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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) (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 
17bills payable for nursing services rendered on or after a new 
18reimbursement system based on the Resource Utilization Groups 
19(RUGs) has been fully operationalized, which shall take effect 
20for services provided on or after January 1, 2014. 
21 (d) The new nursing services reimbursement methodology 
22utilizing RUG-IV 48 grouper model, which shall be referred to 
23as the RUGs reimbursement system, taking effect January 1, 
 
 
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12014, shall be based on the following: 
2  (1) The methodology shall be resident-driven, 
3 facility-specific, and cost-based. 
4  (2) Costs shall be annually rebased and case mix index 
5 quarterly updated. The nursing services methodology will 
6 be assigned to the Medicaid enrolled residents on record as 
7 of 30 days prior to the beginning of the rate period in the 
8 Department's Medicaid Management Information System (MMIS) 
9 as present on the last day of the second quarter preceding 
10 the rate period. 
11  (3) Regional wage adjustors based on the Health Service 
12 Areas (HSA) groupings and adjusters in effect on April 30, 
13 2012 shall be included. 
14  (4) Case mix index shall be assigned to each resident 
15 class based on the Centers for Medicare and Medicaid 
16 Services staff time measurement study in effect on July 1, 
17 2013, utilizing an index maximization approach.
18  (5) The pool of funds available for distribution by 
19 case mix and the base facility rate shall be determined 
20 using the formula contained in subsection (d-1). 
21 (d-1) Calculation of base year Statewide RUG-IV nursing 
22base per diem rate. 
23  (1) Base rate spending pool shall be: 
24   (A) The base year resident days which are 
25 calculated by multiplying the number of Medicaid 
26 residents in each nursing home as indicated in the MDS 
 
 
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1 data defined in paragraph (4) by 365.
2   (B) Each facility's nursing component per diem in 
3 effect on July 1, 2012 shall be multiplied by 
4 subsection (A).
5   (C) Thirteen million is added to the product of 
6 subparagraph (A) and subparagraph (B) to adjust for the 
7 exclusion of nursing homes defined in paragraph (5). 
8  (2) For each nursing home with Medicaid residents as 
9 indicated by the MDS data defined in paragraph (4), 
10 weighted days adjusted for case mix and regional wage 
11 adjustment shall be calculated. For each home this 
12 calculation is the product of:
13   (A) Base year resident days as calculated in 
14 subparagraph (A) of paragraph (1).
15   (B) The nursing home's regional wage adjustor 
16 based on the Health Service Areas (HSA) groupings and 
17 adjustors in effect on April 30, 2012.
18   (C) Facility weighted case mix which is the number 
19 of Medicaid residents as indicated by the MDS data 
20 defined in paragraph (4) multiplied by the associated 
21 case weight for the RUG-IV 48 grouper model using 
22 standard RUG-IV procedures for index maximization.
23   (D) The sum of the products calculated for each 
24 nursing home in subparagraphs (A) through (C) above 
25 shall be the base year case mix, rate adjusted weighted 
26 days.
 
 
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1  (3) The Statewide RUG-IV nursing base per diem rate on 
2 January 1, 2014 shall be the quotient of the paragraph (1) 
3 divided by the sum calculated under subparagraph (D) of 
4 paragraph (2).
5  (3-1) Beginning January 1, 2015 and every quarter 
6 thereafter, the base per diem rate set by the calculations 
7 contained in this Section, which is $83.49, shall be 
8 adjusted by the addition of the quotient of $32,000,000 set 
9 aside for this purpose and any additional moneys as 
10 provided in paragraph (4) of subsection (e) and subsection 
11 (e-3) divided by the sum calculated under subparagraph (D) 
12 of paragraph (2). 
13  (4) Minimum Data Set (MDS) comprehensive assessments 
14 for Medicaid residents on March 31, 2012 the last day of 
15 the quarter used to establish the base rate.
16  (5) Nursing facilities designated as of July 1, 2012 by 
17 the Department as "Institutions for Mental Disease" shall 
18 be excluded from all calculations under this subsection. 
19 The data from these facilities shall not be used in the 
20 computations described in paragraphs (1) through (4) above 
21 to establish the base rate. 
22 (e) Notwithstanding any other provision of this Code, the 
23Department shall by rule develop a reimbursement methodology 
24reflective of the intensity of care and services requirements 
25of low need residents in the lowest RUG IV groupers and 
26corresponding regulations. Only that portion of the RUGs 
 
