104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB1490 Introduced 1/31/2025, by Sen. Mary Edly-Allen SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5.2 Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning PDPM STRIVE staffing ratio calculations for nursing facilities, provides that beginning January 1, 2025, the staffing percentage used in the calculation of the per diem staffing add-on shall be its PDPM STRIVE Staffing Ratio which equals: its Reported Total Nurse Staffing Hours Per Resident Per Day as published in the most recent federal staffing report (the Provider Information file), divided by the facility's PDPM STRIVE Staffing Target. Provides that each facility's PDPM STRIVE Staffing Target is equal to .76 times the facility's Illinois Adjusted Facility Case-Mix Hours Per Resident Per Day. Provides that a facility's Illinois Adjusted Facility Case-Mix Hours Per Resident Per Day is equal to its Nursing Case-Mix (as published in the most recent federal Provider Information file) divided by 1.4627 times 3.79 (which is the Reported Total Nurse Staffing Hours Per Resident Per Day for the Nation as reported in the January 2024 State US Averages file). Effective July 1, 2025. LRB104 09237 KTG 19294 b A BILL FOR 104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB1490 Introduced 1/31/2025, by Sen. Mary Edly-Allen SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-5.2 305 ILCS 5/5-5.2 Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning PDPM STRIVE staffing ratio calculations for nursing facilities, provides that beginning January 1, 2025, the staffing percentage used in the calculation of the per diem staffing add-on shall be its PDPM STRIVE Staffing Ratio which equals: its Reported Total Nurse Staffing Hours Per Resident Per Day as published in the most recent federal staffing report (the Provider Information file), divided by the facility's PDPM STRIVE Staffing Target. Provides that each facility's PDPM STRIVE Staffing Target is equal to .76 times the facility's Illinois Adjusted Facility Case-Mix Hours Per Resident Per Day. Provides that a facility's Illinois Adjusted Facility Case-Mix Hours Per Resident Per Day is equal to its Nursing Case-Mix (as published in the most recent federal Provider Information file) divided by 1.4627 times 3.79 (which is the Reported Total Nurse Staffing Hours Per Resident Per Day for the Nation as reported in the January 2024 State US Averages file). Effective July 1, 2025. LRB104 09237 KTG 19294 b LRB104 09237 KTG 19294 b A BILL FOR
104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB1490 Introduced 1/31/2025, by Sen. Mary Edly-Allen SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-5.2 305 ILCS 5/5-5.2
305 ILCS 5/5-5.2
Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning PDPM STRIVE staffing ratio calculations for nursing facilities, provides that beginning January 1, 2025, the staffing percentage used in the calculation of the per diem staffing add-on shall be its PDPM STRIVE Staffing Ratio which equals: its Reported Total Nurse Staffing Hours Per Resident Per Day as published in the most recent federal staffing report (the Provider Information file), divided by the facility's PDPM STRIVE Staffing Target. Provides that each facility's PDPM STRIVE Staffing Target is equal to .76 times the facility's Illinois Adjusted Facility Case-Mix Hours Per Resident Per Day. Provides that a facility's Illinois Adjusted Facility Case-Mix Hours Per Resident Per Day is equal to its Nursing Case-Mix (as published in the most recent federal Provider Information file) divided by 1.4627 times 3.79 (which is the Reported Total Nurse Staffing Hours Per Resident Per Day for the Nation as reported in the January 2024 State US Averages file). Effective July 1, 2025.
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A BILL FOR
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SB1490 LRB104 09237 KTG 19294 b
1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-5.2 as follows:
6 (305 ILCS 5/5-5.2)
7 Sec. 5-5.2. Payment.
8 (a) All nursing facilities that are grouped pursuant to
9 Section 5-5.1 of this Act shall receive the same rate of
10 payment for similar services.
11 (b) It shall be a matter of State policy that the Illinois
12 Department shall utilize a uniform billing cycle throughout
13 the State for the long-term care providers.
14 (c) (Blank).
