103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5847

 

Introduced 5/15/2024, by Rep. Anna Moeller - Yolonda Morris

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5.2

    Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning payments to nursing facilities, sets forth how to calculate each facility's variable per diem staffing add-on amount beginning October 1, 2024. Increases the per diem maximum amounts paid to facilities based on the STRIVE study. Effective October 1, 2024.


LRB103 40684 KTG 73450 b

 

 

A BILL FOR

 

HB5847LRB103 40684 KTG 73450 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
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)
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
13the State for the long-term care providers.
14    (c) (Blank).
15    (c-1) Notwithstanding any other provisions of this Code,
16the methodologies for reimbursement of nursing services as
17provided under this Article shall no longer be applicable for
18bills payable for nursing services rendered on or after a new
19reimbursement system based on the Patient Driven Payment Model
20(PDPM) has been fully operationalized, which shall take effect
21for services provided on or after the implementation of the
22PDPM reimbursement system begins. For the purposes of Public
23Act 102-1035 this amendatory Act of the 102nd General

 

 

HB5847- 2 -LRB103 40684 KTG 73450 b

1Assembly, the implementation date of the PDPM reimbursement
2system and all related provisions shall be July 1, 2022 if the
3following conditions are met: (i) the Centers for Medicare and
4Medicaid Services has approved corresponding changes in the
5reimbursement system and bed assessment; and (ii) the
6Department has filed rules to implement these changes no later
7than June 1, 2022. Failure of the Department to file rules to
8implement the changes provided in Public Act 102-1035 this
9amendatory Act of the 102nd General Assembly no later than
10June 1, 2022 shall result in the implementation date being
11delayed to October 1, 2022.
12    (d) The new nursing services reimbursement methodology
13utilizing the Patient Driven Payment Model, which shall be
14referred to as the PDPM reimbursement system, taking effect
15July 1, 2022, upon federal approval by the Centers for
16Medicare and Medicaid Services, shall be based on the
17following:
18        (1) The methodology shall be resident-centered,
19    facility-specific, cost-based, and based on guidance from
20    the Centers for Medicare and Medicaid Services.
21        (2) Costs shall be annually rebased and case mix index
22    quarterly updated. The nursing services methodology will
23    be assigned to the Medicaid enrolled residents on record
24    as of 30 days prior to the beginning of the rate period in
25    the Department's Medicaid Management Information System
26    (MMIS) as present on the last day of the second quarter

 

 

HB5847- 3 -LRB103 40684 KTG 73450 b

1    preceding the rate period based upon the Assessment
2    Reference Date of the Minimum Data Set (MDS).
3        (3) Regional wage adjustors based on the Health
4    Service Areas (HSA) groupings and adjusters in effect on
5    April 30, 2012 shall be included, except no adjuster shall
6    be lower than 1.06.
7        (4) PDPM nursing case mix indices in effect on March
8    1, 2022 shall be assigned to each resident class at no less
9    than 0.7858 of the Centers for Medicare and Medicaid
10    Services PDPM unadjusted case mix values, in effect on
11    March 1, 2022.
12        (5) The pool of funds available for distribution by
13    case mix and the base facility rate shall be determined
14    using the formula contained in subsection (d-1).
15        (6) The Department shall establish a variable per diem
16    staffing add-on in accordance with the most recent
17    available federal staffing report, currently the Payroll
18    Based Journal, for the same period of time, and if
19    applicable adjusted for acuity using the same quarter's
20    MDS. The Department shall rely on Payroll Based Journals
21    provided to the Department of Public Health to make a
22    determination of non-submission. If the Department is
23    notified by a facility of missing or inaccurate Payroll
24    Based Journal data or an incorrect calculation of
25    staffing, the Department must make a correction as soon as
26    the error is verified for the applicable quarter.

