Illinois General Assembly - Full Text of HB3125
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Full Text of HB3125  103rd General Assembly




State of Illinois
2023 and 2024


Introduced 2/17/2023, by Rep. Elizabeth "Lisa" Hernandez


305 ILCS 5/5-5.2  from Ch. 23, par. 5-5.2

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, on and after July 1, 2023 (rather than 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%. Effective July 1, 2023.

LRB103 29884 KTG 56295 b





HB3125LRB103 29884 KTG 56295 b

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
13the State for the long-term care providers.
14    (c) (Blank).
15    (c-1) Notwithstanding any other provisions of this Code,
16the methodologies for reimbursement of nursing services as
17provided under this Article shall no longer be applicable for
18bills payable for nursing services rendered on or after a new
19reimbursement system based on the Patient Driven Payment Model
20(PDPM) has been fully operationalized, which shall take effect
21for services provided on or after the implementation of the
22PDPM reimbursement system begins. For the purposes of this
23amendatory Act of the 102nd General Assembly, the



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1implementation date of the PDPM reimbursement system and all
2related provisions shall be July 1, 2022 if the following
3conditions are met: (i) the Centers for Medicare and Medicaid
4Services has approved corresponding changes in the
5reimbursement system and bed assessment; and (ii) the
6Department has filed rules to implement these changes no later
7than June 1, 2022. Failure of the Department to file rules to
8implement the changes provided in this amendatory Act of the
9102nd General Assembly no later than June 1, 2022 shall result
10in the implementation date being delayed to October 1, 2022.
11    (d) The new nursing services reimbursement methodology
12utilizing the Patient Driven Payment Model, which shall be
13referred to as the PDPM reimbursement system, taking effect
14July 1, 2022, upon federal approval by the Centers for
15Medicare and Medicaid Services, shall be based on the
17        (1) The methodology shall be resident-centered,
18    facility-specific, cost-based, and based on guidance from
19    the Centers for Medicare and Medicaid Services.
20        (2) Costs shall be annually rebased and case mix index
21    quarterly updated. The nursing services methodology will
22    be assigned to the Medicaid enrolled residents on record
23    as of 30 days prior to the beginning of the rate period in
24    the Department's Medicaid Management Information System
25    (MMIS) as present on the last day of the second quarter
26    preceding the rate period based upon the Assessment



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1    Reference Date of the Minimum Data Set (MDS).
2        (3) Regional wage adjustors based on the Health
3    Service Areas (HSA) groupings and adjusters in effect on
4    April 30, 2012 shall be included, except no adjuster shall
5    be lower than 1.06.
6        (4) PDPM nursing case mix indices in effect on March
7    1, 2022 shall be assigned to each resident class at no less
8    than 0.7858 of the Centers for Medicare and Medicaid
9    Services PDPM unadjusted case mix values, in effect on
10    March 1, 2022.
11        (5) The pool of funds available for distribution by
12    case mix and the base facility rate shall be determined
13    using the formula contained in subsection (d-1).
14        (6) The Department shall establish a variable per diem
15    staffing add-on in accordance with the most recent
16    available federal staffing report, currently the Payroll
17    Based Journal, for the same period of time, and if
18    applicable adjusted for acuity using the same quarter's
19    MDS. The Department shall rely on Payroll Based Journals
20    provided to the Department of Public Health to make a
21    determination of non-submission. If the Department is
22    notified by a facility of missing or inaccurate Payroll
23    Based Journal data or an incorrect calculation of
24    staffing, the Department must make a correction as soon as
25    the error is verified for the applicable quarter.
26        Facilities with at least 70% of the staffing indicated



