Sen. Donne E. Trotter
Filed: 3/31/2014
 
 


 




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1
AMENDMENT TO SENATE BILL 741




2 AMENDMENT NO. ______. Amend Senate Bill 741 by replacing 
3everything after the enacting clause with the following:


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) (from Ch. 23, par. 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 the 
13State for the
long-term care providers.

14 (c) Notwithstanding any other provisions of this Code, the 
15methodologies for reimbursement of nursing services as 
16provided under this Article shall no longer be applicable for 
 
 
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1bills payable for nursing services rendered on or after a new 
2reimbursement system based on the Resource Utilization Groups 
3(RUGs) has been fully operationalized, which shall take effect 
4for services provided on or after January 1, 2014. 
5 (d) The new nursing services reimbursement methodology 
6utilizing RUG-IV 48 grouper model, which shall be referred to 
7as the RUGs reimbursement system, taking effect January 1, 
82014, shall be based on the following: 
9  (1) The methodology shall be resident-driven, 
10 facility-specific, and cost-based. 
11  (2) Costs shall be annually rebased and case mix index 
12 quarterly updated. The nursing services methodology will 
13 be assigned to the Medicaid enrolled residents on record as 
14 of 30 days prior to the beginning of the rate period in the 
15 Department's Medicaid Management Information System (MMIS) 
16 as present on the last day of the second quarter preceding 
17 the rate period. 
18  (3) Regional wage adjustors based on the Health Service 
19 Areas (HSA) groupings and adjusters in effect on April 30, 
20 2012 shall be included. 
21  (4) Case mix index shall be assigned to each resident 
22 class based on the Centers for Medicare and Medicaid 
23 Services staff time measurement study in effect on July 1, 
24 2013, utilizing an index maximization approach.
25  (5) The pool of funds available for distribution by 
26 case mix and the base facility rate shall be determined 
 
 
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1 using the formula contained in subsection (d-1). 
2 (d-1) Calculation of base year Statewide RUG-IV nursing 
3base per diem rate. 
4  (1) Base rate spending pool shall be: 
5   (A) The base year resident days which are 
6 calculated by multiplying the number of Medicaid 
7 residents in each nursing home as indicated in the MDS 
8 data defined in paragraph (4) by 365.
9   (B) Each facility's nursing component per diem in 
10 effect on July 1, 2012 shall be multiplied by 
11 subsection (A).
12   (C) Thirteen million is added to the product of 
13 subparagraph (A) and subparagraph (B) to adjust for the 
14 exclusion of nursing homes defined in paragraph (5). 
15  (2) For each nursing home with Medicaid residents as 
16 indicated by the MDS data defined in paragraph (4), 
17 weighted days adjusted for case mix and regional wage 
18 adjustment shall be calculated. For each home this 
19 calculation is the product of:
20   (A) Base year resident days as calculated in 
21 subparagraph (A) of paragraph (1).
22   (B) The nursing home's regional wage adjustor 
23 based on the Health Service Areas (HSA) groupings and 
24 adjustors in effect on April 30, 2012.
25   (C) Facility weighted case mix which is the number 
26 of Medicaid residents as indicated by the MDS data 
 
 
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1 defined in paragraph (4) multiplied by the associated 
2 case weight for the RUG-IV 48 grouper model using 
3 standard RUG-IV procedures for index maximization.
4   (D) The sum of the products calculated for each 
5 nursing home in subparagraphs (A) through (C) above 
6 shall be the base year case mix, rate adjusted weighted 
7 days.
8  (3) The Statewide RUG-IV nursing base per diem rate on 
9 January 1, 2014 shall be the quotient of the paragraph (1) 
10 divided by the sum calculated under subparagraph (D) of 
11 paragraph (2).
12  (3-1) Beginning January 1, 2015 and every quarter 
13 thereafter, the base per diem rate set by the calculations 
14 contained in this Section, which is $83.49, shall be 
15 adjusted by the addition of the quotient of $32,000,000 set 
16 aside for this purpose and any additional moneys as 
17 provided in paragraph (4) of subsection (e) and subsection 
18 (e-3) divided by the sum calculated under subparagraph (D) 
19 of paragraph (2). 
20  (4) Minimum Data Set (MDS) comprehensive assessments 
21 for Medicaid residents on March 31, 2012 the last day of 
22 the quarter used to establish the base rate.
23  (5) Nursing facilities designated as of July 1, 2012 by 
24 the Department as "Institutions for Mental Disease" shall 
25 be excluded from all calculations under this subsection. 
26 The data from these facilities shall not be used in the 
 
 
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1 computations described in paragraphs (1) through (4) above 
2 to establish the base rate. 
3 (e) Notwithstanding any other provision of this Code, the 
4Department shall by rule develop a reimbursement methodology 
5reflective of the intensity of care and services requirements 
6of low need residents in the lowest RUG IV groupers and 
7corresponding regulations. Only that portion of the RUGs 
8Reimbursement System spending pool described in subsection 
9(d-1) attributed to the groupers as of July 1, 2013 for which 
10the methodology in this Section is developed may be diverted 
11for this purpose. The Department shall submit the rules no 
12later than January 1, 2014 for an implementation date no later 
13than January 1, 2015 which shall establish at a minimum the 
14following add-on adjustments to the facility's RUG-IV rate: .
15  (1) at a minimum a $208 per day add-on for each 
16 resident qualifying for ventilator care adjustment as 
17 outlined in the administrative rules of the Department of 
18 Healthcare and Family Services; 
19  (2) at a minimum a $5 per day add-on for each resident 
20 residing in a dedicated Alzheimer's unit with an 
21 Alzheimer's or a non-Alzheimer's dementia diagnosis as 
22 scored on the MDS 3.0; 
23  (3) at a minimum a $2.50 per day add-on for each 
24 resident falling in the bottom 4 RUG-IV groupers with an 
25 Alzheimer's or a non-Alzheimer's dementia diagnosis not 
26 residing in a dedicated Alzheimer's unit as scored on the 
 
