Section 147.5  Minimum Data Set-Mental Health (MDS-MH) Based Reimbursement System

a)         For Class I Institution for Mental Diseases (IMDs), until data can be collected and the payment methodology implemented using the Illinois Minimum Data Set- Mental Health (IL MDS-MH), appropriate for the care needs of the IMD resident population, as described in Table B of this Part, the nursing component shall be the rate in effect on July 1, 2006.  The payment methodology using the IL MDS-MH shall be implemented on July 1, 2010.

b)         To receive payment based on Table B, Class I IMDs shall obtain software that produces the Mental Health Assessment Protocols, outcome measures, and quality indicators, which are part of the MDS-MH system, and train staff to utilize this clinical information in resident treatment and care planning.

c)         The nursing component of the rate shall be calculated annually and may be adjusted  semi-annually.  The determination of rates shall be based upon a composite of MDS-MH data collected from each eligible resident in accordance with Table B for those eligible residents who are recorded in the Department's Medicaid Management Information System as of 30 days prior to the rate period as present in the facility on the last day of the six-month period preceding the rate period.  Residents for whom MDS-MH resident identification information is missing or inaccurate, or for whom there is no current MDS-MH record for that period, shall be placed in the lowest MDS-MH acuity level for calculation purposes for that rate period.  The nursing component of the rate may be adjusted on a semi-annual basis if any of the following conditions are met:

1)         Total variable nursing time for a rate period as calculated in subsection (d)(1) of this Section exceeds total variable nursing time calculated for the previous rate period by more than five percent.

2)         Total variable nursing time for a rate period as calculated in subsection (d)(1) of this Section exceeds:

A)        total variable nursing time as calculated for the annual rate period by more than 10 percent;

B)        total variable nursing time as recalculated and adjusted for the annual period by more than five percent.

3)         Total variable nursing time for a rate period as calculated in subsection (d)(1) of this Section declines from the total variable nursing time as calculated for the annual period by more than five percent.  No semi-annual nursing component rate reduction shall exceed five percent from the annual rate determination.

d)         Per diem reimbursement rates for nursing care in nursing facilities consist of three elements: variable time reimbursement; fringe benefit reimbursement; and reimbursement for supplies, consultants, medical directors and nursing directors.

1)         Variable Time Reimbursement.  Variable nursing time is that time necessary to meet the major service needs of residents that vary due to their physical or mental conditions.  Each need level or specific nursing service measured by the MDS-MH is associated with an amount of time and staff level (Table B).  Reimbursement is developed by multiplying the time for each service by the wages of the type of staff performing the service, except for occupational therapy, physical therapy and speech therapy.  If more than one level of staff are involved in delivering a service, reimbursement for that service will be weighted by the wage and number of minutes allocated to each staff type.  In calculating a facility's rate, the figures used by the Department for wages will be determined in the following manner:

A)        The mean wages for the applicable staff levels (licensed staff, RNs, LPNs, certified nursing assistants (CNAs), social workers), as reported on the cost reports and determined by regional rate area, will be the mean wages.

B)        Fringe benefits shall be calculated in accordance with Section 147.150(c)(1)(B).

C)        The base wage shall be calculated in accordance with Section 147.150(c)(1)(C).

D)        Special minimum wage factor shall be calculated in accordance with Section 147.150(c)(1)(D).

E)         Beginning July 1, 2010, Class I IMDs shall be paid a rate based upon the sum of the following:

i)          The facility MDS-MH system based rate multiplied by a ratio the numerator of which is the quotient obtained by dividing the funds appropriated specifically to pay for rates based upon the MDS-MH methodology by the total number of Medicaid patient days utilized by facilities covered by the MDS-MH based system and the denominator of which is the difference between the weighted mean rate obtained by the MDS-MH methodology and the weighted mean rate direct care rate for IMDs in effect on July 1, 2006.

ii)         The facility rate in effect on July 1, 2006, multiplied by one minus the ratio computed in subsection (d)(1)(E)(i).

2)         Vacation, sick leave and holiday time shall be calculated in accordance with Section 147.150(c)(2).

3)         Special supplies, consultants and the Director of Nursing shall be calculated in accordance with Section 147.150(c)(3).

e)         Determination of Facility Rates

An amount for each resident will be calculated by multiplying the number of minutes from the assessment by the appropriate wages for each assessment item (see subsection(d)(1) of this Section), adding the amounts for vacation, sick and holiday time (see Section 147.150(c)(2)), and supplies, consultants, and the Director of Nursing (see  Section 147.150(c)(3)).  The average of the rates for eligible residents assessed will become the facility's per diem reimbursement rate for each eligible resident in the facility.

f)          In order to code any item on the MDS-MH and receive subsequent reimbursement according to Table B, Class I IMDs shall follow all criteria and specific guidelines in the IL MDS-MH manual (Hirdes et al., RAI-MH Training Manual and Resource Guide 2.0, Toronto, Ontario Joint Policy and Planning Committee, 2003).

g)         In order for services to qualify for reimbursement according to Table B, Class I IMDs shall maintain a minimum ratio for Psychiatric Rehabilitation Services Coordinator staff of one for every 20 residents.

h)         The Department shall not pay for any new admissions to the Class I IMDs who are age 60 years or older or do not have a severe mental illness as determined by the State's mental health pre-admission screening program.

i)          Service providers under Section L, Service Utilization/Treatments, of the MDS-MH shall be coded in column A when services are delivered by staff employed by the facility.  Column B shall be coded for services delivered by outside individuals not employed by the facility.  The Medicaid rate shall reflect only those services delivered by staff that is employed by the facility.

j)          The Medicaid rate determined by Table B for Class I IMDs shall be the combination of a nursing component and socio-development component.

k)         The Department of Healthcare and Family Services and the Department of Human Services-Division of Mental Health shall have the right of entry and inspection to all Class I IMD facilities in order to assess resident mix, monitor data quality, develop service quality indicators, and conduct studies, such as staff time samples, in order to test and refine the payment method.

(Source:  Section repealed at 27 Ill. Reg. 18680, effective November 26, 2003; new Section added at 31 Ill. Reg. 8654, effective June 11, 2007)