 

 

HB5847- 4 -LRB103 40684 KTG 73450 b

1        Beginning October 1, 2024, the staffing percentage
2    used in the calculation of the per diem staffing add-on
3    shall be its PDPM STRIVE Staffing Ratio which equals: its
4    Reported Total Nurse Staffing Hours Per Resident Per Day
5    as published in the most recent federal staffing report
6    (the Provider Information File), divided by the facility's
7    PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
8    Staffing Target is equal to .82 times the facility's
9    Illinois Adjusted Facility Case-Mix Hours Per Resident Per
10    Day. A facility's Illinois Adjusted Facility Case Mix
11    Hours Per Resident Per Day is equal to its Case-Mix Total
12    Nurse Staffing Hours Per Resident Per Day (as published in
13    the most recent federal staffing report) times 3.662
14    (which reflects the national resident days-weighted mean
15    Reported Total Nurse Staffing Hours Per Resident Per Day
16    as calculated using the January 2024 federal Provider
17    Information Files), divided by the national resident
18    days-weighted mean Reported Total Nurse Staffing Hours Per
19    Resident Per Day calculated using the most recent federal
20    Provider Information File. Facilities with at least 70% of
21    the staffing indicated by the STRIVE study shall be paid a
22    per diem add-on of $9, increasing by equivalent steps for
23    each whole percentage point until the facilities reach a
24    per diem of $16.52 $14.88. Facilities with at least 80% of
25    the staffing indicated by the STRIVE study shall be paid a
26    per diem add-on of $16.52 $14.88, increasing by equivalent

 

 

HB5847- 5 -LRB103 40684 KTG 73450 b

1    steps for each whole percentage point until the facilities
2    reach a per diem add-on of $25.77 $23.80. Facilities with
3    at least 92% of the staffing indicated by the STRIVE study
4    shall be paid a per diem add-on of $25.77 $23.80,
5    increasing by equivalent steps for each whole percentage
6    point until the facilities reach a per diem add-on of
7    $30.98 $29.75. Facilities with at least 100% of the
8    staffing indicated by the STRIVE study shall be paid a per
9    diem add-on of $30.98 $29.75, increasing by equivalent
10    steps for each whole percentage point until the facilities
11    reach a per diem add-on of $36.44 $35.70. Facilities with
12    at least 110% of the staffing indicated by the STRIVE
13    study shall be paid a per diem add-on of $36.44 $35.70,
14    increasing by equivalent steps for each whole percentage
15    point until the facilities reach a per diem add-on of
16    $38.68. Facilities with at least 125% or higher of the
17    staffing indicated by the STRIVE study shall be paid a per
18    diem add-on of $38.68. No Beginning April 1, 2023, no
19    nursing facility's variable staffing per diem add-on shall
20    be reduced by more than 5% in 2 consecutive quarters. For
21    the quarters beginning July 1, 2022 and October 1, 2022,
22    no facility's variable per diem staffing add-on shall be
23    calculated at a rate lower than 85% of the staffing
24    indicated by the STRIVE study. No facility below 70% of
25    the staffing indicated by the STRIVE study shall receive a
26    variable per diem staffing add-on after December 31, 2022.

 

 

HB5847- 6 -LRB103 40684 KTG 73450 b

1        (7) For dates of services beginning July 1, 2022, the
2    PDPM nursing component per diem for each nursing facility
3    shall be the product of the facility's (i) statewide PDPM
4    nursing base per diem rate, $92.25, adjusted for the
5    facility average PDPM case mix index calculated quarterly
6    and (ii) the regional wage adjuster, and then add the
7    Medicaid access adjustment as defined in (e-3) of this
8    Section. Transition rates for services provided between
9    July 1, 2022 and October 1, 2023 shall be the greater of
10    the PDPM nursing component per diem or:
11            (A) for the quarter beginning July 1, 2022, the
12        RUG-IV nursing component per diem;
13            (B) for the quarter beginning October 1, 2022, the
14        sum of the RUG-IV nursing component per diem
15        multiplied by 0.80 and the PDPM nursing component per
16        diem multiplied by 0.20;
17            (C) for the quarter beginning January 1, 2023, the
18        sum of the RUG-IV nursing component per diem
19        multiplied by 0.60 and the PDPM nursing component per
20        diem multiplied by 0.40;
21            (D) for the quarter beginning April 1, 2023, the
22        sum of the RUG-IV nursing component per diem
23        multiplied by 0.40 and the PDPM nursing component per
24        diem multiplied by 0.60;
25            (E) for the quarter beginning July 1, 2023, the
26        sum of the RUG-IV nursing component per diem

