HB2518 94TH GENERAL ASSEMBLY

LRB094 07494 DRJ 41052 b

94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
HB2518

Introduced 2/17/2005, by Rep. Jack McGuire

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-5.4	from Ch. 23, par. 5-5.4
305 ILCS 5/5-5.5	from Ch. 23, par. 5-5.5

Amends the Illinois Public Aid Code. Provides that under the Medicaid program, the Department of Public Aid's standards of payment for long-term care must take into account a nursing facility's transactions with related individuals or entities, including overpayments made to a related individual or entity. Provides for deductions from the Medicaid reimbursement otherwise due a nursing facility if the facility (i) had combined transactions with related individuals and related entities totaling more than 10% of the facility's total expenses for a fiscal year or (ii) made payments to a related entity that exceeded the entity's operating costs for a fiscal year. Provides that in determining payment rates for long-term care, the Department shall assure the opportunity for a profit not to exceed 10% of a facility's total revenue for a fiscal year (instead of simply "a profit"). Provides for deductions from the Medicaid reimbursement otherwise due a facility if the facility (i) failed to apply any profits in excess of 10% of revenues to patient-care-related expenses or (ii) paid a salary to a person holding an ownership interest in the facility or in a related entity that exceeded 1% of the facility's Medicaid reimbursement. Effective January 1, 2006.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Public Aid Code is amended by changing Sections 5-5.4 and 5-5.5 as follows:

(305 ILCS 5/5-5.4) (from Ch. 23, par. 5-5.4)

Sec. 5-5.4. Standards of Payment - Department of Public Aid. The Department of Public Aid shall develop standards of payment of skilled nursing and intermediate care services in facilities providing such services under this Article which:

(1) Provide for the determination of a facility's payment for skilled nursing and intermediate care services on a prospective basis. The amount of the payment rate for all nursing facilities certified by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities, Long Term Care for Under Age 22 facilities, Skilled Nursing facilities, or Intermediate Care facilities under the medical assistance program shall be prospectively established annually on the basis of historical, financial, and statistical data reflecting actual costs from prior years, which shall be applied to the current rate year and updated for inflation, except that the capital cost element for newly constructed facilities shall be based upon projected budgets. The annually established payment rate shall take effect on July 1 in 1984 and subsequent years. No rate increase and no update for inflation shall be provided on or after July 1, 1994 and before July 1, 2005, unless specifically provided for in this Section. The changes made by this amendatory Act of the 93rd General Assembly extending the duration of the prohibition against a rate increase or update for inflation are effective retroactive to July 1, 2004.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 1998 shall include an increase of 3%. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 1998 shall include an increase of 3% plus $1.10 per resident-day, as defined by the Department.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 1999 shall include an increase of 1.6% plus $3.00 per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 1999 shall include an increase of 1.6% and, for services provided on or after October 1, 1999, shall be increased by $4.00 per resident-day, as defined by the Department.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on July 1, 2000 shall include an increase of 2.5% per resident-day, as defined by the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Skilled Nursing facilities or Intermediate Care facilities, the rates taking effect on July 1, 2000 shall include an increase of 2.5% per resident-day, as defined by the Department.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, a new payment methodology must be implemented for the nursing component of the rate effective July 1, 2003. The Department of Public Aid shall develop the new payment methodology using the Minimum Data Set (MDS) as the instrument to collect information concerning nursing home resident condition necessary to compute the rate. The Department of Public Aid shall develop the new payment methodology to meet the unique needs of Illinois nursing home residents while remaining subject to the appropriations provided by the General Assembly. A transition period from the payment methodology in effect on June 30, 2003 to the payment methodology in effect on July 1, 2003 shall be provided for a period not exceeding 2 years after implementation of the new payment methodology as follows:

(A) For a facility that would receive a lower nursing component rate per patient day under the new system than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be held at the level in effect on the date immediately preceding the date that the Department implements the new payment methodology until a higher nursing component rate of reimbursement is achieved by that facility.

