This blended rate shall be in effect until the
26reimbursement methodology is implemented or until July 1, 2019,

 

 

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1whichever is sooner.
2    (e-1) Notwithstanding any other provision of this Article,
3rates established pursuant to this subsection shall not apply
4to any and all nursing facilities designated by the Department
5as "Institutions for Mental Disease" and shall be excluded from
6the RUGs Reimbursement System applicable to facilities not
7designated as "Institutions for the Mentally Diseased" by the
8Department.
9    (e-2) For dates of services beginning January 1, 2014, the
10RUG-IV nursing component per diem for a nursing home shall be
11the product of the statewide RUG-IV nursing base per diem rate,
12the facility average case mix index, and the regional wage
13adjustor. Transition rates for services provided between
14January 1, 2014 and December 31, 2014 shall be as follows:
15        (1) The transition RUG-IV per diem nursing rate for
16    nursing homes whose rate calculated in this subsection
17    (e-2) is greater than the nursing component rate in effect
18    July 1, 2012 shall be paid the sum of:
19            (A) The nursing component rate in effect July 1,
20        2012; plus
21            (B) The difference of the RUG-IV nursing component
22        per diem calculated for the current quarter minus the
23        nursing component rate in effect July 1, 2012
24        multiplied by 0.88.
25        (2) The transition RUG-IV per diem nursing rate for
26    nursing homes whose rate calculated in this subsection

 

 

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1    (e-2) is less than the nursing component rate in effect
2    July 1, 2012 shall be paid the sum of:
3            (A) The nursing component rate in effect July 1,
4        2012; plus
5            (B) The difference of the RUG-IV nursing component
6        per diem calculated for the current quarter minus the
7        nursing component rate in effect July 1, 2012
8        multiplied by 0.13.
9    (e-3) Notwithstanding any other provision of this Code, an
10amount equal to $16,000,000 shall be set aside for the
11establishment of a quality incentive initiative effective
12January 1, 2015. In any quarter in which quality incentive
13awards do not equal $16,000,000, the difference shall be added
14to the base rate adjustment as provided in paragraph (3-1) of
15subsection (d-1).
16    (f) Notwithstanding any other provision of this Code, on
17and after July 1, 2012, reimbursement rates associated with the
18nursing or support components of the current nursing facility
19rate methodology shall not increase beyond the level effective
20May 1, 2011 until a new reimbursement system based on the RUGs
21IV 48 grouper model has been fully operationalized.
22    (g) Notwithstanding any other provision of this Code, on
23and after July 1, 2012, for facilities not designated by the
24Department of Healthcare and Family Services as "Institutions
25for Mental Disease", rates effective May 1, 2011 shall be
26adjusted as follows:

 

 

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1        (1) Individual nursing rates for residents classified
2    in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter
3    ending March 31, 2012 shall be reduced by 10%;
4        (2) Individual nursing rates for residents classified
5    in all other RUG IV groups shall be reduced by 1.0%;
6        (3) Facility rates for the capital and support
7    components shall be reduced by 1.7%.
8    (h) Notwithstanding any other provision of this Code, on
9and after July 1, 2012, nursing facilities designated by the
10Department of Healthcare and Family Services as "Institutions
11for Mental Disease" and "Institutions for Mental Disease" that
12are facilities licensed under the Specialized Mental Health
13Rehabilitation Act of 2013 shall have the nursing,
14socio-developmental, capital, and support components of their
15reimbursement rate effective May 1, 2011 reduced in total by
162.7%.
17(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section
186-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff.
197-22-13; revised 9-19-13.)
 
20    Section 99. Effective date. This Act takes effect upon
21becoming law.".