 
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1Reimbursement System spending pool described in subsection 
2(d-1) attributed to the groupers as of July 1, 2013 for which 
3the methodology in this Section is developed may be diverted 
4for this purpose. The Department shall submit the rules no 
5later than January 1, 2014 for an implementation date no later 
6than January 1, 2015 which shall establish at a minimum the 
7following add-on adjustments to the facility's RUG-IV rate: .
8  (1) at a minimum a $208 per day add-on for each 
9 resident qualifying for ventilator care adjustment as 
10 outlined in the administrative rules of the Department of 
11 Healthcare and Family Services; 
12  (2) at a minimum a $5 per day add-on for each resident 
13 residing in a dedicated Alzheimer's unit with an 
14 Alzheimer's or a non-Alzheimer's dementia diagnosis as 
15 scored on the MDS 3.0; 
16  (3) at a minimum a $2.50 per day add-on for each 
17 resident falling in the bottom 4 RUG-IV groupers with an 
18 Alzheimer's or a non-Alzheimer's dementia diagnosis not 
19 residing in a dedicated Alzheimer's unit as scored on the 
20 MDS 3.0; and 
21  (4) at a minimum a $3.00 per day add-on for each 
22 resident with a diagnosis of a serious mental illness. If 
23 for any quarter the amount needed for the serious mental 
24 illness add-on is less than $2,000,000, the difference 
25 shall be added to the base rate adjustment as provided in 
26 paragraph (3-1) of subsection (d-1). 
 
 
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1 For the purpose of the add-on calculations, a dedicated 
2Alzheimer's unit must meet the criteria set forth in Subpart U 
3of Title 77, Part 300 of the Illinois Administrative Code. 
4"Serious mental illness" means a primary or secondary SMI 
5diagnosis in one of MDS 3.0 items S1200 A through I. 
6"Alzheimer's" and "non-Alzheimer's dementia" means a diagnosis 
7in MDS 3.0 item I4200 or I4800.  
8 If the Department does not implement this reimbursement 
9methodology by the required date, the nursing component per 
10diem on January 1, 2015 for residents classified in RUG-IV 
11groups PA1, PA2, BA1, and BA2 shall be the blended rate of the 
12calculated RUG-IV nursing component per diem and the nursing 
13component per diem in effect on July 1, 2012. This blended rate 
14shall be applied only to nursing homes whose resident 
15population is greater than or equal to 70% of the total 
16residents served and whose RUG-IV nursing component per diem 
17rate is less than the nursing component per diem in effect on 
18July 1, 2012. This blended rate shall be in effect until the 
19reimbursement methodology is implemented or until July 1, 2019, 
20whichever is sooner. 
21 (e-1) Notwithstanding any other provision of this Article, 
22rates established pursuant to this subsection shall not apply 
23to any and all nursing facilities designated by the Department 
24as "Institutions for Mental Disease" and shall be excluded from 
25the RUGs Reimbursement System applicable to facilities not 
26designated as "Institutions for the Mentally Diseased" by the 
 
 
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1Department.
2 (e-2) For dates of services beginning January 1, 2014, the 
3RUG-IV nursing component per diem for a nursing home shall be 
4the product of the statewide RUG-IV nursing base per diem rate, 
5the facility average case mix index, and the regional wage 
6adjustor. Transition rates for services provided between 
7January 1, 2014 and December 31, 2014 shall be as follows:
8  (1) The transition RUG-IV per diem nursing rate for 
9 nursing homes whose rate calculated in this subsection 
10 (e-2) is greater than the nursing component rate in effect 
11 July 1, 2012 shall be paid the sum of:
12   (A) The nursing component rate in effect July 1, 
13 2012; plus
14   (B) The difference of the RUG-IV nursing component 
15 per diem calculated for the current quarter minus the 
16 nursing component rate in effect July 1, 2012 
17 multiplied by 0.88.
18  (2) The transition RUG-IV per diem nursing rate for 
19 nursing homes whose rate calculated in this subsection 
20 (e-2) is less than the nursing component rate in effect 
21 July 1, 2012 shall be paid the sum of:
22   (A) The nursing component rate in effect July 1, 
23 2012; plus
24   (B) The difference of the RUG-IV nursing component 
25 per diem calculated for the current quarter minus the 
26 nursing component rate in effect July 1, 2012 
 
 
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1 multiplied by 0.13. 
2 (e-3) Notwithstanding any other provision of this Code, an 
3amount equal to $16,000,000 shall be set aside for the 
4establishment of a quality incentive initiative effective 
5January 1, 2015. In any quarter in which quality incentive 
6awards do not equal $4,000,000, the difference shall be added 
7to the base rate adjustment as provided in paragraph (3-1) of 
8subsection (d-1). 
9 (f) Notwithstanding any other provision of this Code, on 
10and after July 1, 2012, reimbursement rates associated with the 
11nursing or support components of the current nursing facility 
12rate methodology shall not increase beyond the level effective 
13May 1, 2011 until a new reimbursement system based on the RUGs 
14IV 48 grouper model has been fully operationalized.
15 (g) Notwithstanding any other provision of this Code, on 
16and after July 1, 2012, for facilities not designated by the 
17Department of Healthcare and Family Services as "Institutions 
18for Mental Disease", rates effective May 1, 2011 shall be 
19adjusted as follows:
20  (1) Individual nursing rates for residents classified 
21 in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter 
22 ending March 31, 2012 shall be reduced by 10%;
23  (2) Individual nursing rates for residents classified 
24 in all other RUG IV groups shall be reduced by 1.0%;
25  (3) Facility rates for the capital and support 
26 components shall be reduced by 1.7%.
 
 
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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(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section 
116-240, eff. 7-22-13; 98-104, Article 11, Section 11-35, eff. 
127-22-13; revised 9-19-13.)