15 (c-1) Notwithstanding any other provisions of this Code,
16 the methodologies for reimbursement of nursing services as
17 provided under this Article shall no longer be applicable for
18 bills payable for nursing services rendered on or after a new
19 reimbursement system based on the Patient Driven Payment Model
20 (PDPM) has been fully operationalized, which shall take effect
21 for services provided on or after the implementation of the
22 PDPM reimbursement system begins. For the purposes of Public
23 Act 102-1035, the implementation date of the PDPM
104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026 SB1490 Introduced 1/31/2025, by Sen. Mary Edly-Allen SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-5.2 305 ILCS 5/5-5.2
305 ILCS 5/5-5.2
Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning PDPM STRIVE staffing ratio calculations for nursing facilities, provides that beginning January 1, 2025, the staffing percentage used in the calculation of the per diem staffing add-on shall be its PDPM STRIVE Staffing Ratio which equals: its Reported Total Nurse Staffing Hours Per Resident Per Day as published in the most recent federal staffing report (the Provider Information file), divided by the facility's PDPM STRIVE Staffing Target. Provides that each facility's PDPM STRIVE Staffing Target is equal to .76 times the facility's Illinois Adjusted Facility Case-Mix Hours Per Resident Per Day. Provides that a facility's Illinois Adjusted Facility Case-Mix Hours Per Resident Per Day is equal to its Nursing Case-Mix (as published in the most recent federal Provider Information file) divided by 1.4627 times 3.79 (which is the Reported Total Nurse Staffing Hours Per Resident Per Day for the Nation as reported in the January 2024 State US Averages file). Effective July 1, 2025.
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A BILL FOR
305 ILCS 5/5-5.2
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1 reimbursement system and all related provisions shall be July
2 1, 2022 if the following conditions are met: (i) the Centers
3 for Medicare and Medicaid Services has approved corresponding
4 changes in the reimbursement system and bed assessment; and
5 (ii) the Department has filed rules to implement these changes
6 no later than June 1, 2022. Failure of the Department to file
7 rules to implement the changes provided in Public Act 102-1035
8 no later than June 1, 2022 shall result in the implementation
9 date being delayed to October 1, 2022.
10 (d) The new nursing services reimbursement methodology
11 utilizing the Patient Driven Payment Model, which shall be
12 referred to as the PDPM reimbursement system, taking effect
13 July 1, 2022, upon federal approval by the Centers for
14 Medicare and Medicaid Services, shall be based on the
15 following:
16 (1) The methodology shall be resident-centered,
17 facility-specific, cost-based, and based on guidance from
18 the Centers for Medicare and Medicaid Services.
19 (2) Costs shall be annually rebased and case mix index
20 quarterly updated. The nursing services methodology will
21 be assigned to the Medicaid enrolled residents on record
22 as of 30 days prior to the beginning of the rate period in
23 the Department's Medicaid Management Information System
24 (MMIS) as present on the last day of the second quarter
25 preceding the rate period based upon the Assessment
26 Reference Date of the Minimum Data Set (MDS).
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1 (3) Regional wage adjustors based on the Health
2 Service Areas (HSA) groupings and adjusters in effect on
3 April 30, 2012 shall be included, except no adjuster shall
4 be lower than 1.06.
5 (4) PDPM nursing case mix indices in effect on March
6 1, 2022 shall be assigned to each resident class at no less
7 than 0.7858 of the Centers for Medicare and Medicaid
8 Services PDPM unadjusted case mix values, in effect on
9 March 1, 2022.
10 (5) The pool of funds available for distribution by
11 case mix and the base facility rate shall be determined
12 using the formula contained in subsection (d-1).
13 (6) The Department shall establish a variable per diem
14 staffing add-on in accordance with the most recent
15 available federal staffing report, currently the Payroll
16 Based Journal, for the same period of time, and if
17 applicable adjusted for acuity using the same quarter's
18 MDS. The Department shall rely on Payroll Based Journals
19 provided to the Department of Public Health to make a
20 determination of non-submission. If the Department is
21 notified by a facility of missing or inaccurate Payroll
22 Based Journal data or an incorrect calculation of
23 staffing, the Department must make a correction as soon as
24 the error is verified for the applicable quarter.
