HB6845 93RD GENERAL ASSEMBLY

LRB093 15225 DRJ 47297 b

93RD GENERAL ASSEMBLY
State of Illinois
2003 and 2004
HB6845

Introduced 02/09/04, by Jack McGuire

SYNOPSIS AS INTRODUCED:

New Act
20 ILCS 105/4.03	from Ch. 23, par. 6104.03
305 ILCS 5/5-5.3a new

Creates the Long-Term Care Consultation Services Act and amends the Illinois Act on the Aging and the Illinois Public Aid Code. Provides for a program of long-term care consultation services, to be provided by the Department on Aging and the departments of Public Aid and Human Services, to assist persons with long-term or chronic care needs in making decisions and selecting options in relation to care. Provides for screening of individuals before admission to a Medicaid-certified nursing home, and makes the Department on Aging's nursing home prescreening program subject to the Long-Term Care Consultation Services Act. Provides for exemptions from preadmission screening requirements, including emergency admissions. Makes preadmission screening a condition of Medicaid reimbursement unless an exemption applies.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning long-term care.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 1. Short title. This Act may be cited as the Long-Term Care Consultation Services Act.

Section 5. Purpose and goal.

(a) The purpose of long-term care consultation services is to assist persons with long-term or chronic care needs in making long-term care decisions and selecting options that meet their needs and reflect their preferences. The availability of, and access to, information and other types of assistance is also intended to prevent or delay nursing facility placements and to provide transition assistance after admission to a nursing facility. The goal of these services is to contain costs associated with unnecessary nursing facility admissions. The Department on Aging, the Department of Human Services, and the Department of Public Aid shall cooperate in seeking to maximize use of available federal and State funds and establish the broadest program possible within the funding available.

(b) The services described in subsection (a) must be provided by the Department on Aging, the Department of Human Services, and the Department of Public Aid when applicable to the population served by each agency. The services must be coordinated with services provided by other public and private agencies in the community to offer a variety of cost-effective alternatives to persons with disabilities and elderly persons. The agency providing long-term care consultation services shall encourage the use of volunteers from families, religious organizations, social clubs, and similar civic and service organizations to provide community-based services.

Section 10. Definitions. In this Act:

"Department" means the the Department on Aging, the Department of Human Services, or the Department of Public Aid, as applicable.

"Long-term care consultation services" includes all of the following:

(1) Providing information and education to the general public regarding availability of the services authorized under this Act.

(2) An intake process that provides access to the services described in this Act.

(3) Assessing the health, psychological, and social needs of referred persons.

(4) Assistance in identifying services needed to maintain an person in the least restrictive environment.

(5) Providing recommendations on cost-effective community services that are available to the person.

(6) Developing a person's community support plan.

(7) Providing information regarding eligibility for Illinois health care programs.

(8) Preadmission screening to determine a person's need for a nursing facility level of care.

(9) Preliminary determination of a person's eligibility for Illinois health care programs for persons who need a nursing facility level of care, with appropriate referrals for final determination.

(10) Providing recommendations for nursing facility placement when there are no cost-effective community services available.

(11) Assistance to transition people back to community settings after admission to a nursing facility.

"Team" means a long-term care consultation team established under this Act.

Section 15. Long-term care consultation team.

(a) The Department shall establish, through the network of area agencies on aging established under the Illinois Act on the Aging, a long-term care consultation team in each designated service region of the State. Each team shall consist of at least one social worker and at least one public health nurse. The area agency on aging may designate and contract with a local public health or social services agency as the lead agency for long-term care consultation services. If a region does not have a public health nurse available, it may request approval from the Department to assign a registered nurse with at least one year experience in home care to participate on the team. A joint local consultation team or teams may serve 2 or more regions.

(b) The team is responsible for providing long-term care consultation services to all persons located in the service region or regions who request the services, regardless of a person's eligibility for any Illinois health care or human services program.

Section 20. Assessment and support planning.

(a) Persons requesting assessment, services planning, or other assistance intended to support community-based living must be visited by a long-term care consultation team within 10 working days after the date on which an assessment was requested or recommended. Assessments must be conducted in accordance with this Section.

(b) A service region may utilize a long-term care consultation team of either the social worker or the public health nurse, or both, to conduct the assessment in a face-to-face interview. The team members must confer regarding the most appropriate care for each person screened or assessed. The team must assess the health and social needs of the person, using an assessment form provided by the Department. The team must conduct the assessment in a face-to-face interview with the person being assessed and the person's legal representative, if applicable.

