Ill. Admin. Code tit. 89, § 147.310 - [Effective 11/28/2022] 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.
Notes
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