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1    by the STRIVE study shall be paid a per diem add-on of $9,
2    increasing by equivalent steps for each whole percentage
3    point until the facilities reach a per diem of $14.88.
4    Facilities with at least 80% of the staffing indicated by
5    the STRIVE study shall be paid a per diem add-on of $14.88,
6    increasing by equivalent steps for each whole percentage
7    point until the facilities reach a per diem add-on of
8    $23.80. Facilities with at least 92% of the staffing
9    indicated by the STRIVE study shall be paid a per diem
10    add-on of $23.80, increasing by equivalent steps for each
11    whole percentage point until the facilities reach a per
12    diem add-on of $29.75. Facilities with at least 100% of
13    the staffing indicated by the STRIVE study shall be paid a
14    per diem add-on of $29.75, increasing by equivalent steps
15    for each whole percentage point until the facilities reach
16    a per diem add-on of $35.70. Facilities with at least 110%
17    of the staffing indicated by the STRIVE study shall be
18    paid a per diem add-on of $35.70, increasing by equivalent
19    steps for each whole percentage point until the facilities
20    reach a per diem add-on of $38.68. Facilities with at
21    least 125% or higher of the staffing indicated by the
22    STRIVE study shall be paid a per diem add-on of $38.68.
23    Beginning April 1, 2023, no nursing facility's variable
24    staffing per diem add-on shall be reduced by more than 5%
25    in 2 consecutive quarters. For the quarters beginning July
26    1, 2022 and October 1, 2022, no facility's variable per



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1    diem staffing add-on shall be calculated at a rate lower
2    than 85% of the staffing indicated by the STRIVE study. No
3    facility below 70% of the staffing indicated by the STRIVE
4    study shall receive a variable per diem staffing add-on
5    after December 31, 2022.
6        (7) For dates of services beginning July 1, 2022, the
7    PDPM nursing component per diem for each nursing facility
8    shall be the product of the facility's (i) statewide PDPM
9    nursing base per diem rate, $92.25, adjusted for the
10    facility average PDPM case mix index calculated quarterly
11    and (ii) the regional wage adjuster, and then add the
12    Medicaid access adjustment as defined in (e-3) of this
13    Section. Transition rates for services provided between
14    July 1, 2022 and October 1, 2023 shall be the greater of
15    the PDPM nursing component per diem or:
16            (A) for the quarter beginning July 1, 2022, the
17        RUG-IV nursing component per diem;
18            (B) for the quarter beginning October 1, 2022, the
19        sum of the RUG-IV nursing component per diem
20        multiplied by 0.80 and the PDPM nursing component per
21        diem multiplied by 0.20;
22            (C) for the quarter beginning January 1, 2023, the
23        sum of the RUG-IV nursing component per diem
24        multiplied by 0.60 and the PDPM nursing component per
25        diem multiplied by 0.40;
26            (D) for the quarter beginning April 1, 2023, the



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1        sum of the RUG-IV nursing component per diem
2        multiplied by 0.40 and the PDPM nursing component per
3        diem multiplied by 0.60;
4            (E) for the quarter beginning July 1, 2023, the
5        sum of the RUG-IV nursing component per diem
6        multiplied by 0.20 and the PDPM nursing component per
7        diem multiplied by 0.80; or
8            (F) for the quarter beginning October 1, 2023 and
9        each subsequent quarter, the transition rate shall end
10        and a nursing facility shall be paid 100% of the PDPM
11        nursing component per diem.
12    (d-1) Calculation of base year Statewide RUG-IV nursing
13base per diem rate.
14        (1) Base rate spending pool shall be:
15            (A) The base year resident days which are
16        calculated by multiplying the number of Medicaid
17        residents in each nursing home as indicated in the MDS
18        data defined in paragraph (4) by 365.
19            (B) Each facility's nursing component per diem in
20        effect on July 1, 2012 shall be multiplied by
21        subsection (A).
22            (C) Thirteen million is added to the product of
23        subparagraph (A) and subparagraph (B) to adjust for
24        the exclusion of nursing homes defined in paragraph
25        (5).
26        (2) For each nursing home with Medicaid residents as