(c) The team must provide the person, or the person's legal representative, with written recommendations for facility-based or community-based services. The team must document that the most cost-effective alternatives available were offered to the person. For purposes of this requirement, "cost-effective alternatives" means community services and living arrangements that cost the same as or less than nursing facility care.

(d) If a person chooses to use community-based services, the team must provide the person or the person's legal representative with a written community support plan, regardless of whether the person is eligible for any Illinois health care or human services program. The person may request assistance in developing a community support plan without participating in a complete assessment.

(e) The team must give the person receiving an assessment or support planning, or the person's legal representative, materials supplied by the Department containing the following information:

(1) The purpose of preadmission screening and assessment.

(2) Information about Illinois health care programs.

(3) The person's freedom to accept or reject the recommendations of the team.

(4) The person's right to confidentiality.

(5) The person's right to appeal the decision regarding the need for nursing facility level of care or the Department's final decisions regarding public programs eligibility.

Section 25. Transition assistance.

(a) A long-term care consultation team shall provide assistance to persons residing in a nursing facility, hospital, regional treatment center, or intermediate care facility for persons with mental retardation who request or are referred for assistance. Transition assistance must include assessment, community support plan development, referrals to Illinois health care programs, and referrals to programs that provide assistance with housing.

(b) The area agency on aging shall develop transition processes with institutional social workers and discharge planners to ensure that:

(1) Persons admitted to facilities receive information about transition assistance that is available.

(2) The assessment is completed for persons within 10 working days after the date of the request or recommendation for assessment.

(3) There is a plan for transition and follow-up for the person's return to the community. The plan must require notification of other local agencies when a person who may require transition assistance is screened in one service region for admission to a facility located in another service region.

(c) If a person who is eligible for an Illinois health care program is admitted to a nursing facility, the nursing facility must include a long-term care consultation team member or the case manager in the discharge planning process.

Section 30. Preadmission screening.

(a) Every applicant to a Medicaid-certified nursing facility must be screened before admission to the facility, regardless of the applicant's income, assets, or funding sources for nursing facility care, except as described in Section 35. The purpose of the screening is to determine the applicant's need for nursing facility level of care as described in subsection (e) and to complete activities required under federal law related to mental illness and mental retardation as described in subsection (b).

(b) A person who has a diagnosis or possible diagnosis of mental illness, mental retardation, or a related condition must receive a preadmission screening before admission to a nursing facility, regardless of the exemptions described in subsection (b) of Section 35, to identify the need for further evaluation and specialized services, unless the admission before screening is authorized by the local mental health authority or the local developmental disabilities case manager, or unless authorized by the Department.

(c) The following criteria apply to the preadmission screening:

(1) the screening must use forms and criteria developed by the Department to identify persons who require referral for further evaluation and determination of the need for specialized services.

(2) The evaluation and determination of the need for specialized services must be done by:

(A) a qualified independent mental health professional, for persons with a primary or secondary diagnosis of a serious mental illness; or

(B) a qualified mental retardation professional, for persons with a primary or secondary diagnosis of mental retardation or related conditions. For purposes of this requirement, a qualified mental retardation professional must meet the standards for a qualified mental retardation professional under 42 CFR 483.430.

(d) The local mental health authority or State mental retardation authority under Public Law 100-203 and Public Law 101-508 may prohibit admission to a nursing facility if the person seeking admission does not meet the nursing facility level of care criteria or needs specialized services as defined in Public Law 100-203 and Public Law 101-508. For purposes of this subsection, "specialized services" for a person with mental retardation or a related condition means active treatment as that term is defined in 42 CFR 483.440.

(e) The determination of a person's need for nursing facility level of care must be made according to criteria developed by the Department. In assessing a person's needs, team members must have a physician available for consultation and must consider the assessment of the person's attending physician, if any. The person's physician must be included if the physician chooses to participate. Other personnel may be included on the team as deemed appropriate by the Department.

Section 35. Persons exempt from prescreening requirements.

(a) Persons exempt from the federal screening requirements described in subsections (b), (c), and (d) of Section 30 are limited to the following:

(1) A person who, having entered an acute care facility from a Medicaid-certified nursing facility, is returning to a Medicaid-certified nursing facility.