(B) For a facility that would receive a higher nursing component rate per patient day under the payment methodology in effect on July 1, 2003 than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be adjusted.

(C) Notwithstanding paragraphs (A) and (B), the nursing component rate per patient day for the facility shall be adjusted subject to appropriations provided by the General Assembly.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on March 1, 2001 shall include a statewide increase of 7.85%, as defined by the Department.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or Long Term Care for Under Age 22 facilities, the rates taking effect on April 1, 2002 shall include a statewide increase of 2.0%, as defined by the Department. This increase terminates on July 1, 2002; beginning July 1, 2002 these rates are reduced to the level of the rates in effect on March 31, 2002, as defined by the Department.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on July 1, 2001 shall be computed using the most recent cost reports on file with the Department of Public Aid no later than April 1, 2000, updated for inflation to January 1, 2001. For rates effective July 1, 2001 only, rates shall be the greater of the rate computed for July 1, 2001 or the rate effective on June 30, 2001.

Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the Illinois Department shall determine by rule the rates taking effect on July 1, 2002, which shall be 5.9% less than the rates in effect on June 30, 2002.

Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, if the payment methodologies required under Section 5A-12 and the waiver granted under 42 CFR 433.68 are approved by the United States Centers for Medicare and Medicaid Services, the rates taking effect on July 1, 2004 shall be 3.0% greater than the rates in effect on June 30, 2004. These rates shall take effect only upon approval and implementation of the payment methodologies required under Section 5A-12.

Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on January 1, 2005 shall be 3% more than the rates in effect on December 31, 2004.

For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care for the Developmentally Disabled facilities or as long-term care facilities for residents under 22 years of age, the rates taking effect on July 1, 2003 shall include a statewide increase of 4%, as defined by the Department.

Rates established effective each July 1 shall govern payment for services rendered throughout that fiscal year, except that rates established on July 1, 1996 shall be increased by 6.8% for services provided on or after January 1, 1997. Such rates will be based upon the rates calculated for the year beginning July 1, 1990, and for subsequent years thereafter until June 30, 2001 shall be based on the facility cost reports for the facility fiscal year ending at any point in time during the previous calendar year, updated to the midpoint of the rate year. The cost report shall be on file with the Department no later than April 1 of the current rate year. Should the cost report not be on file by April 1, the Department shall base the rate on the latest cost report filed by each skilled care facility and intermediate care facility, updated to the midpoint of the current rate year. In determining rates for services rendered on and after July 1, 1985, fixed time shall not be computed at less than zero. The Department shall not make any alterations of regulations which would reduce any component of the Medicaid rate to a level below what that component would have been utilizing in the rate effective on July 1, 1984.

(2) Shall take into account the actual costs incurred by facilities in providing services for recipients of skilled nursing and intermediate care services under the medical assistance program.

(2.5) Take into account a facility's transactions with a related individual or entity, including any overpayment made by the facility to a related entity, as provided in this item (2.5).

A facility must disclose in each cost report filed with the Department of Public Aid all relevant information regarding related entities, including:

(A) Every individual or organization that holds a legal interest in the facility.

(B) Every individual or entity that holds a legal interest in the facility and also holds a legal interest in an entity that provides reimbursable goods and services to the facility or its residents.

(C) The total compensation for each individual listed in paragraph (A) or (B), including, but not limited to: salary, benefits, dividends, and bonuses, for the fiscal year for which the cost report is filed.

A facility may not have combined transactions with related individuals and related entities in excess of 10% of the facility's total expenses for a particular fiscal year. The Department shall deduct from a facility's reimbursements under this Article the amount of any payment by the facility to a related entity in excess of 10% of the facility's total expenses reported on its most recently filed cost report.

A facility may not pay to a related individual or entity a sum in excess of the related entity's operating costs on behalf of the facility. The Department shall deduct any payment by a facility to a related entity in excess of the related entity's operating costs on behalf of the facility from the facility's reimbursements under this Article for the following year.