25 Beginning October 1, 2024, the staffing percentage
26 used in the calculation of the per diem staffing add-on
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1 shall be its PDPM STRIVE Staffing Ratio which equals: its
2 Reported Total Nurse Staffing Hours Per Resident Per Day
3 as published in the most recent federal staffing report
4 (the Provider Information File), divided by the facility's
5 PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
6 Staffing Target is equal to .82 times the facility's
7 Illinois Adjusted Facility Case-Mix Hours Per Resident Per
8 Day. A facility's Illinois Adjusted Facility Case Mix
9 Hours Per Resident Per Day is equal to its Case-Mix Total
10 Nurse Staffing Hours Per Resident Per Day (as published in
11 the most recent federal Provider Information file staffing
12 report) times 3.662 (which reflects the national resident
13 days-weighted mean Reported Total Nurse Staffing Hours Per
14 Resident Per Day as calculated using the January 2024
15 federal Provider Information Files), divided by the
16 national resident days-weighted mean Reported Total Nurse
17 Staffing Hours Per Resident Per Day calculated using the
18 most recent State US Averages file federal Provider
19 Information File.
20 Beginning July 1, 2025, the staffing percentage used
21 in the calculation of the per diem staffing add-on shall
22 be its PDPM STRIVE Staffing Ratio which equals: its
23 Reported Total Nurse Staffing Hours Per Resident Per Day
24 as published in the most recent federal staffing report
25 (the Provider Information file), divided by the facility's
26 PDPM STRIVE Staffing Target. Each facility's PDPM STRIVE
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1 Staffing Target is equal to .76 times the facility's
2 Illinois Adjusted Facility Case-Mix Hours Per Resident Per
3 Day. A facility's Illinois Adjusted Facility Case-Mix
4 Hours Per Resident Per Day is equal to its Nursing
5 Case-Mix (as published in the most recent federal Provider
6 Information file) divided by 1.4627 times 3.79 (which is
7 the Reported Total Nurse Staffing Hours Per Resident Per
8 Day for the Nation as reported in the January 2024 State US
9 Averages file).
10 (6.5) Beginning July 1, 2024, the paid per diem
11 staffing add-on shall be the paid per diem staffing add-on
12 in effect April 1, 2024. For dates beginning October 1,
13 2024 and through September 30, 2025, the denominator for
14 the staffing percentage shall be the lesser of the
15 facility's PDPM STRIVE Staffing Target and:
16 (A) For the quarter beginning October 1, 2024, the
17 sum of 20% of the facility's PDPM STRIVE Staffing
18 Target and 80% of the facility's Case-Mix Total Nurse
19 Staffing Hours Per Resident Per Day (as published in
20 the January 2024 federal staffing report).
21 (B) For the quarter beginning January 1, 2025, the
22 sum of 40% of the facility's PDPM STRIVE Staffing
23 Target and 60% of the facility's Case-Mix Total Nurse
24 Staffing Hours Per Resident Per Day (as published in
25 the January 2024 federal staffing report).
26 (C) For the quarter beginning March 1, 2025, the
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1 sum of 60% of the facility's PDPM STRIVE Staffing
2 Target and 40% of the facility's Case-Mix Total Nurse
3 Staffing Hours Per Resident Per Day (as published in
4 the January 2024 federal staffing report).
5 (D) For the quarter beginning July 1, 2025, the
6 sum of 80% of the facility's PDPM STRIVE Staffing
7 Target and 20% of the facility's Case-Mix Total Nurse
8 Staffing Hours Per Resident Per Day (as published in
9 the January 2024 federal staffing report).
10 Facilities with at least 70% of the staffing
11 indicated by the STRIVE study shall be paid a per diem
12 add-on of $9, increasing by equivalent steps for each
13 whole percentage point until the facilities reach a per
14 diem of $16.52. Facilities with at least 80% of the
15 staffing indicated by the STRIVE study shall be paid a per
16 diem add-on of $16.52, increasing by equivalent steps for
17 each whole percentage point until the facilities reach a
18 per diem add-on of $25.77. Facilities with at least 92% of
19 the staffing indicated by the STRIVE study shall be paid a
20 per diem add-on of $25.77, increasing by equivalent steps
21 for each whole percentage point until the facilities reach
22 a per diem add-on of $30.98. Facilities with at least 100%
23 of the staffing indicated by the STRIVE study shall be
24 paid a per diem add-on of $30.98, increasing by equivalent
25 steps for each whole percentage point until the facilities
26 reach a per diem add-on of $36.44. Facilities with at
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1 least 110% of the staffing indicated by the STRIVE study
2 shall be paid a per diem add-on of $36.44, increasing by
3 equivalent steps for each whole percentage point until the
4 facilities reach a per diem add-on of $38.68. Facilities
5 with at least 125% or higher of the staffing indicated by
6 the STRIVE study shall be paid a per diem add-on of $38.68.
