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(305 ILCS 5/5-5.2)
(from Ch. 23, par. 5-5.2)
(a) All nursing facilities that are grouped pursuant to Section
5-5.1 of this Act shall receive the same rate of payment for similar
(b) It shall be a matter of State policy that the Illinois Department
shall utilize a uniform billing cycle throughout the State for the
long-term care providers.
(c) Notwithstanding any other provisions of this Code, the methodologies for reimbursement of nursing services as provided under this Article shall no longer be applicable for bills payable for nursing services rendered on or after a new reimbursement system based on the Resource Utilization Groups (RUGs) has been fully operationalized, which shall take effect for services provided on or after January 1, 2014.
(d) The new nursing services reimbursement methodology utilizing RUG-IV 48 grouper model, which shall be referred to as the RUGs reimbursement system, taking effect January 1, 2014, shall be based on the following:
(1) The methodology shall be resident-driven,
facility-specific, and cost-based.
(2) Costs shall be annually rebased and case mix
index quarterly updated. The nursing services methodology will be assigned to the 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) as present on the last day of the second quarter preceding the rate period based upon the Assessment Reference Date of the Minimum Data Set (MDS).
(3) Regional wage adjustors based on the Health
Service Areas (HSA) groupings and adjusters in effect on April 30, 2012 shall be included, except no adjuster shall be lower than 1.0.
(4) Case mix index shall be assigned to each
resident class based on the Centers for Medicare and Medicaid Services staff time measurement study in effect on July 1, 2013, utilizing an index maximization approach.
(5) The pool of funds available for distribution by
case mix and the base facility rate shall be determined using the formula contained in subsection (d-1).
(d-1) Calculation of base year Statewide RUG-IV nursing base per diem rate.
(1) Base rate spending pool shall be:
(A) The base year resident days which are
calculated by multiplying the number of Medicaid residents in each nursing home as indicated in the MDS data defined in paragraph (4) by 365.
(B) Each facility's nursing component per diem
in effect on July 1, 2012 shall be multiplied by subsection (A).
(C) Thirteen million is added to the product of
subparagraph (A) and subparagraph (B) to adjust for the exclusion of nursing homes defined in paragraph (5).
(2) For each nursing home with Medicaid residents as
indicated by the MDS data defined in paragraph (4), weighted days adjusted for case mix and regional wage adjustment shall be calculated. For each home this calculation is the product of:
(A) Base year resident days as calculated in
subparagraph (A) of paragraph (1).
(B) The nursing home's regional wage adjustor
based on the Health Service Areas (HSA) groupings and adjustors in effect on April 30, 2012.
(C) Facility weighted case mix which is the
number of Medicaid residents as indicated by the MDS data defined in paragraph (4) multiplied by the associated case weight for the RUG-IV 48 grouper model using standard RUG-IV procedures for index maximization.
(D) The sum of the products calculated for each
nursing home in subparagraphs (A) through (C) above shall be the base year case mix, rate adjusted weighted days.
(3) The Statewide RUG-IV nursing base per diem rate:
(A) on January 1, 2014 shall be the quotient of
the paragraph (1) divided by the sum calculated under subparagraph (D) of paragraph (2); and
(B) on and after July 1, 2014, shall be the
amount calculated under subparagraph (A) of this paragraph (3) plus $1.76.
(4) Minimum Data Set (MDS) comprehensive assessments
for Medicaid residents on the last day of the quarter used to establish the base rate.
(5) Nursing facilities designated as of July 1, 2012
by the Department as "Institutions for Mental Disease" shall be excluded from all calculations under this subsection. The data from these facilities shall not be used in the computations described in paragraphs (1) through (4) above to establish the base rate.
(e) Beginning July 1, 2014, the Department shall allocate funding in the amount up to $10,000,000 for per diem add-ons to the RUGS methodology for dates of service on and after July 1, 2014:
(1) $0.63 for each resident who scores in I4200
Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
(2) $2.67 for each resident who scores either a "1"
or "2" in any items S1200A through S1200I and also scores in RUG groups PA1, PA2, BA1, or BA2.
(e-2) For dates of services beginning January 1, 2014, the RUG-IV nursing component per diem for a nursing home shall be the product of the statewide RUG-IV nursing base per diem rate, the facility average case mix index, and the regional wage adjustor. Transition rates for services provided between January 1, 2014 and December 31, 2014 shall be as follows:
(1) The transition RUG-IV per diem nursing rate for
nursing homes whose rate calculated in this subsection (e-2) is greater than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
(A) The nursing component rate in effect July
(B) 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.
(2) The transition RUG-IV per diem nursing rate for
nursing homes whose rate calculated in this subsection (e-2) is less than the nursing component rate in effect July 1, 2012 shall be paid the sum of:
(A) The nursing component rate in effect July
(B) 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.