For purposes of this item (2.5):

"Related individual or entity" means (i) an individual or entity with a 5% or greater ownership interest in each of 2 or more nursing facilities or in both a nursing facility and any entity that conducts transactions with any nursing facility, or (ii) an entity with any ownership interest held by relatives of the owners of a nursing facility.

"Relatives" includes spouses, children, parents, brothers and sisters, grandparents, grandchildren, parents-in-law, sisters-in-law or brothers-in-law, sons-in-law or daughters-in-law, aunts, uncles, and cousins, as is consistent with the Department of Public Aid's rules for filing Medicaid cost reports.

"Operating cost of a related entity" means the actual cost of any goods or services provided by a related entity to a facility, as is consistent with the Department of Public Aid's rules for filing Medicaid cost reports.

(3) Shall take into account the medical and psycho-social characteristics and needs of the patients.

(4) Shall take into account the actual costs incurred by facilities in meeting licensing and certification standards imposed and prescribed by the State of Illinois, any of its political subdivisions or municipalities and by the U.S. Department of Health and Human Services pursuant to Title XIX of the Social Security Act.

The Department of Public Aid shall develop precise standards for payments to reimburse nursing facilities for any utilization of appropriate rehabilitative personnel for the provision of rehabilitative services which is authorized by federal regulations, including reimbursement for services provided by qualified therapists or qualified assistants, and which is in accordance with accepted professional practices. Reimbursement also may be made for utilization of other supportive personnel under appropriate supervision.

(Source: P.A. 92-10, eff. 6-11-01; 92-31, eff. 6-28-01; 92-597, eff. 6-28-02; 92-651, eff. 7-11-02; 92-848, eff. 1-1-03; 93-20, eff. 6-20-03; 93-649, eff. 1-8-04; 93-659, eff. 2-3-04; 93-841, eff. 7-30-04.)

(305 ILCS 5/5-5.5) (from Ch. 23, par. 5-5.5)

Sec. 5-5.5. Elements of Payment Rate.

(a) The Department of Public Aid shall develop a prospective method for determining payment rates for skilled nursing and intermediate care services in nursing facilities composed of the following cost elements:

(1) Standard Services, with the cost of this component being determined by taking into account the actual costs to the facilities of these services subject to cost ceilings to be defined in the Department's rules.

(2) Resident Services, with the cost of this component being determined by taking into account the actual costs, needs and utilization of these services, as derived from an assessment of the resident needs in the nursing facilities. The Department shall adopt rules governing reimbursement for resident services as listed in Section 5-1.1. Surveys or assessments of resident needs under this Section shall include a review by the facility of the results of such assessments and a discussion of issues in dispute with authorized survey staff, unless the facility elects not to participate in such a review process. Surveys or assessments of resident needs under this Section may be conducted semi-annually and payment rates relating to resident services may be changed on a semi-annual basis. The Illinois Department shall initiate a project, either on a pilot basis or Statewide, to reimburse the cost of resident services based on a methodology which utilizes an assessment of resident needs to determine the level of reimbursement. This methodology shall be different from the payment criteria for resident services utilized by the Illinois Department on July 1, 1981. On March 1, 1982, and each year thereafter, until such time when the Illinois Department adopts the methodology used in such project for use statewide, the Illinois Department shall report to the General Assembly on the implementation and progress of such project. The report shall include:

(A) A statement of the Illinois Department's goals and objectives for such project;

(B) A description of such project, including the number and type of nursing facilities involved in the project;

(C) A description of the methodology used in such project;

(D) A description of the Illinois Department's application of the methodology;

(E) A statement on the methodology's effect on the quality of care given to residents in the sample nursing facilities; and

(F) A statement on the cost of the methodology used in such project and a comparison of this cost with the cost of the current payment criteria.

(3) Ancillary Services, with the payment rate being developed for each individual type of service. Payment shall be made only when authorized under procedures developed by the Department of Public Aid.