(2) A person transferring from one Medicaid-certified nursing facility in Illinois to another Medicaid-certified nursing facility in Illinois.

(3) A person, 21 years of age or older, who satisfies the following criteria, as specified in 42 CFR 106(b)(2):

(A) the person is admitted to a nursing facility directly from a hospital after receiving acute inpatient care at the hospital;

(B) the person requires nursing facility services for the same condition for which care was provided in the hospital; and

(C) the attending physician has certified before the person's admission to the nursing facility that the person is likely to receive less than 30 days of nursing facility services.

A nursing facility must provide a written notice to a person who satisfies the criteria in paragraph (3) regarding the person's right to request and receive long-term care consultation services as defined in this Act. The notice must be provided before the person's discharge from the facility and in a format specified by the Department.

(b) Persons who are exempt from preadmission screening for purposes of level-of-care determination include the following:

(1) Persons described in subsection (a).

(2) A person who has a contractual right to have nursing facility care paid for indefinitely by the Veterans' Administration.

(3) A person currently being served under the alternative care program or under a home and community-based services waiver authorized under Section 1915(c) of the Social Security Act.

(4) Persons admitted to a Medicaid-certified nursing facility for a short-term stay, which is expected to be 14 days or less in duration based on a physician's certification, and who have been assessed and approved for nursing facility admission within the previous 6 months. This exemption applies only if the long-term care consultation team member determines at the time of the initial assessment of the 6-month period that it is appropriate to use the nursing facility for short-term stays and that there is an adequate plan of care for return to the home or community-based setting. If a stay exceeds 14 days, the person must be referred no later than the first working day following the 14th resident day for a screening, which must be completed within 5 working days after the referral.

Section 40. Emergency admission to a nursing facility.

(a) Persons admitted to a Medicaid-certified nursing facility from the community on an emergency basis as described in subsection (b) or from an acute care facility on a day other than a working day must be screened on the first working day after admission.

(b) Emergency admission to a nursing facility before screening is permitted when all of the following conditions are met:

(1) The person is admitted from the community to a certified nursing facility during county nonworking hours.

(2) A physician has determined that delaying admission until preadmission screening is completed would adversely affect the person's health and safety.

(3) There is a recent precipitating event that precludes the person from living safely in the community, such as the person sustaining an injury, the sudden onset of an acute illness, or a caregiver's inability to continue to provide care.

(4) The person's attending physician has authorized the emergency placement and has documented the reason that the emergency placement is recommended.

(5) The Department is contacted on the first working day following the emergency admission.

(c) Transfer of a patient from an acute care hospital to a nursing facility is not considered an emergency except for a person who has received hospital services in the following situations: hospital admission for observation, care in an emergency room without hospital admission, or following hospital 24-hour bed care.

Section 45. Screening procedure.

(a) A person may be screened for nursing facility admission by telephone or in a face-to-face screening interview. Long-term care consultation team members must identify each person's needs using one of the following categories:

(1) The person does not need a face-to-face screening interview to determine the need for nursing facility level of care based on information obtained from other health care professionals.

(2) The person needs an immediate face-to-face screening interview to determine the need for nursing facility level of care and to complete activities required under Section 30.

(3) The person may be exempt from screening requirements as described in Section 35 or 40 but will need transitional assistance after admission or in-person follow-along after a return home.

(b) Persons admitted on a nonemergency basis to a Medicaid-certified nursing facility must be screened before admission.

(c) The long-term care consultation team shall recommend a case mix classification for persons admitted to a certified nursing facility when sufficient information is received to make that classification. The nursing facility may conduct all case mix assessments for persons who have been screened before admission for whom the team did not recommend a case mix classification. The nursing facility may conduct all case mix assessments for persons admitted to the facility before a preadmission screening.

(d) The team's screening or intake activity must include processes to identify persons who may require transition assistance as described in Section 25.

Section 50. Preadmission screening of persons under age 65.

(a) It is the policy of the State of Illinois to ensure that persons with disabilities or chronic illness are served in the most integrated setting appropriate to their needs and have the necessary information to make informed choices about home and community-based service options. The Department of Public Aid and the Department of Human Services shall administer this Section.

(b) A person under 65 years of age who is admitted to a nursing facility from a hospital must be screened before admission as described in Sections 30, 35, 40, and 45.