(f) Notwithstanding any other provision of this Code, on and after July 1, 2012, reimbursement rates associated with the nursing or support components of the current nursing facility rate methodology shall not increase beyond the level effective May 1, 2011 until a new reimbursement system based on the RUGs IV 48 grouper model has been fully operationalized.
(g) Notwithstanding any other provision of this Code, on and after July 1, 2012, for facilities not designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease", rates effective May 1, 2011 shall be adjusted as follows:
(1) Individual nursing rates for residents classified
in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter ending March 31, 2012 shall be reduced by 10%;
(2) Individual nursing rates for residents classified
in all other RUG IV groups shall be reduced by 1.0%;
(3) Facility rates for the capital and support
components shall be reduced by 1.7%.
(h) Notwithstanding any other provision of this Code, on and after July 1, 2012, nursing facilities designated by the Department of Healthcare and Family Services as "Institutions for Mental Disease" and "Institutions for Mental Disease" that are facilities licensed under the Specialized Mental Health Rehabilitation Act of 2013 shall have the nursing, socio-developmental, capital, and support components of their reimbursement rate effective May 1, 2011 reduced in total by 2.7%.
(i) On and after July 1, 2014, the reimbursement rates for the support component of the nursing facility rate for facilities licensed under the Nursing Home Care Act as skilled or intermediate care facilities shall be the rate in effect on June 30, 2014 increased by 8.17%.
(j) Notwithstanding any other provision of law, subject to federal approval, effective July 1, 2019, sufficient funds shall be allocated for changes to rates for facilities licensed under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities for dates of services on and after July 1, 2019: (i) to establish a per diem add-on to the direct care per diem rate not to exceed $70,000,000 annually in the aggregate taking into account federal matching funds for the purpose of addressing the facility's unique staffing needs, adjusted quarterly and distributed by a weighted formula based on Medicaid bed days on the last day of the second quarter preceding the quarter for which the rate is being adjusted; and (ii) in an amount not to exceed $170,000,000 annually in the aggregate taking into account federal matching funds to permit the support component of the nursing facility rate to be updated as follows:
(1) 80%, or $136,000,000, of the funds shall be used
to update each facility's rate in effect on June 30, 2019 using the most recent cost reports on file, which have had a limited review conducted by the Department of Healthcare and Family Services and will not hold up enacting the rate increase, with the Department of Healthcare and Family Services and taking into account subsection (i).
(2) After completing the calculation in paragraph
(1), any facility whose rate is less than the rate in effect on June 30, 2019 shall have its rate restored to the rate in effect on June 30, 2019 from the 20% of the funds set aside.
(3) The remainder of the 20%, or $34,000,000, shall
be used to increase each facility's rate by an equal percentage.
To implement item (i) in this subsection, facilities shall file quarterly reports documenting compliance with its annually approved staffing plan, which shall permit compliance with Section 3-202.05 of the Nursing Home Care Act. A facility that fails to meet the benchmarks and dates contained in the plan may have its add-on adjusted in the quarter following the quarterly review. Nothing in this Section shall limit the ability of the facility to appeal a ruling of non-compliance and a subsequent reduction to the add-on. Funds adjusted for noncompliance shall be maintained in the Long-Term Care Provider Fund and accounted for separately. At the end of each fiscal year, these funds shall be made available to facilities for special staffing projects.
In order to provide for the expeditious and timely
implementation of the provisions of Public Act 101-10, emergency rules to implement any provision of Public Act 101-10 may be adopted in accordance with this subsection by the agency charged with administering that provision or
initiative. The agency shall simultaneously file emergency rules and permanent rules to ensure that there is no interruption in administrative guidance. The 150-day limitation of the effective period of emergency rules does not apply to rules adopted under this
subsection, and the effective period may continue through
June 30, 2021. The 24-month limitation on the adoption of
emergency rules does not apply to rules adopted under this
subsection. The adoption of emergency rules authorized by this subsection is deemed to be necessary for the public interest, safety, and welfare.
(k) During the first quarter of State Fiscal Year 2020, the Department of Healthcare of Family Services must convene a technical advisory group consisting of members of all trade associations representing Illinois skilled nursing providers to discuss changes necessary with federal implementation of Medicare's Patient-Driven Payment Model. Implementation of Medicare's Patient-Driven Payment Model shall, by September 1, 2020, end the collection of the MDS data that is necessary to maintain the current RUG-IV Medicaid payment methodology. The technical advisory group must consider a revised reimbursement methodology that takes into account transparency, accountability, actual staffing as reported under the federally required Payroll Based Journal system, changes to the minimum wage, adequacy in coverage of the cost of care, and a quality component that rewards quality improvements.
(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19; 102-77, eff. 7-9-21; 102-558, eff. 8-20-21.)