TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 147 REIMBURSEMENT FOR NURSING COSTS FOR GERIATRIC FACILITIES
SECTION 147.310 IMPLEMENTATION OF A CASE MIX SYSTEM
Section 147.310 Implementation of a Case Mix System
a) P.A. 98-0104 requires the Department to implement, effective January 1, 2014, an evidence-based payment methodology for the reimbursement of nursing services. The methodology shall take into consideration the needs of individual residents, as assessed and reported by the most current version of the nursing facility Minimum Data Set (MDS), adopted and in use by the federal government.
b) This Section establishes the method and criteria used to determine the resident reimbursement classification based upon the assessments of residents in nursing facilities. Resident reimbursement classification shall be established utilizing the 48-group, Resource Utilization Groups IV (RUG-IV) classification scheme and weights as published by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (federal CMS). An Illinois specific default group is established in subsection (f)(3) and identified as AA1 with an assigned weight equal to the weight assigned to group PA1.
c) The pool of funds available for distribution by case mix shall be determined using the formula contained below. Base rate spending pool shall be:
1) The base year resident days, which are calculated by multiplying the number of Medicaid residents in each nursing facility based on MDS comprehensive assessments for Medicaid residents on March 31, 2012, multiplied by 365 days.
2) Each facility's nursing component per diem in effect on July 1, 2012 shall be multiplied by the number determined in subsection (c)(1).
3) Thirteen million is added to the result of subsection (c)(2), to adjust for the exclusion of nursing facilities defined as Class I IMDs.
d) For each nursing facility with Medicaid residents as indicated by the MDS data defined in subsection (c)(1), weighted days adjusted for case mix and regional wage adjustment shall be calculated. For each nursing facility this calculation is the product of:
1) Base year resident days as calculated in subsection (c)(1).
2) The nursing facility's regional wage adjustor based on the Health Service Areas (HSA) groupings and adjustors in effect on April 30, 2012.
3) Facility weighted case mix, which is the number of Medicaid residents as indicated by the MDS data defined in subsection (c)(1) multiplied by the associated case weight for the RUG-IV 48-group model using standard RUG-IV procedures for index maximization.
4) The sum of the products calculated for each nursing facility in subsections (d)(1) through (d)(3) shall be the base year case mix, rate adjusted weighted days.
e) The statewide RUG-IV nursing base per diem rate effective on:
1) January 1, 2014 shall be the quotient of subsection (c) divided by the sum calculated under subsection (d)(4) and is $83.49.
2) July 1, 2014 shall be the rate calculated in subsection (e)(1) increased by $1.76.
f) Nursing Component Per Diem:
1) For services provided on or after January 1, 2014, the Department shall compute and pay a facility-specific nursing component of the per diem rate as the arithmetic mean of the resident-specific nursing components, as determined in subsection (d), assigned to 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), or any successor system, as present in the facility on the last day of the second quarter preceding the rate period. The RUG-IV nursing component per diem for a nursing facility shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index to be calculated quarterly, and the regional wage adjustor. Transition rates for services provided between January 1, 2014 and December 31, 2014 shall be as follows:
A) The transition RUG-IV per diem nursing rate for nursing facilities whose rate calculated in this subsection (f) is greater than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
i) The nursing component rate in effect July 1, 2012; plus
ii) 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.
B) The transition RUG-IV per diem nursing rate for nursing facilities whose rate calculated in this subsection (f) is less than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
i) The nursing component rate in effect July 1, 2012; plus
ii) 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.
C) Effective January 1, 2020, the regional wage adjustor referenced in this subsection (f)(1) cannot be lower than 0.95.
D) Effective July 1, 2020, the regional wage adjustor referenced in this subsection (f)(1) cannot be lower than 1.0.
2) Effective for dates of service on or after July 1, 2014, a per diem add-on to the RUGS methodology will be included as follows:
A) $0.63 for each resident who scores I4200 Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
B) $2.67 for each resident who scores "1" or "2" in any items S1200A through S1200I and also scores in the RUG groups PA1, PA2, BA1 and BA2.
3) The Department shall determine the group to which a resident is assigned using the 48-group RUG-IV classification scheme with an index maximization approach. A resident for whom RUGs resident identification information is missing, or inaccurate, or for whom there is no current MDS record for that quarter, shall be assigned to default group AA1. A resident for whom an MDS assessment does not meet the federal CMS edit requirements as described in the Long Term Care Resident Assessment Instrument (RAI) Users Manual or for whom an MDS assessment has not been submitted within 14 calendar days after the time requirements in Section 147.315 shall be assigned to default group AA1.
4) The assessment used for the purpose of rate calculation shall be identified as an Omnibus Budget Reconciliation Act (OBRA) assessment on the MDS following the guidance in the RAI Manual.
5) The MDS used for the purpose of rate calculation shall be determined by the Assessment Reference Date (ARD) identified on the MDS assessment.
g) The Department shall provide each nursing facility with information that identifies the group to which each resident has been assigned.
(Source: Amended at 45 Ill. Reg. 8326, effective June 28, 2021)