(c) A person under 65 years of age who is admitted to a nursing facility with only a telephone preadmission screening must receive a face-to-face assessment from the long-term care consultation team member from the service region in which the facility is located or from the person's case manager within 40 calendar days after admission.

(d) A person under 65 years of age who is admitted to a nursing facility without a preadmission screening in accordance with subdivision (a)(3) of Section 35 and who remains in the facility longer than 30 days must receive a face-to-face assessment within 40 days after admission.

(e) At the face-to-face assessment, the long-term care consultation team member or case manager must perform the activities required under Section 25.

(f) For a person under 21 years of age, a screening interview that recommends nursing facility admission must be conducted face-to-face and must be approved by the Department before the person is admitted to the nursing facility.

(g) If a person under 65 years of age is admitted to a nursing facility on an emergency basis, the Department must be notified of the admission on the next working day, and a face-to-face assessment as described in subsection (c) must be conducted within 40 calendar days after admission.

(h) At the face-to-face assessment, the team member or the case manager must present information about home and community-based options so that the person can make informed choices. If the person chooses home and community-based services, the team member or case manager must complete a written relocation plan within 20 working days after the assessment. The plan must describe the services needed to enable the person to move out of the facility and must include a time line for the move that is designed to ensure a smooth transition to the person's home and community.

(i) A person under 65 years of age residing in a nursing facility is entitled to a face-to-face assessment at least every 12 months to review the person's service choices and available alternatives unless the person indicates, in writing, that he or she does not desire annual assessments. In this case, the person must receive a face-to-face assessment at least every 36 months for the same purposes.

Section 55. Administration. The Department shall minimize the number of forms required in the provision of long-term care consultation services and shall limit the screening document to items necessary for community support plan approval, reimbursement, program planning, evaluation, and policy development.

Section 60. Medicaid reimbursement.

(a) Reimbursement for a nursing facility under Article V of the Illinois Public Aid Code shall be authorized for a recipient of medical assistance under that Article V only if a preadmission screening has been conducted before the recipient's admission to the facility or the Department has authorized an exemption from the preadmission screening requirement as provided in this Act. Reimbursement under Article V of the Illinois Public Aid Code shall not be provided for any medical assistance recipient who, as determined by the local screener, does not meet the level of care criteria for nursing facility placement or, if indicated, has not had a level II OBRA evaluation as required under the federal Omnibus Budget Reconciliation Act of 1987 completed, unless an admission for a recipient with mental illness is approved by the local mental health authority or an admission for a recipient with mental retardation or a related condition is approved by the State mental retardation authority.

(b) A nursing facility must not bill a person who is not a medical assistance recipient for resident days that preceded the date of completion of screening activities as required under Sections 30, 35, 40, and 45. The nursing facility must include unreimbursed resident days in the nursing facility resident day totals reported to the Department.

(c) The Department shall make a request to the Centers for Medicare and Medicaid Services for a waiver allowing team approval of Medicaid payments for certified nursing facility care. A person has a choice and makes the final decision between nursing facility placement and community placement after the screening team's recommendation, except as provided in subsection (d) of Section 30.

Section 90. The Illinois Act on the Aging is amended by changing Section 4.03 as follows:

(20 ILCS 105/4.03) (from Ch. 23, par. 6104.03)

Sec. 4.03. Nursing home prescreening program. (a) The Department on Aging, in cooperation with the Department of Human Services and any other appropriate State, local or federal agency, shall, without regard to income guidelines, establish a nursing home prescreening program to determine whether Alzheimer's Disease and related disorders victims, and persons who are deemed as blind or disabled as defined by the Social Security Act and who are in need of long term care, may be satisfactorily cared for in their homes through the use of home and community based services. Case coordination units under contract with the Department may charge a fee for the prescreening provided under this Section and the fee shall be no greater than the cost of such services to the case coordination unit.

(b) The program established under this Section must comply with the Long-Term Care Consultation Services Act.

(Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97.)

Section 95. The Illinois Public Aid Code is amended by adding Section 5-5.3a as follows:

(305 ILCS 5/5-5.3a new)

Sec. 5-5.3a. Long-Term Care Consultation Services Act. Payments to a nursing facility under this Article are subject to preadmission screening requirements as provided in Section 60 of the Long-Term Care Consultation Services Act.