SB0741eng 98TH GENERAL ASSEMBLY

SB0741 Engrossed LRB098 04975 KTG 35005 b

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 Section 5-5.2 as follows:

(305 ILCS 5/5-5.2) (from Ch. 23, par. 5-5.2)

Sec. 5-5.2. Payment.

(a) All nursing facilities that are grouped pursuant to Section 5-5.1 of this Act shall receive the same rate of payment for similar services.

(b) It shall be a matter of State policy that the Illinois Department shall utilize a uniform billing cycle throughout the State for the long-term care providers.

(c) Notwithstanding any other provisions of this Code, the methodologies for reimbursement of nursing services as provided under this Article shall no longer be applicable for bills payable for nursing services rendered on or after a new reimbursement system based on the Resource Utilization Groups (RUGs) has been fully operationalized, which shall take effect for services provided on or after January 1, 2014.

(d) The new nursing services reimbursement methodology utilizing RUG-IV 48 grouper model, which shall be referred to as the RUGs reimbursement system, taking effect January 1, 2014, shall be based on the following:

(1) The methodology shall be resident-driven, facility-specific, and cost-based.

(2) Costs shall be annually rebased and case mix index quarterly updated. The nursing services methodology will be assigned to the Medicaid enrolled residents on record as of 30 days prior to the beginning of the rate period in the Department's Medicaid Management Information System (MMIS) as present on the last day of the second quarter preceding the rate period.

(3) Regional wage adjustors based on the Health Service Areas (HSA) groupings and adjusters in effect on April 30, 2012 shall be included.

(4) Case mix index shall be assigned to each resident class based on the Centers for Medicare and Medicaid Services staff time measurement study in effect on July 1, 2013, utilizing an index maximization approach.

(5) The pool of funds available for distribution by case mix and the base facility rate shall be determined using the formula contained in subsection (d-1).

(d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate.

(1) Base rate spending pool shall be:

(A) The base year resident days which are calculated by multiplying the number of Medicaid residents in each nursing home as indicated in the MDS data defined in paragraph (4) by 365.

(B) Each facility's nursing component per diem in effect on July 1, 2012 shall be multiplied by subsection (A).

(C) Thirteen million is added to the product of subparagraph (A) and subparagraph (B) to adjust for the exclusion of nursing homes defined in paragraph (5).

(2) For each nursing home with Medicaid residents as indicated by the MDS data defined in paragraph (4), weighted days adjusted for case mix and regional wage adjustment shall be calculated. For each home this calculation is the product of:

(A) Base year resident days as calculated in subparagraph (A) of paragraph (1).

(B) The nursing home's regional wage adjustor based on the Health Service Areas (HSA) groupings and adjustors in effect on April 30, 2012.

(C) Facility weighted case mix which is the number of Medicaid residents as indicated by the MDS data defined in paragraph (4) multiplied by the associated case weight for the RUG-IV 48 grouper model using standard RUG-IV procedures for index maximization.

(D) The sum of the products calculated for each nursing home in subparagraphs (A) through (C) above shall be the base year case mix, rate adjusted weighted days.

(3) The Statewide RUG-IV nursing base per diem rate on January 1, 2014 shall be the quotient of the paragraph (1) divided by the sum calculated under subparagraph (D) of paragraph (2).

(3-1) Beginning January 1, 2015 and every quarter thereafter, the base per diem rate set by the calculations contained in this Section, which is $83.49, shall be adjusted by the addition of the quotient of $32,000,000 set aside for this purpose and any additional moneys as provided in paragraph (4) of subsection (e) and subsection (e-3) divided by the sum calculated under subparagraph (D) of paragraph (2).

(4) Minimum Data Set (MDS) comprehensive assessments for Medicaid residents on March 31, 2012 the last day of the quarter used to establish the base rate.

(5) Nursing facilities designated as of July 1, 2012 by the Department as "Institutions for Mental Disease" shall be excluded from all calculations under this subsection. The data from these facilities shall not be used in the computations described in paragraphs (1) through (4) above to establish the base rate.

(e) Notwithstanding any other provision of this Code, the Department shall by rule develop a reimbursement methodology reflective of the intensity of care and services requirements of low need residents in the lowest RUG IV groupers and corresponding regulations. Only that portion of the RUGs Reimbursement System spending pool described in subsection (d-1) attributed to the groupers as of July 1, 2013 for which the methodology in this Section is developed may be diverted for this purpose. The Department shall submit the rules no later than January 1, 2014 for an implementation date no later than January 1, 2015 which shall establish at a minimum the following add-on adjustments to the facility's RUG-IV rate: .