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1    indicated by the MDS data defined in paragraph (4),
2    weighted days adjusted for case mix and regional wage
3    adjustment shall be calculated. For each home this
4    calculation is the product of:
5            (A) Base year resident days as calculated in
6        subparagraph (A) of paragraph (1).
7            (B) The nursing home's regional wage adjustor
8        based on the Health Service Areas (HSA) groupings and
9        adjustors in effect on April 30, 2012.
10            (C) Facility weighted case mix which is the number
11        of Medicaid residents as indicated by the MDS data
12        defined in paragraph (4) multiplied by the associated
13        case weight for the RUG-IV 48 grouper model using
14        standard RUG-IV procedures for index maximization.
15            (D) The sum of the products calculated for each
16        nursing home in subparagraphs (A) through (C) above
17        shall be the base year case mix, rate adjusted
18        weighted days.
19        (3) The Statewide RUG-IV nursing base per diem rate:
20            (A) on January 1, 2014 shall be the quotient of the
21        paragraph (1) divided by the sum calculated under
22        subparagraph (D) of paragraph (2);
23            (B) on and after July 1, 2014 and until July 1,
24        2022, shall be the amount calculated under
25        subparagraph (A) of this paragraph (3) plus $1.76; and
26            (C) beginning July 1, 2022 and thereafter, $7



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1        shall be added to the amount calculated under
2        subparagraph (B) of this paragraph (3) of this
3        Section.
4        (4) Minimum Data Set (MDS) comprehensive assessments
5    for Medicaid residents on the last day of the quarter used
6    to establish the base rate.
7        (5) Nursing facilities designated as of July 1, 2012
8    by the Department as "Institutions for Mental Disease"
9    shall be excluded from all calculations under this
10    subsection. The data from these facilities shall not be
11    used in the computations described in paragraphs (1)
12    through (4) above to establish the base rate.
13    (e) Beginning July 1, 2014, the Department shall allocate
14funding in the amount up to $10,000,000 for per diem add-ons to
15the RUGS methodology for dates of service on and after July 1,
17        (1) $0.63 for each resident who scores in I4200
18    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
19        (2) $2.67 for each resident who scores either a "1" or
20    "2" in any items S1200A through S1200I and also scores in
21    RUG groups PA1, PA2, BA1, or BA2.
22    (e-1) (Blank).
23    (e-2) For dates of services beginning January 1, 2014 and
24ending September 30, 2023, the RUG-IV nursing component per
25diem for a nursing home shall be the product of the statewide
26RUG-IV nursing base per diem rate, the facility average case



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1mix index, and the regional wage adjustor. For dates of
2service beginning July 1, 2022 and ending September 30, 2023,
3the Medicaid access adjustment described in subsection (e-3)
4shall be added to the product.
5    (e-3) A Medicaid Access Adjustment of $4 adjusted for the
6facility average PDPM case mix index calculated quarterly
7shall be added to the statewide PDPM nursing per diem for all
8facilities with annual Medicaid bed days of at least 70% of all
9occupied bed days adjusted quarterly. For each new calendar
10year and for the 6-month period beginning July 1, 2022, the
11percentage of a facility's occupied bed days comprised of
12Medicaid bed days shall be determined by the Department
13quarterly. For dates of service beginning January 1, 2023, the
14Medicaid Access Adjustment shall be increased to $4.75. This
15subsection shall be inoperative on and after January 1, 2028.
16    (f) (Blank).
17    (g) Notwithstanding any other provision of this Code, on
18and after July 1, 2012, for facilities not designated by the
19Department of Healthcare and Family Services as "Institutions
20for Mental Disease", rates effective May 1, 2011 shall be
21adjusted as follows:
22        (1) (Blank);
23        (2) (Blank);
24        (3) Facility rates for the capital and support
25    components shall be reduced by 1.7%.
26    (h) Notwithstanding any other provision of this Code, on



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1and after July 1, 2012, nursing facilities designated by the
2Department of Healthcare and Family Services as "Institutions
3for Mental Disease" and "Institutions for Mental Disease" that
4are facilities licensed under the Specialized Mental Health
5Rehabilitation Act of 2013 shall have the nursing,
6socio-developmental, capital, and support components of their
7reimbursement rate effective May 1, 2011 reduced in total by
9    (i) On and after July 1, 2023 2014, the reimbursement
10rates for the support component of the nursing facility rate
11for facilities licensed under the Nursing Home Care Act as
12skilled or intermediate care facilities shall be the rate in
13effect on June 30, 2014 increased by 8.17%.
14    (j) Notwithstanding any other provision of law, subject to
15federal approval, effective July 1, 2019, sufficient funds
16shall be allocated for changes to rates for facilities
17licensed under the Nursing Home Care Act as skilled nursing
18facilities or intermediate care facilities for dates of
19services on and after July 1, 2019: (i) to establish, through
20June 30, 2022 a per diem add-on to the direct care per diem
21rate not to exceed $70,000,000 annually in the aggregate
22taking into account federal matching funds for the purpose of
23addressing the facility's unique staffing needs, adjusted
24quarterly and distributed by a weighted formula based on
25Medicaid bed days on the last day of the second quarter
26preceding the quarter for which the rate is being adjusted.