7 No nursing facility's variable staffing per diem add-on
8 shall be reduced by more than 5% in 2 consecutive
9 quarters. For the quarters beginning July 1, 2022 and
10 October 1, 2022, no facility's variable per diem staffing
11 add-on shall be calculated at a rate lower than 85% of the
12 staffing indicated by the STRIVE study. No facility below
13 70% of the staffing indicated by the STRIVE study shall
14 receive a variable per diem staffing add-on after December
15 31, 2022.
16 (7) For dates of services beginning July 1, 2022, the
17 PDPM nursing component per diem for each nursing facility
18 shall be the product of the facility's (i) statewide PDPM
19 nursing base per diem rate, $92.25, adjusted for the
20 facility average PDPM case mix index calculated quarterly
21 and (ii) the regional wage adjuster, and then add the
22 Medicaid access adjustment as defined in (e-3) of this
23 Section. Transition rates for services provided between
24 July 1, 2022 and October 1, 2023 shall be the greater of
25 the PDPM nursing component per diem or:
26 (A) for the quarter beginning July 1, 2022, the
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1 RUG-IV nursing component per diem;
2 (B) for the quarter beginning October 1, 2022, the
3 sum of the RUG-IV nursing component per diem
4 multiplied by 0.80 and the PDPM nursing component per
5 diem multiplied by 0.20;
6 (C) for the quarter beginning January 1, 2023, the
7 sum of the RUG-IV nursing component per diem
8 multiplied by 0.60 and the PDPM nursing component per
9 diem multiplied by 0.40;
10 (D) for the quarter beginning April 1, 2023, the
11 sum of the RUG-IV nursing component per diem
12 multiplied by 0.40 and the PDPM nursing component per
13 diem multiplied by 0.60;
14 (E) for the quarter beginning July 1, 2023, the
15 sum of the RUG-IV nursing component per diem
16 multiplied by 0.20 and the PDPM nursing component per
17 diem multiplied by 0.80; or
18 (F) for the quarter beginning October 1, 2023 and
19 each subsequent quarter, the transition rate shall end
20 and a nursing facility shall be paid 100% of the PDPM
21 nursing component per diem.
22 (d-1) Calculation of base year Statewide RUG-IV nursing
23 base per diem rate.
24 (1) Base rate spending pool shall be:
25 (A) The base year resident days which are
26 calculated by multiplying the number of Medicaid
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1 residents in each nursing home as indicated in the MDS
2 data defined in paragraph (4) by 365.
3 (B) Each facility's nursing component per diem in
4 effect on July 1, 2012 shall be multiplied by
5 subsection (A).
6 (C) Thirteen million is added to the product of
7 subparagraph (A) and subparagraph (B) to adjust for
8 the exclusion of nursing homes defined in paragraph
9 (5).
10 (2) For each nursing home with Medicaid residents as
11 indicated by the MDS data defined in paragraph (4),
12 weighted days adjusted for case mix and regional wage
13 adjustment shall be calculated. For each home this
14 calculation is the product of:
15 (A) Base year resident days as calculated in
16 subparagraph (A) of paragraph (1).
17 (B) The nursing home's regional wage adjustor
18 based on the Health Service Areas (HSA) groupings and
19 adjustors in effect on April 30, 2012.
20 (C) Facility weighted case mix which is the number
21 of Medicaid residents as indicated by the MDS data
22 defined in paragraph (4) multiplied by the associated
23 case weight for the RUG-IV 48 grouper model using
24 standard RUG-IV procedures for index maximization.
25 (D) The sum of the products calculated for each
26 nursing home in subparagraphs (A) through (C) above
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1 shall be the base year case mix, rate adjusted
2 weighted days.
