103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB1846

 

Introduced 2/9/2023, by Sen. Elgie R. Sims, Jr.

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5.4h

    Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning the tiered exceptional care per diem rates for medically complex for the developmentally disabled facilities, provides that on and after January 1, 2024, each tier rate shall be increased 6% over the amount in effect December 31, 2023. Provides that any reimbursement increases applied to the base rate to providers licensed under the ID/DD Community Care Act must also be applied in an equivalent manner to each tier of exceptional care per diem rates for medically complex for the developmentally disabled facilities. Effective immediately.


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A BILL FOR

 

SB1846LRB103 28495 KTG 54876 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 5-5.4h as follows:
 
6    (305 ILCS 5/5-5.4h)
7    Sec. 5-5.4h. Medicaid reimbursement for medically complex
8for the developmentally disabled facilities licensed under the
9MC/DD Act.
10    (a) Facilities licensed as medically complex for the
11developmentally disabled facilities that serve severely and
12chronically ill patients shall have a specific reimbursement
13system designed to recognize the characteristics and needs of
14the patients they serve.
15    (b) For dates of services starting July 1, 2013 and until a
16new reimbursement system is designed, medically complex for
17the developmentally disabled facilities that meet the
18following criteria:
19        (1) serve exceptional care patients; and
20        (2) have 30% or more of their patients receiving
21    ventilator care;
22shall receive Medicaid reimbursement on a 30-day expedited
23schedule.

 

 

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1    (c) Subject to federal approval of changes to the Title
2XIX State Plan, for dates of services starting July 1, 2014
3through March 31, 2019, medically complex for the
4developmentally disabled facilities which meet the criteria in
5subsection (b) of this Section shall receive a per diem rate
6for clinically complex residents of $304. Clinically complex
7residents on a ventilator shall receive a per diem rate of
8$669. Subject to federal approval of changes to the Title XIX
9State Plan, for dates of services starting April 1, 2019,
10medically complex for the developmentally disabled facilities
11must be reimbursed an exceptional care per diem rate, instead
12of the base rate, for services to residents with complex or
13extensive medical needs. Exceptional care per diem rates must
14be paid for the conditions or services specified under
15subsection (f) at the following per diem rates: Tier 1 $326,
16Tier 2 $546, and Tier 3 $735. On and after January 1, 2024,
17each tier rate shall be increased 6% over the amount in effect
18December 31, 2023. Any reimbursement increases applied to the
19base rate to providers licensed under the ID/DD Community Care
20Act must also be applied in an equivalent manner to each tier
21of exceptional care per diem rates for medically complex for
22the developmentally disabled facilities.
23    (d) For residents on a ventilator pursuant to subsection
24(c) or subsection (f), facilities shall have a policy
25documenting their method of routine assessment of a resident's
26weaning potential with interventions implemented noted in the

 

 

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1resident's medical record.
2    (e) For services provided prior to April 1, 2019 and for
3the purposes of this Section, a resident is considered
4clinically complex if the resident requires at least one of
5the following medical services:
6        (1) Tracheostomy care with dependence on mechanical
7    ventilation for a minimum of 6 hours each day.
8        (2) Tracheostomy care requiring suctioning at least
9    every 6 hours, room air mist or oxygen as needed, and
10    dependence on one of the treatment procedures listed under
11    paragraph (4) excluding the procedure listed in
12    subparagraph (A) of paragraph (4).
13        (3) Total parenteral nutrition or other intravenous
14    nutritional support and one of the treatment procedures
15    listed under paragraph (4).
16        (4) The following treatment procedures apply to the
17    conditions in paragraphs (2) and (3) of this subsection:
18            (A) Intermittent suctioning at least every 8 hours
19        and room air mist or oxygen as needed.
20            (B) Continuous intravenous therapy including
21        administration of therapeutic agents necessary for
22        hydration or of intravenous pharmaceuticals; or
23        intravenous pharmaceutical administration of more than
24        one agent via a peripheral or central line, without
25        continuous infusion.
26            (C) Peritoneal dialysis treatments requiring at

 

 

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1        least 4 exchanges every 24 hours.
2            (D) Tube feeding via nasogastric or gastrostomy
3        tube.
4            (E) Other medical technologies required
5        continuously, which in the opinion of the attending
6        physician require the services of a professional
7        nurse.
8    (f) Complex or extensive medical needs for exceptional
9care reimbursement. The conditions and services used for the
10purposes of this Section have the same meanings as ascribed to
11those conditions and services under the Minimum Data Set (MDS)
12Resident Assessment Instrument (RAI) and specified in the most
13recent manual. Instead of submitting minimum data set
14assessments to the Department, medically complex for the
15developmentally disabled facilities must document within each
16resident's medical record the conditions or services using the
17minimum data set documentation standards and requirements to
18qualify for exceptional care reimbursement.
19        (1) Tier 1 reimbursement is for residents who are
20    receiving at least 51% of their caloric intake via a
21    feeding tube.
22        (2) Tier 2 reimbursement is for residents who are
23    receiving tracheostomy care without a ventilator.
24        (3) Tier 3 reimbursement is for residents who are
25    receiving tracheostomy care and ventilator care.
26    (g) For dates of services starting April 1, 2019,

 

 

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1reimbursement calculations and direct payment for services
2provided by medically complex for the developmentally disabled
3facilities are the responsibility of the Department of
4Healthcare and Family Services instead of the Department of
5Human Services. Appropriations for medically complex for the
6developmentally disabled facilities must be shifted from the
7Department of Human Services to the Department of Healthcare
8and Family Services. Nothing in this Section prohibits the
9Department of Healthcare and Family Services from paying more
10than the rates specified in this Section. The rates in this
11Section must be interpreted as a minimum amount. Any
12reimbursement increases applied to providers licensed under
13the ID/DD Community Care Act must also be applied in an
14equivalent manner to medically complex for the developmentally
15disabled facilities.
16    (h) The Department of Healthcare and Family Services shall
17pay the rates in effect on March 31, 2019 until the changes
18made to this Section by this amendatory Act of the 100th
19General Assembly have been approved by the Centers for
20Medicare and Medicaid Services of the U.S. Department of
21Health and Human Services.
22    (i) The Department of Healthcare and Family Services may
23adopt rules as allowed by the Illinois Administrative
24Procedure Act to implement this Section; however, the
25requirements of this Section must be implemented by the
26Department of Healthcare and Family Services even if the

 

 

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1Department of Healthcare and Family Services has not adopted
2rules by the implementation date of April 1, 2019.
3(Source: P.A. 100-646, eff. 7-27-18.)
 
4    Section 99. Effective date. This Act takes effect upon
5becoming law.