 

 

HB5847- 7 -LRB103 40684 KTG 73450 b

1        multiplied by 0.20 and the PDPM nursing component per
2        diem multiplied by 0.80; or
3            (F) for the quarter beginning October 1, 2023 and
4        each subsequent quarter, the transition rate shall end
5        and a nursing facility shall be paid 100% of the PDPM
6        nursing component per diem.
7    (d-1) Calculation of base year Statewide RUG-IV nursing
8base per diem rate.
9        (1) Base rate spending pool shall be:
10            (A) The base year resident days which are
11        calculated by multiplying the number of Medicaid
12        residents in each nursing home as indicated in the MDS
13        data defined in paragraph (4) by 365.
14            (B) Each facility's nursing component per diem in
15        effect on July 1, 2012 shall be multiplied by
16        subsection (A).
17            (C) Thirteen million is added to the product of
18        subparagraph (A) and subparagraph (B) to adjust for
19        the exclusion of nursing homes defined in paragraph
20        (5).
21        (2) For each nursing home with Medicaid residents as
22    indicated by the MDS data defined in paragraph (4),
23    weighted days adjusted for case mix and regional wage
24    adjustment shall be calculated. For each home this
25    calculation is the product of:
26            (A) Base year resident days as calculated in

 

 

HB5847- 8 -LRB103 40684 KTG 73450 b

1        subparagraph (A) of paragraph (1).
2            (B) The nursing home's regional wage adjustor
3        based on the Health Service Areas (HSA) groupings and
4        adjustors in effect on April 30, 2012.
5            (C) Facility weighted case mix which is the number
6        of Medicaid residents as indicated by the MDS data
7        defined in paragraph (4) multiplied by the associated
8        case weight for the RUG-IV 48 grouper model using
9        standard RUG-IV procedures for index maximization.
10            (D) The sum of the products calculated for each
11        nursing home in subparagraphs (A) through (C) above
12        shall be the base year case mix, rate adjusted
13        weighted days.
14        (3) The Statewide RUG-IV nursing base per diem rate:
15            (A) on January 1, 2014 shall be the quotient of the
16        paragraph (1) divided by the sum calculated under
17        subparagraph (D) of paragraph (2);
18            (B) on and after July 1, 2014 and until July 1,
19        2022, shall be the amount calculated under
20        subparagraph (A) of this paragraph (3) plus $1.76; and
21            (C) beginning July 1, 2022 and thereafter, $7
22        shall be added to the amount calculated under
23        subparagraph (B) of this paragraph (3) of this
24        Section.
25        (4) Minimum Data Set (MDS) comprehensive assessments
26    for Medicaid residents on the last day of the quarter used

 

 