HB3125- 11 -LRB103 29884 KTG 56295 b

1Beginning July 1, 2022, the annual $70,000,000 described in
2the preceding sentence shall be dedicated to the variable per
3diem add-on for staffing under paragraph (6) of subsection
4(d); and (ii) in an amount not to exceed $170,000,000 annually
5in the aggregate taking into account federal matching funds to
6permit the support component of the nursing facility rate to
7be updated as follows:
8        (1) 80%, or $136,000,000, of the funds shall be used
9    to update each facility's rate in effect on June 30, 2019
10    using the most recent cost reports on file, which have had
11    a limited review conducted by the Department of Healthcare
12    and Family Services and will not hold up enacting the rate
13    increase, with the Department of Healthcare and Family
14    Services.
15        (2) After completing the calculation in paragraph (1),
16    any facility whose rate is less than the rate in effect on
17    June 30, 2019 shall have its rate restored to the rate in
18    effect on June 30, 2019 from the 20% of the funds set
19    aside.
20        (3) The remainder of the 20%, or $34,000,000, shall be
21    used to increase each facility's rate by an equal
22    percentage.
23    (k) During the first quarter of State Fiscal Year 2020,
24the Department of Healthcare of Family Services must convene a
25technical advisory group consisting of members of all trade
26associations representing Illinois skilled nursing providers



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1to discuss changes necessary with federal implementation of
2Medicare's Patient-Driven Payment Model. Implementation of
3Medicare's Patient-Driven Payment Model shall, by September 1,
42020, end the collection of the MDS data that is necessary to
5maintain the current RUG-IV Medicaid payment methodology. The
6technical advisory group must consider a revised reimbursement
7methodology that takes into account transparency,
8accountability, actual staffing as reported under the
9federally required Payroll Based Journal system, changes to
10the minimum wage, adequacy in coverage of the cost of care, and
11a quality component that rewards quality improvements.
12    (l) The Department shall establish per diem add-on
13payments to improve the quality of care delivered by
14facilities, including:
15        (1) Incentive payments determined by facility
16    performance on specified quality measures in an initial
17    amount of $70,000,000. Nothing in this subsection shall be
18    construed to limit the quality of care payments in the
19    aggregate statewide to $70,000,000, and, if quality of
20    care has improved across nursing facilities, the
21    Department shall adjust those add-on payments accordingly.
22    The quality payment methodology described in this
23    subsection must be used for at least State Fiscal Year
24    2023. Beginning with the quarter starting July 1, 2023,
25    the Department may add, remove, or change quality metrics
26    and make associated changes to the quality payment



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1    methodology as outlined in subparagraph (E). Facilities
2    designated by the Centers for Medicare and Medicaid
3    Services as a special focus facility or a hospital-based
4    nursing home do not qualify for quality payments.
5            (A) Each quality pool must be distributed by
6        assigning a quality weighted score for each nursing
7        home which is calculated by multiplying the nursing
8        home's quality base period Medicaid days by the
9        nursing home's star rating weight in that period.
10            (B) Star rating weights are assigned based on the
11        nursing home's star rating for the LTS quality star
12        rating. As used in this subparagraph, "LTS quality
13        star rating" means the long-term stay quality rating
14        for each nursing facility, as assigned by the Centers
15        for Medicare and Medicaid Services under the Five-Star
16        Quality Rating System. The rating is a number ranging
17        from 0 (lowest) to 5 (highest).
18                (i) Zero-star or one-star rating has a weight
19            of 0.
20                (ii) Two-star rating has a weight of 0.75.
21                (iii) Three-star rating has a weight of 1.5.
22                (iv) Four-star rating has a weight of 2.5.
23                (v) Five-star rating has a weight of 3.5.
24            (C) Each nursing home's quality weight score is
25        divided by the sum of all quality weight scores for
26        qualifying nursing homes to determine the proportion