3 (3) The Statewide RUG-IV nursing base per diem rate:
4 (A) on January 1, 2014 shall be the quotient of the
5 paragraph (1) divided by the sum calculated under
6 subparagraph (D) of paragraph (2);
7 (B) on and after July 1, 2014 and until July 1,
8 2022, shall be the amount calculated under
9 subparagraph (A) of this paragraph (3) plus $1.76; and
10 (C) beginning July 1, 2022 and thereafter, $7
11 shall be added to the amount calculated under
12 subparagraph (B) of this paragraph (3) of this
13 Section.
14 (4) Minimum Data Set (MDS) comprehensive assessments
15 for Medicaid residents on the last day of the quarter used
16 to establish the base rate.
17 (5) Nursing facilities designated as of July 1, 2012
18 by the Department as "Institutions for Mental Disease"
19 shall be excluded from all calculations under this
20 subsection. The data from these facilities shall not be
21 used in the computations described in paragraphs (1)
22 through (4) above to establish the base rate.
23 (e) Beginning July 1, 2014, the Department shall allocate
24 funding in the amount up to $10,000,000 for per diem add-ons to
25 the RUGS methodology for dates of service on and after July 1,
26 2014:
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1 (1) $0.63 for each resident who scores in I4200
2 Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
3 (2) $2.67 for each resident who scores either a "1" or
4 "2" in any items S1200A through S1200I and also scores in
5 RUG groups PA1, PA2, BA1, or BA2.
6 (e-1) (Blank).
7 (e-2) For dates of services beginning January 1, 2014 and
8 ending September 30, 2023, the RUG-IV nursing component per
9 diem for a nursing home shall be the product of the statewide
10 RUG-IV nursing base per diem rate, the facility average case
11 mix index, and the regional wage adjustor. For dates of
12 service beginning July 1, 2022 and ending September 30, 2023,
13 the Medicaid access adjustment described in subsection (e-3)
14 shall be added to the product.
15 (e-3) A Medicaid Access Adjustment of $4 adjusted for the
16 facility average PDPM case mix index calculated quarterly
17 shall be added to the statewide PDPM nursing per diem for all
18 facilities with annual Medicaid bed days of at least 70% of all
19 occupied bed days adjusted quarterly. For each new calendar
20 year and for the 6-month period beginning July 1, 2022, the
21 percentage of a facility's occupied bed days comprised of
22 Medicaid bed days shall be determined by the Department
23 quarterly. For dates of service beginning January 1, 2023, the
24 Medicaid Access Adjustment shall be increased to $4.75. This
25 subsection shall be inoperative on and after January 1, 2028.
26 (e-4) Subject to federal approval, on and after January 1,
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1 2024, the Department shall increase the rate add-on at
2 paragraph (7) subsection (a) under 89 Ill. Adm. Code 147.335
3 for ventilator services from $208 per day to $481 per day.
4 Payment is subject to the criteria and requirements under 89
5 Ill. Adm. Code 147.335.
6 (f) (Blank).
7 (g) Notwithstanding any other provision of this Code, on
8 and after July 1, 2012, for facilities not designated by the
9 Department of Healthcare and Family Services as "Institutions
10 for Mental Disease", rates effective May 1, 2011 shall be
11 adjusted as follows:
12 (1) (Blank);
13 (2) (Blank);
14 (3) Facility rates for the capital and support
15 components shall be reduced by 1.7%.
16 (h) Notwithstanding any other provision of this Code, on
17 and after July 1, 2012, nursing facilities designated by the
18 Department of Healthcare and Family Services as "Institutions
19 for Mental Disease" and "Institutions for Mental Disease" that
20 are facilities licensed under the Specialized Mental Health
21 Rehabilitation Act of 2013 shall have the nursing,
22 socio-developmental, capital, and support components of their
23 reimbursement rate effective May 1, 2011 reduced in total by
24 2.7%.
25 (i) On and after July 1, 2014, the reimbursement rates for
26 the support component of the nursing facility rate for
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1 facilities licensed under the Nursing Home Care Act as skilled
2 or intermediate care facilities shall be the rate in effect on
3 June 30, 2014 increased by 8.17%.
4 (i-1) Subject to federal approval, on and after January 1,
5 2024, the reimbursement rates for the support component of the
6 nursing facility rate for facilities licensed under the
7 Nursing Home Care Act as skilled or intermediate care
8 facilities shall be the rate in effect on June 30, 2023
9 increased by 12%.