HB5847- 9 -LRB103 40684 KTG 73450 b

1    to establish the base rate.
2        (5) Nursing facilities designated as of July 1, 2012
3    by the Department as "Institutions for Mental Disease"
4    shall be excluded from all calculations under this
5    subsection. The data from these facilities shall not be
6    used in the computations described in paragraphs (1)
7    through (4) above to establish the base rate.
8    (e) Beginning July 1, 2014, the Department shall allocate
9funding in the amount up to $10,000,000 for per diem add-ons to
10the RUGS methodology for dates of service on and after July 1,
112014:
12        (1) $0.63 for each resident who scores in I4200
13    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
14        (2) $2.67 for each resident who scores either a "1" or
15    "2" in any items S1200A through S1200I and also scores in
16    RUG groups PA1, PA2, BA1, or BA2.
17    (e-1) (Blank).
18    (e-2) For dates of services beginning January 1, 2014 and
19ending September 30, 2023, the RUG-IV nursing component per
20diem for a nursing home shall be the product of the statewide
21RUG-IV nursing base per diem rate, the facility average case
22mix index, and the regional wage adjustor. For dates of
23service beginning July 1, 2022 and ending September 30, 2023,
24the Medicaid access adjustment described in subsection (e-3)
25shall be added to the product.
26    (e-3) A Medicaid Access Adjustment of $4 adjusted for the

 

 

HB5847- 10 -LRB103 40684 KTG 73450 b

1facility average PDPM case mix index calculated quarterly
2shall be added to the statewide PDPM nursing per diem for all
3facilities with annual Medicaid bed days of at least 70% of all
4occupied bed days adjusted quarterly. For each new calendar
5year and for the 6-month period beginning July 1, 2022, the
6percentage of a facility's occupied bed days comprised of
7Medicaid bed days shall be determined by the Department
8quarterly. For dates of service beginning January 1, 2023, the
9Medicaid Access Adjustment shall be increased to $4.75. This
10subsection shall be inoperative on and after January 1, 2028.
11    (e-4) Subject to federal approval, on and after January 1,
122024, the Department shall increase the rate add-on at
13paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
14for ventilator services from $208 per day to $481 per day.
15Payment is subject to the criteria and requirements under 89
16Ill. Adm. Code 147.335.
17    (f) (Blank).
18    (g) Notwithstanding any other provision of this Code, on
19and after July 1, 2012, for facilities not designated by the
20Department of Healthcare and Family Services as "Institutions
21for Mental Disease", rates effective May 1, 2011 shall be
22adjusted as follows:
23        (1) (Blank);
24        (2) (Blank);
25        (3) Facility rates for the capital and support
26    components shall be reduced by 1.7%.

 

 

HB5847- 11 -LRB103 40684 KTG 73450 b

1    (h) Notwithstanding any other provision of this Code, on
2and after July 1, 2012, nursing facilities designated by the
3Department of Healthcare and Family Services as "Institutions
4for Mental Disease" and "Institutions for Mental Disease" that
5are facilities licensed under the Specialized Mental Health
6Rehabilitation Act of 2013 shall have the nursing,
7socio-developmental, capital, and support components of their
8reimbursement rate effective May 1, 2011 reduced in total by
92.7%.
10    (i) On and after July 1, 2014, the reimbursement rates for
11the support component of the nursing facility rate for
12facilities licensed under the Nursing Home Care Act as skilled
13or intermediate care facilities shall be the rate in effect on
14June 30, 2014 increased by 8.17%.
15    (i-1) Subject to federal approval, on and after January 1,
162024, the reimbursement rates for the support component of the
17nursing facility rate for facilities licensed under the
18Nursing Home Care Act as skilled or intermediate care
19facilities shall be the rate in effect on June 30, 2023
20increased by 12%.
21    (j) Notwithstanding any other provision of law, subject to
22federal approval, effective July 1, 2019, sufficient funds
23shall be allocated for changes to rates for facilities
24licensed under the Nursing Home Care Act as skilled nursing
25facilities or intermediate care facilities for dates of
26services on and after July 1, 2019: (i) to establish, through

 

 

