Sen. Donne E. Trotter
Filed: 3/31/2014
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| 1 | AMENDMENT TO SENATE BILL 741
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| 2 | AMENDMENT NO. ______. Amend Senate Bill 741 by replacing | ||||||
| 3 | everything after the enacting clause with the following:
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| 4 | "Section 5. The Illinois Public Aid Code is amended by | ||||||
| 5 | changing Section 5-5.2 as follows:
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| 6 | (305 ILCS 5/5-5.2) (from Ch. 23, par. 5-5.2)
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| 7 | Sec. 5-5.2. Payment.
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| 8 | (a) All nursing facilities that are grouped pursuant to | ||||||
| 9 | Section
5-5.1 of this Act shall receive the same rate of | ||||||
| 10 | payment for similar
services.
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| 11 | (b) It shall be a matter of State policy that the Illinois | ||||||
| 12 | Department
shall utilize a uniform billing cycle throughout the | ||||||
| 13 | State for the
long-term care providers.
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| 14 | (c) Notwithstanding any other provisions of this Code, the | ||||||
| 15 | methodologies for reimbursement of nursing services as | ||||||
| 16 | provided under this Article shall no longer be applicable for | ||||||
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| 1 | bills payable for nursing services rendered on or after a new | ||||||
| 2 | reimbursement system based on the Resource Utilization Groups | ||||||
| 3 | (RUGs) has been fully operationalized, which shall take effect | ||||||
| 4 | for services provided on or after January 1, 2014. | ||||||
| 5 | (d) The new nursing services reimbursement methodology | ||||||
| 6 | utilizing RUG-IV 48 grouper model, which shall be referred to | ||||||
| 7 | as the RUGs reimbursement system, taking effect January 1, | ||||||
| 8 | 2014, 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 | ||||||
| 3 | base 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 | ||||||
| 4 | Department shall by rule develop a reimbursement methodology | ||||||
| 5 | reflective of the intensity of care and services requirements | ||||||
| 6 | of low need residents in the lowest RUG IV groupers and | ||||||
| 7 | corresponding regulations. Only that portion of the RUGs | ||||||
| 8 | Reimbursement System spending pool described in subsection | ||||||
| 9 | (d-1) attributed to the groupers as of July 1, 2013 for which | ||||||
| 10 | the methodology in this Section is developed may be diverted | ||||||
| 11 | for this purpose. The Department shall submit the rules no | ||||||
| 12 | later than January 1, 2014 for an implementation date no later | ||||||
| 13 | than January 1, 2015 which shall establish at a minimum the | ||||||
| 14 | following 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 | ||||||
| 9 | Alzheimer's unit must meet the criteria set forth in Subpart U | ||||||
| 10 | of Title 77, Part 300 of the Illinois Administrative Code. | ||||||
| 11 | "Serious mental illness" means a primary or secondary SMI | ||||||
| 12 | diagnosis in one of MDS 3.0 items S1200 A through I. | ||||||
| 13 | "Alzheimer's" and "non-Alzheimer's dementia" means a diagnosis | ||||||
| 14 | in MDS 3.0 item I4200 or I4800. | ||||||
| 15 | If the Department does not implement this reimbursement | ||||||
| 16 | methodology by the required date, the nursing component per | ||||||
| 17 | diem on January 1, 2015 for residents classified in RUG-IV | ||||||
| 18 | groups PA1, PA2, BA1, and BA2 shall be the blended rate of the | ||||||
| 19 | calculated RUG-IV nursing component per diem and the nursing | ||||||
| 20 | component per diem in effect on July 1, 2012. This blended rate | ||||||
| 21 | shall be applied only to nursing homes whose resident | ||||||
| 22 | population is greater than or equal to 70% of the total | ||||||
| 23 | residents served and whose RUG-IV nursing component per diem | ||||||
| 24 | rate is less than the nursing component per diem in effect on | ||||||
| 25 | July 1, 2012. This blended rate shall be in effect until the | ||||||
| 26 | reimbursement methodology is implemented or until July 1, 2019, | ||||||
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| 1 | whichever is sooner. | ||||||
| 2 | (e-1) Notwithstanding any other provision of this Article, | ||||||
| 3 | rates established pursuant to this subsection shall not apply | ||||||
| 4 | to any and all nursing facilities designated by the Department | ||||||
| 5 | as "Institutions for Mental Disease" and shall be excluded from | ||||||
| 6 | the RUGs Reimbursement System applicable to facilities not | ||||||
| 7 | designated as "Institutions for the Mentally Diseased" by the | ||||||
| 8 | Department. | ||||||
| 9 | (e-2) For dates of services beginning January 1, 2014, the | ||||||
| 10 | RUG-IV nursing component per diem for a nursing home shall be | ||||||
| 11 | the product of the statewide RUG-IV nursing base per diem rate, | ||||||
| 12 | the facility average case mix index, and the regional wage | ||||||
| 13 | adjustor. Transition rates for services provided between | ||||||
| 14 | January 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 | ||||||
| 10 | amount equal to $16,000,000 shall be set aside for the | ||||||
| 11 | establishment of a quality incentive initiative effective | ||||||
| 12 | January 1, 2015. In any quarter in which quality incentive | ||||||
| 13 | awards do not equal $4,000,000, the difference shall be added | ||||||
| 14 | to the base rate adjustment as provided in paragraph (3-1) of | ||||||
| 15 | subsection (d-1). | ||||||
| 16 | (f) Notwithstanding any other provision of this Code, on | ||||||
| 17 | and after July 1, 2012, reimbursement rates associated with the | ||||||
| 18 | nursing or support components of the current nursing facility | ||||||
| 19 | rate methodology shall not increase beyond the level effective | ||||||
| 20 | May 1, 2011 until a new reimbursement system based on the RUGs | ||||||
| 21 | IV 48 grouper model has been fully operationalized. | ||||||
| 22 | (g) Notwithstanding any other provision of this Code, on | ||||||
| 23 | and after July 1, 2012, for facilities not designated by the | ||||||
| 24 | Department of Healthcare and Family Services as "Institutions | ||||||
| 25 | for Mental Disease", rates effective May 1, 2011 shall be | ||||||
| 26 | adjusted 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 | ||||||
| 9 | and after July 1, 2012, nursing facilities designated by the | ||||||
| 10 | Department of Healthcare and Family Services as "Institutions | ||||||
| 11 | for Mental Disease" and "Institutions for Mental Disease" that | ||||||
| 12 | are facilities licensed under the Specialized Mental Health | ||||||
| 13 | Rehabilitation Act of 2013 shall have the nursing, | ||||||
| 14 | socio-developmental, capital, and support components of their | ||||||
| 15 | reimbursement rate effective May 1, 2011 reduced in total by | ||||||
| 16 | 2.7%. | ||||||
| 17 | (Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section | ||||||
| 18 | 6-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. | ||||||
| 19 | 7-22-13; revised 9-19-13.)
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| 20 | Section 99. Effective date. This Act takes effect upon | ||||||
| 21 | becoming law.".
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