(4) Nurse's Aide Training, with the cost of this component being determined by taking into account the actual cost to the facilities of such training.

(5) Real Estate Taxes, with the cost of this component being determined by taking into account the figures contained in the most currently available cost reports (with no imposition of maximums) updated to the midpoint of the current rate year for long term care services rendered between July 1, 1984 and June 30, 1985, and with the cost of this component being determined by taking into account the actual 1983 taxes for which the nursing homes were assessed (with no imposition of maximums) updated to the midpoint of the current rate year for long term care services rendered between July 1, 1985 and June 30, 1986.

(b) In developing a prospective method for determining payment rates for skilled nursing and intermediate care services in nursing facilities, the Department of Public Aid shall consider the following cost elements:

(1) Reasonable capital cost determined by utilizing incurred interest rate and the current value of the investment, including land, utilizing composite rates, or by utilizing such other reasonable cost related methods determined by the Department. However, beginning with the rate reimbursement period effective July 1, 1987, the Department shall be prohibited from establishing, including, and implementing any depreciation factor in calculating the capital cost element.

(2) Profit, with the actual amount being produced and accruing to the providers in the form of a return on their total investment, on the basis of their ability to economically and efficiently deliver a type of service. The method of payment may assure the opportunity for a profit not exceeding 10% of the facility's total revenue for a particular fiscal year, but shall not guarantee or establish a specific amount as a cost.

(b-1) A facility must treat any profits in excess of 10% as moneys earmarked for patient care related expenses for the following fiscal year. The Department shall deduct from a facility's reimbursements under this Article the amount of the facility's profits in excess of 10% of revenues from 2 years prior to the current fiscal year not applied to patient-care-related expenses in the fiscal year immediately prior to the current fiscal year.

Any salary paid to a person holding an ownership interest in a facility or in a related entity in a particular fiscal year may not exceed the equivalent of 1% of that facility's reimbursements under this Article for that fiscal year. The Department shall deduct from a facility's reimbursements the amount of any salary paid to a person holding an ownership interest in the facility or in a related entity that exceeds 1% of that facility's reimbursements under this Article for a particular fiscal year.

For purposes of this subsection (b-1):

"Related individual or entity" means (i) an individual or entity with a 5% or greater ownership interest in each of 2 or more nursing facilities or in both a nursing facility and any entity that conducts transactions with any nursing facility, or (ii) an entity with any ownership interest held by relatives of the owners of a nursing facility.

"Relatives" includes spouses, children, parents, brothers and sisters, grandparents, grandchildren, parents-in-law, sisters-in-law or brothers-in-law, sons-in-law or daughters-in-law, aunts, uncles, and cousins, as is consistent with the Department of Public Aid's rules for filing Medicaid cost reports.

"Operating cost of a related entity" means the actual cost of any goods or services provided by a related entity to a facility, as is consistent with the Department of Public Aid's rules for filing Medicaid cost reports.

"Patient-care-related expenses" means any expense listed in the "General Services" or "Health Care and Programs" cost centers as defined in the Department of Public Aid's rules for filing Medicaid cost reports.

(c) The Illinois Department may implement the amendatory changes to this Section made by this amendatory Act of 1991 through the use of emergency rules in accordance with the provisions of Section 5.02 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the adoption of rules to implement the amendatory changes to this Section made by this amendatory Act of 1991 shall be deemed an emergency and necessary for the public interest, safety and welfare.

(d) No later than January 1, 2001, the Department of Public Aid shall file with the Joint Committee on Administrative Rules, pursuant to the Illinois Administrative Procedure Act, a proposed rule, or a proposed amendment to an existing rule, regarding payment for appropriate services, including assessment, care planning, discharge planning, and treatment provided by nursing facilities to residents who have a serious mental illness.

(Source: P.A. 93-632, eff. 2-1-04.)

Section 99. Effective date. This Act takes effect January 1, 2006.