HB5847- 12 -LRB103 40684 KTG 73450 b

1June 30, 2022 a per diem add-on to the direct care per diem
2rate not to exceed $70,000,000 annually in the aggregate
3taking into account federal matching funds for the purpose of
4addressing the facility's unique staffing needs, adjusted
5quarterly and distributed by a weighted formula based on
6Medicaid bed days on the last day of the second quarter
7preceding the quarter for which the rate is being adjusted.
8Beginning July 1, 2022, the annual $70,000,000 described in
9the preceding sentence shall be dedicated to the variable per
10diem add-on for staffing under paragraph (6) of subsection
11(d); and (ii) in an amount not to exceed $170,000,000 annually
12in the aggregate taking into account federal matching funds to
13permit the support component of the nursing facility rate to
14be updated as follows:
15        (1) 80%, or $136,000,000, of the funds shall be used
16    to update each facility's rate in effect on June 30, 2019
17    using the most recent cost reports on file, which have had
18    a limited review conducted by the Department of Healthcare
19    and Family Services and will not hold up enacting the rate
20    increase, with the Department of Healthcare and Family
21    Services.
22        (2) After completing the calculation in paragraph (1),
23    any facility whose rate is less than the rate in effect on
24    June 30, 2019 shall have its rate restored to the rate in
25    effect on June 30, 2019 from the 20% of the funds set
26    aside.

 

 

HB5847- 13 -LRB103 40684 KTG 73450 b

1        (3) The remainder of the 20%, or $34,000,000, shall be
2    used to increase each facility's rate by an equal
3    percentage.
4    (k) During the first quarter of State Fiscal Year 2020,
5the Department of Healthcare of Family Services must convene a
6technical advisory group consisting of members of all trade
7associations representing Illinois skilled nursing providers
8to discuss changes necessary with federal implementation of
9Medicare's Patient-Driven Payment Model. Implementation of
10Medicare's Patient-Driven Payment Model shall, by September 1,
112020, end the collection of the MDS data that is necessary to
12maintain the current RUG-IV Medicaid payment methodology. The
13technical advisory group must consider a revised reimbursement
14methodology that takes into account transparency,
15accountability, actual staffing as reported under the
16federally required Payroll Based Journal system, changes to
17the minimum wage, adequacy in coverage of the cost of care, and
18a quality component that rewards quality improvements.
19    (l) The Department shall establish per diem add-on
20payments to improve the quality of care delivered by
21facilities, including:
22        (1) Incentive payments determined by facility
23    performance on specified quality measures in an initial
24    amount of $70,000,000. Nothing in this subsection shall be
25    construed to limit the quality of care payments in the
26    aggregate statewide to $70,000,000, and, if quality of

 

 

HB5847- 14 -LRB103 40684 KTG 73450 b

1    care has improved across nursing facilities, the
2    Department shall adjust those add-on payments accordingly.
3    The quality payment methodology described in this
4    subsection must be used for at least State Fiscal Year
5    2023. Beginning with the quarter starting July 1, 2023,
6    the Department may add, remove, or change quality metrics
7    and make associated changes to the quality payment
8    methodology as outlined in subparagraph (E). Facilities
9    designated by the Centers for Medicare and Medicaid
10    Services as a special focus facility or a hospital-based
11    nursing home do not qualify for quality payments.
12            (A) Each quality pool must be distributed by
13        assigning a quality weighted score for each nursing
14        home which is calculated by multiplying the nursing
15        home's quality base period Medicaid days by the
16        nursing home's star rating weight in that period.
17            (B) Star rating weights are assigned based on the
18        nursing home's star rating for the LTS quality star
19        rating. As used in this subparagraph, "LTS quality
20        star rating" means the long-term stay quality rating
21        for each nursing facility, as assigned by the Centers
22        for Medicare and Medicaid Services under the Five-Star
23        Quality Rating System. The rating is a number ranging
24        from 0 (lowest) to 5 (highest).
25                (i) Zero-star or one-star rating has a weight
26            of 0.