(1) at a minimum a $208 per day add-on for each resident qualifying for ventilator care adjustment as outlined in the administrative rules of the Department of Healthcare and Family Services;

(2) at a minimum a $5 per day add-on for each resident residing in a dedicated Alzheimer's unit with an Alzheimer's or a non-Alzheimer's dementia diagnosis as scored on the MDS 3.0;

(3) at a minimum a $2.50 per day add-on for each resident falling in the bottom 4 RUG-IV groupers with an Alzheimer's or a non-Alzheimer's dementia diagnosis not residing in a dedicated Alzheimer's unit as scored on the MDS 3.0; and

(4) at a minimum a $3.00 per day add-on for each resident with a diagnosis of a serious mental illness. If for any quarter the amount needed for the serious mental illness add-on is less than $2,000,000, the difference shall be added to the base rate adjustment as provided in paragraph (3-1) of subsection (d-1).

For the purpose of the add-on calculations, a dedicated Alzheimer's unit must meet the criteria set forth in Subpart U of Title 77, Part 300 of the Illinois Administrative Code. "Serious mental illness" means a primary or secondary SMI diagnosis in one of MDS 3.0 items S1200 A through I. "Alzheimer's" and "non-Alzheimer's dementia" means a diagnosis in MDS 3.0 item I4200 or I4800.

If the Department does not implement this reimbursement methodology by the required date, the nursing component per diem on January 1, 2015 for residents classified in RUG-IV groups PA1, PA2, BA1, and BA2 shall be the blended rate of the calculated RUG-IV nursing component per diem and the nursing component per diem in effect on July 1, 2012. This blended rate shall be applied only to nursing homes whose resident population is greater than or equal to 70% of the total residents served and whose RUG-IV nursing component per diem rate is less than the nursing component per diem in effect on July 1, 2012. This blended rate shall be in effect until the reimbursement methodology is implemented or until July 1, 2019, whichever is sooner.

(e-1) Notwithstanding any other provision of this Article, rates established pursuant to this subsection shall not apply to any and all nursing facilities designated by the Department as "Institutions for Mental Disease" and shall be excluded from the RUGs Reimbursement System applicable to facilities not designated as "Institutions for the Mentally Diseased" by the Department.

(e-2) For dates of services beginning January 1, 2014, the RUG-IV nursing component per diem for a nursing home shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index, and the regional wage adjustor. Transition rates for services provided between January 1, 2014 and December 31, 2014 shall be as follows:

(1) The transition RUG-IV per diem nursing rate for nursing homes whose rate calculated in this subsection (e-2) is greater than the nursing component rate in effect July 1, 2012 shall be paid the sum of:

(A) The nursing component rate in effect July 1, 2012; plus

(B) The difference of the RUG-IV nursing component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.88.

(2) The transition RUG-IV per diem nursing rate for nursing homes whose rate calculated in this subsection (e-2) is less than the nursing component rate in effect July 1, 2012 shall be paid the sum of:

(A) The nursing component rate in effect July 1, 2012; plus

(B) The difference of the RUG-IV nursing component per diem calculated for the current quarter minus the nursing component rate in effect July 1, 2012 multiplied by 0.13.

(e-3) Notwithstanding any other provision of this Code, an amount equal to $16,000,000 shall be set aside for the establishment of a quality incentive initiative effective January 1, 2015. In any quarter in which quality incentive awards do not equal $4,000,000, the difference shall be added to the base rate adjustment as provided in paragraph (3-1) of subsection (d-1).

(f) Notwithstanding any other provision of this Code, on and after July 1, 2012, reimbursement rates associated with the nursing or support components of the current nursing facility rate methodology shall not increase beyond the level effective May 1, 2011 until a new reimbursement system based on the RUGs IV 48 grouper model has been fully operationalized.

(g) Notwithstanding any other provision of this Code, on and after July 1, 2012, for facilities not designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease", rates effective May 1, 2011 shall be adjusted as follows:

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

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

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

(h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall have the nursing, socio-developmental, capital, and support components of their reimbursement rate effective May 1, 2011 reduced in total by 2.7%.

(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section 6-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. 7-22-13; revised 9-19-13.)

Section 99. Effective date. This Act takes effect upon becoming law.