 
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1 MDS 3.0; and 
2  (4) at a minimum a $3.00 per day add-on for each 
3 resident with a diagnosis of a serious mental illness. If 
4 for any quarter the amount needed for the serious mental 
5 illness add-on is less than $2,000,000, the difference 
6 shall be added to the base rate adjustment as provided in 
7 paragraph (3-1) of subsection (d-1). 
8 For the purpose of the add-on calculations, a dedicated 
9Alzheimer's unit must meet the criteria set forth in Subpart U 
10of Title 77, Part 300 of the Illinois Administrative Code. 
11"Serious mental illness" means a primary or secondary SMI 
12diagnosis in one of MDS 3.0 items S1200 A through I. 
13"Alzheimer's" and "non-Alzheimer's dementia" means a diagnosis 
14in MDS 3.0 item I4200 or I4800.  
15 If the Department does not implement this reimbursement 
16methodology by the required date, the nursing component per 
17diem on January 1, 2015 for residents classified in RUG-IV 
18groups PA1, PA2, BA1, and BA2 shall be the blended rate of the 
19calculated RUG-IV nursing component per diem and the nursing 
20component per diem in effect on July 1, 2012. This blended rate 
21shall be applied only to nursing homes whose resident 
22population is greater than or equal to 70% of the total 
23residents served and whose RUG-IV nursing component per diem 
24rate is less than the nursing component per diem in effect on 
25July 1, 2012. This blended rate shall be in effect until the 
26reimbursement methodology is implemented or until July 1, 2019, 
 
 
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1whichever is sooner. 
2 (e-1) Notwithstanding any other provision of this Article, 
3rates established pursuant to this subsection shall not apply 
4to any and all nursing facilities designated by the Department 
5as "Institutions for Mental Disease" and shall be excluded from 
6the RUGs Reimbursement System applicable to facilities not 
7designated as "Institutions for the Mentally Diseased" by the 
8Department.
9 (e-2) For dates of services beginning January 1, 2014, the 
10RUG-IV nursing component per diem for a nursing home shall be 
11the product of the statewide RUG-IV nursing base per diem rate, 
12the facility average case mix index, and the regional wage 
13adjustor. Transition rates for services provided between 
14January 1, 2014 and December 31, 2014 shall be as follows:
15  (1) The transition RUG-IV per diem nursing rate for 
16 nursing homes whose rate calculated in this subsection 
17 (e-2) is greater than the nursing component rate in effect 
18 July 1, 2012 shall be paid the sum of:
19   (A) The nursing component rate in effect July 1, 
20 2012; plus
21   (B) The difference of the RUG-IV nursing component 
22 per diem calculated for the current quarter minus the 
23 nursing component rate in effect July 1, 2012 
24 multiplied by 0.88.
25  (2) The transition RUG-IV per diem nursing rate for 
26 nursing homes whose rate calculated in this subsection 
 
 
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1 (e-2) is less than the nursing component rate in effect 
2 July 1, 2012 shall be paid the sum of:
3   (A) The nursing component rate in effect July 1, 
4 2012; plus
5   (B) The difference of the RUG-IV nursing component 
6 per diem calculated for the current quarter minus the 
7 nursing component rate in effect July 1, 2012 
8 multiplied by 0.13. 
9 (e-3) Notwithstanding any other provision of this Code, an 
10amount equal to $16,000,000 shall be set aside for the 
11establishment of a quality incentive initiative effective 
12January 1, 2015. In any quarter in which quality incentive 
13awards do not equal $4,000,000, the difference shall be added 
14to the base rate adjustment as provided in paragraph (3-1) of 
15subsection (d-1). 
16 (f) Notwithstanding any other provision of this Code, on 
17and after July 1, 2012, reimbursement rates associated with the 
18nursing or support components of the current nursing facility 
19rate methodology shall not increase beyond the level effective 
20May 1, 2011 until a new reimbursement system based on the RUGs 
21IV 48 grouper model has been fully operationalized.
22 (g) Notwithstanding any other provision of this Code, on 
23and after July 1, 2012, for facilities not designated by the 
24Department of Healthcare and Family Services as "Institutions 
25for Mental Disease", rates effective May 1, 2011 shall be 
26adjusted as follows:
 
 
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1  (1) Individual nursing rates for residents classified 
2 in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter 
3 ending March 31, 2012 shall be reduced by 10%;
4  (2) Individual nursing rates for residents classified 
5 in all other RUG IV groups shall be reduced by 1.0%;
6  (3) Facility rates for the capital and support 
7 components shall be reduced by 1.7%.
8 (h) Notwithstanding any other provision of this Code, on 
9and after July 1, 2012, nursing facilities designated by the 
10Department of Healthcare and Family Services as "Institutions 
11for Mental Disease" and "Institutions for Mental Disease" that 
12are facilities licensed under the Specialized Mental Health 
13Rehabilitation Act of 2013 shall have the nursing, 
14socio-developmental, capital, and support components of their 
15reimbursement rate effective May 1, 2011 reduced in total by 
162.7%.
17(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section 
186-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. 
197-22-13; revised 9-19-13.)



20 Section 99. Effective date. This Act takes effect upon 
21becoming law.".