10 (j) Notwithstanding any other provision of law, subject to
11 federal approval, effective July 1, 2019, sufficient funds
12 shall be allocated for changes to rates for facilities
13 licensed under the Nursing Home Care Act as skilled nursing
14 facilities or intermediate care facilities for dates of
15 services on and after July 1, 2019: (i) to establish, through
16 June 30, 2022 a per diem add-on to the direct care per diem
17 rate not to exceed $70,000,000 annually in the aggregate
18 taking into account federal matching funds for the purpose of
19 addressing the facility's unique staffing needs, adjusted
20 quarterly and distributed by a weighted formula based on
21 Medicaid bed days on the last day of the second quarter
22 preceding the quarter for which the rate is being adjusted.
23 Beginning July 1, 2022, the annual $70,000,000 described in
24 the preceding sentence shall be dedicated to the variable per
25 diem add-on for staffing under paragraph (6) of subsection
26 (d); and (ii) in an amount not to exceed $170,000,000 annually
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1 in the aggregate taking into account federal matching funds to
2 permit the support component of the nursing facility rate to
3 be updated as follows:
4 (1) 80%, or $136,000,000, of the funds shall be used
5 to update each facility's rate in effect on June 30, 2019
6 using the most recent cost reports on file, which have had
7 a limited review conducted by the Department of Healthcare
8 and Family Services and will not hold up enacting the rate
9 increase, with the Department of Healthcare and Family
10 Services.
11 (2) After completing the calculation in paragraph (1),
12 any facility whose rate is less than the rate in effect on
13 June 30, 2019 shall have its rate restored to the rate in
14 effect on June 30, 2019 from the 20% of the funds set
15 aside.
16 (3) The remainder of the 20%, or $34,000,000, shall be
17 used to increase each facility's rate by an equal
18 percentage.
19 (k) During the first quarter of State Fiscal Year 2020,
20 the Department of Healthcare of Family Services must convene a
21 technical advisory group consisting of members of all trade
22 associations representing Illinois skilled nursing providers
23 to discuss changes necessary with federal implementation of
24 Medicare's Patient-Driven Payment Model. Implementation of
25 Medicare's Patient-Driven Payment Model shall, by September 1,
26 2020, end the collection of the MDS data that is necessary to
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1 maintain the current RUG-IV Medicaid payment methodology. The
2 technical advisory group must consider a revised reimbursement
3 methodology that takes into account transparency,
4 accountability, actual staffing as reported under the
5 federally required Payroll Based Journal system, changes to
6 the minimum wage, adequacy in coverage of the cost of care, and
7 a quality component that rewards quality improvements.
8 (l) The Department shall establish per diem add-on
9 payments to improve the quality of care delivered by
10 facilities, including:
11 (1) Incentive payments determined by facility
12 performance on specified quality measures in an initial
13 amount of $70,000,000. Nothing in this subsection shall be
14 construed to limit the quality of care payments in the
15 aggregate statewide to $70,000,000, and, if quality of
16 care has improved across nursing facilities, the
17 Department shall adjust those add-on payments accordingly.
18 The quality payment methodology described in this
19 subsection must be used for at least State Fiscal Year
20 2023. Beginning with the quarter starting July 1, 2023,
21 the Department may add, remove, or change quality metrics
22 and make associated changes to the quality payment
23 methodology as outlined in subparagraph (E). Facilities
24 designated by the Centers for Medicare and Medicaid
25 Services as a special focus facility or a hospital-based
26 nursing home do not qualify for quality payments.
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1 (A) Each quality pool must be distributed by
2 assigning a quality weighted score for each nursing
3 home which is calculated by multiplying the nursing
4 home's quality base period Medicaid days by the
5 nursing home's star rating weight in that period.
6 (B) Star rating weights are assigned based on the
7 nursing home's star rating for the LTS quality star
8 rating. As used in this subparagraph, "LTS quality
9 star rating" means the long-term stay quality rating
10 for each nursing facility, as assigned by the Centers
11 for Medicare and Medicaid Services under the Five-Star
12 Quality Rating System. The rating is a number ranging
13 from 0 (lowest) to 5 (highest).
14 (i) Zero-star or one-star rating has a weight
15 of 0.
16 (ii) Two-star rating has a weight of 0.75.