 

 

HB5847- 15 -LRB103 40684 KTG 73450 b

1                (ii) Two-star rating has a weight of 0.75.
2                (iii) Three-star rating has a weight of 1.5.
3                (iv) Four-star rating has a weight of 2.5.
4                (v) Five-star rating has a weight of 3.5.
5            (C) Each nursing home's quality weight score is
6        divided by the sum of all quality weight scores for
7        qualifying nursing homes to determine the proportion
8        of the quality pool to be paid to the nursing home.
9            (D) The quality pool is no less than $70,000,000
10        annually or $17,500,000 per quarter. The Department
11        shall publish on its website the estimated payments
12        and the associated weights for each facility 45 days
13        prior to when the initial payments for the quarter are
14        to be paid. The Department shall assign each facility
15        the most recent and applicable quarter's STAR value
16        unless the facility notifies the Department within 15
17        days of an issue and the facility provides reasonable
18        evidence demonstrating its timely compliance with
19        federal data submission requirements for the quarter
20        of record. If such evidence cannot be provided to the
21        Department, the STAR rating assigned to the facility
22        shall be reduced by one from the prior quarter.
23            (E) The Department shall review quality metrics
24        used for payment of the quality pool and make
25        recommendations for any associated changes to the
26        methodology for distributing quality pool payments in

 

 

HB5847- 16 -LRB103 40684 KTG 73450 b

1        consultation with associations representing long-term
2        care providers, consumer advocates, organizations
3        representing workers of long-term care facilities, and
4        payors. The Department may establish, by rule, changes
5        to the methodology for distributing quality pool
6        payments.
7            (F) The Department shall disburse quality pool
8        payments from the Long-Term Care Provider Fund on a
9        monthly basis in amounts proportional to the total
10        quality pool payment determined for the quarter.
11            (G) The Department shall publish any changes in
12        the methodology for distributing quality pool payments
13        prior to the beginning of the measurement period or
14        quality base period for any metric added to the
15        distribution's methodology.
16        (2) Payments based on CNA tenure, promotion, and CNA
17    training for the purpose of increasing CNA compensation.
18    It is the intent of this subsection that payments made in
19    accordance with this paragraph be directly incorporated
20    into increased compensation for CNAs. As used in this
21    paragraph, "CNA" means a certified nursing assistant as
22    that term is described in Section 3-206 of the Nursing
23    Home Care Act, Section 3-206 of the ID/DD Community Care
24    Act, and Section 3-206 of the MC/DD Act. The Department
25    shall establish, by rule, payments to nursing facilities
26    equal to Medicaid's share of the tenure wage increments

 

 

HB5847- 17 -LRB103 40684 KTG 73450 b

1    specified in this paragraph for all reported CNA employee
2    hours compensated according to a posted schedule
3    consisting of increments at least as large as those
4    specified in this paragraph. The increments are as
5    follows: an additional $1.50 per hour for CNAs with at
6    least one and less than 2 years' experience plus another
7    $1 per hour for each additional year of experience up to a
8    maximum of $6.50 for CNAs with at least 6 years of
9    experience. For purposes of this paragraph, Medicaid's
10    share shall be the ratio determined by paid Medicaid bed
11    days divided by total bed days for the applicable time
12    period used in the calculation. In addition, and additive
13    to any tenure increments paid as specified in this
14    paragraph, the Department shall establish, by rule,
15    payments supporting Medicaid's share of the
16    promotion-based wage increments for CNA employee hours
17    compensated for that promotion with at least a $1.50
18    hourly increase. Medicaid's share shall be established as
19    it is for the tenure increments described in this
20    paragraph. Qualifying promotions shall be defined by the
21    Department in rules for an expected 10-15% subset of CNAs
22    assigned intermediate, specialized, or added roles such as
23    CNA trainers, CNA scheduling "captains", and CNA
24    specialists for resident conditions like dementia or
25    memory care or behavioral health.
26    (m) The Department shall work with nursing facility

 

 

HB5847- 18 -LRB103 40684 KTG 73450 b

1industry representatives to design policies and procedures to
2permit facilities to address the integrity of data from
3federal reporting sites used by the Department in setting
4facility rates.
5(Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
6102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
7Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
8Section 50-5, eff. 1-1-24; revised 12-15-23.)
 
9    Section 99. Effective date. This Act takes effect October
101, 2024.