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1        of the quality pool to be paid to the nursing home.
2            (D) The quality pool is no less than $70,000,000
3        annually or $17,500,000 per quarter. The Department
4        shall publish on its website the estimated payments
5        and the associated weights for each facility 45 days
6        prior to when the initial payments for the quarter are
7        to be paid. The Department shall assign each facility
8        the most recent and applicable quarter's STAR value
9        unless the facility notifies the Department within 15
10        days of an issue and the facility provides reasonable
11        evidence demonstrating its timely compliance with
12        federal data submission requirements for the quarter
13        of record. If such evidence cannot be provided to the
14        Department, the STAR rating assigned to the facility
15        shall be reduced by one from the prior quarter.
16            (E) The Department shall review quality metrics
17        used for payment of the quality pool and make
18        recommendations for any associated changes to the
19        methodology for distributing quality pool payments in
20        consultation with associations representing long-term
21        care providers, consumer advocates, organizations
22        representing workers of long-term care facilities, and
23        payors. The Department may establish, by rule, changes
24        to the methodology for distributing quality pool
25        payments.
26            (F) The Department shall disburse quality pool



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1        payments from the Long-Term Care Provider Fund on a
2        monthly basis in amounts proportional to the total
3        quality pool payment determined for the quarter.
4            (G) The Department shall publish any changes in
5        the methodology for distributing quality pool payments
6        prior to the beginning of the measurement period or
7        quality base period for any metric added to the
8        distribution's methodology.
9        (2) Payments based on CNA tenure, promotion, and CNA
10    training for the purpose of increasing CNA compensation.
11    It is the intent of this subsection that payments made in
12    accordance with this paragraph be directly incorporated
13    into increased compensation for CNAs. As used in this
14    paragraph, "CNA" means a certified nursing assistant as
15    that term is described in Section 3-206 of the Nursing
16    Home Care Act, Section 3-206 of the ID/DD Community Care
17    Act, and Section 3-206 of the MC/DD Act. The Department
18    shall establish, by rule, payments to nursing facilities
19    equal to Medicaid's share of the tenure wage increments
20    specified in this paragraph for all reported CNA employee
21    hours compensated according to a posted schedule
22    consisting of increments at least as large as those
23    specified in this paragraph. The increments are as
24    follows: an additional $1.50 per hour for CNAs with at
25    least one and less than 2 years' experience plus another
26    $1 per hour for each additional year of experience up to a



HB3125- 16 -LRB103 29884 KTG 56295 b

1    maximum of $6.50 for CNAs with at least 6 years of
2    experience. For purposes of this paragraph, Medicaid's
3    share shall be the ratio determined by paid Medicaid bed
4    days divided by total bed days for the applicable time
5    period used in the calculation. In addition, and additive
6    to any tenure increments paid as specified in this
7    paragraph, the Department shall establish, by rule,
8    payments supporting Medicaid's share of the
9    promotion-based wage increments for CNA employee hours
10    compensated for that promotion with at least a $1.50
11    hourly increase. Medicaid's share shall be established as
12    it is for the tenure increments described in this
13    paragraph. Qualifying promotions shall be defined by the
14    Department in rules for an expected 10-15% subset of CNAs
15    assigned intermediate, specialized, or added roles such as
16    CNA trainers, CNA scheduling "captains", and CNA
17    specialists for resident conditions like dementia or
18    memory care or behavioral health.
19    (m) The Department shall work with nursing facility
20industry representatives to design policies and procedures to
21permit facilities to address the integrity of data from
22federal reporting sites used by the Department in setting
23facility rates.
24(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19;
25102-77, eff. 7-9-21; 102-558, eff. 8-20-21; 102-1035, eff.
265-31-22; 102-1118, eff. 1-18-23.)



HB3125- 17 -LRB103 29884 KTG 56295 b

1    Section 99. Effective date. This Act takes effect July 1,