17 (iii) Three-star rating has a weight of 1.5.
18 (iv) Four-star rating has a weight of 2.5.
19 (v) Five-star rating has a weight of 3.5.
20 (C) Each nursing home's quality weight score is
21 divided by the sum of all quality weight scores for
22 qualifying nursing homes to determine the proportion
23 of the quality pool to be paid to the nursing home.
24 (D) The quality pool is no less than $70,000,000
25 annually or $17,500,000 per quarter. The Department
26 shall publish on its website the estimated payments
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1 and the associated weights for each facility 45 days
2 prior to when the initial payments for the quarter are
3 to be paid. The Department shall assign each facility
4 the most recent and applicable quarter's STAR value
5 unless the facility notifies the Department within 15
6 days of an issue and the facility provides reasonable
7 evidence demonstrating its timely compliance with
8 federal data submission requirements for the quarter
9 of record. If such evidence cannot be provided to the
10 Department, the STAR rating assigned to the facility
11 shall be reduced by one from the prior quarter.
12 (E) The Department shall review quality metrics
13 used for payment of the quality pool and make
14 recommendations for any associated changes to the
15 methodology for distributing quality pool payments in
16 consultation with associations representing long-term
17 care providers, consumer advocates, organizations
18 representing workers of long-term care facilities, and
19 payors. The Department may establish, by rule, changes
20 to the methodology for distributing quality pool
21 payments.
22 (F) The Department shall disburse quality pool
23 payments from the Long-Term Care Provider Fund on a
24 monthly basis in amounts proportional to the total
25 quality pool payment determined for the quarter.
26 (G) The Department shall publish any changes in
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1 the methodology for distributing quality pool payments
2 prior to the beginning of the measurement period or
3 quality base period for any metric added to the
4 distribution's methodology.
5 (2) Payments based on CNA tenure, promotion, and CNA
6 training for the purpose of increasing CNA compensation.
7 It is the intent of this subsection that payments made in
8 accordance with this paragraph be directly incorporated
9 into increased compensation for CNAs. As used in this
10 paragraph, "CNA" means a certified nursing assistant as
11 that term is described in Section 3-206 of the Nursing
12 Home Care Act, Section 3-206 of the ID/DD Community Care
13 Act, and Section 3-206 of the MC/DD Act. The Department
14 shall establish, by rule, payments to nursing facilities
15 equal to Medicaid's share of the tenure wage increments
16 specified in this paragraph for all reported CNA employee
17 hours compensated according to a posted schedule
18 consisting of increments at least as large as those
19 specified in this paragraph. The increments are as
20 follows: an additional $1.50 per hour for CNAs with at
21 least one and less than 2 years' experience plus another
22 $1 per hour for each additional year of experience up to a
23 maximum of $6.50 for CNAs with at least 6 years of
24 experience. For purposes of this paragraph, Medicaid's
25 share shall be the ratio determined by paid Medicaid bed
26 days divided by total bed days for the applicable time
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1 period used in the calculation. In addition, and additive
2 to any tenure increments paid as specified in this
3 paragraph, the Department shall establish, by rule,
4 payments supporting Medicaid's share of the
5 promotion-based wage increments for CNA employee hours
6 compensated for that promotion with at least a $1.50
7 hourly increase. Medicaid's share shall be established as
8 it is for the tenure increments described in this
9 paragraph. Qualifying promotions shall be defined by the
10 Department in rules for an expected 10-15% subset of CNAs
11 assigned intermediate, specialized, or added roles such as
12 CNA trainers, CNA scheduling "captains", and CNA
13 specialists for resident conditions like dementia or
14 memory care or behavioral health.
15 (m) The Department shall work with nursing facility
16 industry representatives to design policies and procedures to
17 permit facilities to address the integrity of data from
18 federal reporting sites used by the Department in setting
19 facility rates.
20 (Source: P.A. 102-77, eff. 7-9-21; 102-558, eff. 8-20-21;
21 102-1035, eff. 5-31-22; 102-1118, eff. 1-18-23; 103-102,
22 Article 40, Section 40-5, eff. 1-1-24; 103-102, Article 50,
23 Section 50-5, eff. 1-1-24; 103-593, eff. 6-7-24; 103-605, eff.
24 7-1-24.)
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