305 ILCS 5/5-5.4
2021 Illinois Compiled Statutes|Chapter 305 - PUBLIC AID|305 ILCS 5/ - Illinois Public Aid Code.|Article V - Medical Assistance

 (from Ch. 23, par. 5-5.4)Sec. 5-5.4. Standards of Payment - Department of Healthcare and Family Services.  The Department of Healthcare and Family Services shall develop standards of payment of  nursing facility and ICF/DD services in facilities providing such services  under this Article which:(1) Provide for the determination of a facility's payment  for nursing facility or ICF/DD services on a prospective basis.  The amount of the payment rate for all nursing facilities certified by the  Department of Public Health under the ID/DD Community Care Act or the Nursing Home Care Act as Intermediate  Care for the Developmentally Disabled facilities, Long Term Care for Under Age  22 facilities, Skilled Nursing facilities, or Intermediate Care facilities  under the  medical assistance program shall be prospectively established annually on the  basis of historical, financial, and statistical data reflecting actual costs  from prior years, which shall be applied to the current rate year and updated  for inflation, except that the capital cost element for newly constructed  facilities shall be based upon projected budgets.  The annually established  payment rate shall take effect on July 1 in 1984 and subsequent years.  No rate  increase and no  update for inflation shall be provided on or after July 1, 1994, unless specifically provided for in this  Section.  The changes made by Public Act 93-841    extending the duration of the prohibition against a rate increase or update for inflation are effective retroactive to July 1, 2004.For facilities licensed by the Department of Public Health under the Nursing  Home Care Act as Intermediate Care for the Developmentally Disabled facilities  or Long Term Care for Under Age 22 facilities, the rates taking effect on July  1, 1998 shall include an increase of 3%.  For facilities licensed by the  Department of Public Health under the Nursing Home Care Act as Skilled Nursing  facilities or Intermediate Care facilities, the rates taking effect on July 1,  1998 shall include an increase of 3% plus $1.10 per resident-day, as defined by  the Department. For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January 1, 2006 shall include an increase of 3%.  For facilities licensed by the Department of Public Health under the Nursing Home Care Act as Intermediate Care Facilities for the Developmentally Disabled or Long Term Care for Under Age 22 facilities, the rates taking effect on January  1, 2009 shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive staff. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities the rates taking effect within 30 days after July 6, 2017 (the effective date of Public Act 100-23) shall include an increase sufficient to provide a $0.75 per hour wage increase for non-executive staff. The Department shall adopt rules, including emergency rules under subsection (y) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this paragraph. For facilities licensed by the Department of Public Health under the ID/DD Community Care Act  as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, the rates taking effect within 30 days after the effective date of this amendatory Act of the 100th General Assembly shall include an increase sufficient to provide a $0.50 per hour wage increase for non-executive  front-line personnel, including, but not limited to, direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff. The Department shall adopt rules, including emergency rules under subsection (bb) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this paragraph.For facilities licensed by the Department of Public Health under the  Nursing Home Care Act as Intermediate Care for the Developmentally Disabled  facilities or Long Term Care for Under Age 22 facilities, the rates taking  effect on July 1, 1999 shall include an increase of 1.6% plus $3.00 per  resident-day, as defined by the Department.  For facilities licensed by the  Department of Public Health under the Nursing Home Care Act as Skilled Nursing  facilities or Intermediate Care facilities, the rates taking effect on July 1,  1999 shall include an increase of 1.6% and, for services provided on or after  October 1, 1999, shall be increased by $4.00 per resident-day, as defined by  the Department.For facilities licensed by the Department of Public Health under the  Nursing Home Care Act as Intermediate Care for the Developmentally Disabled  facilities or Long Term Care for Under Age 22 facilities, the rates taking  effect on July 1, 2000 shall include an increase of 2.5% per resident-day,  as defined by the Department.  For facilities licensed by the Department of  Public Health under the Nursing Home Care Act as Skilled Nursing facilities or  Intermediate Care facilities, the rates taking effect on July 1, 2000 shall  include an increase of 2.5% per resident-day, as defined by the Department.For facilities licensed by the Department of Public Health under the  Nursing Home Care Act as skilled nursing facilities or intermediate care  facilities, a new payment methodology must be implemented for the nursing  component of the rate effective July 1, 2003. The Department of Public Aid  (now Healthcare and Family Services) shall develop the new payment methodology using the Minimum Data Set  (MDS) as the instrument to collect information concerning nursing home  resident condition necessary to compute the rate. The Department  shall develop the new payment methodology to meet the unique needs of  Illinois nursing home residents while remaining subject to the appropriations  provided by the General Assembly.  A transition period from the payment methodology in effect on June 30, 2003  to the payment methodology in effect on July 1, 2003 shall be provided for a  period not exceeding 3 years and 184 days after implementation of the new payment  methodology as follows:(A) For a facility that would receive a lower nursing     component rate per patient day under the new system than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be held at the level in effect on the date immediately preceding the date that the Department implements the new payment methodology until a higher nursing component rate of reimbursement is achieved by that facility.(B) For a facility that would receive a higher     nursing component rate per patient day under the payment methodology in effect on July 1, 2003 than the facility received effective on the date immediately preceding the date that the Department implements the new payment methodology, the nursing component rate per patient day for the facility shall be adjusted.(C) Notwithstanding paragraphs (A) and (B), the     nursing component rate per patient day for the facility shall be adjusted subject to appropriations provided by the General Assembly.For facilities licensed by the Department of Public Health under the  Nursing Home Care Act as Intermediate Care for the Developmentally Disabled  facilities or Long Term Care for Under Age 22 facilities, the rates taking  effect on March 1, 2001 shall include a statewide increase of 7.85%, as  defined by the Department.Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the  Nursing Home Care Act as skilled nursing facilities or intermediate care  facilities, except facilities participating in the Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, the numerator of the ratio used by the Department of Healthcare and Family Services to compute the rate payable under this Section using the Minimum Data Set (MDS) methodology shall incorporate the following annual amounts as the additional funds appropriated to the Department specifically to pay for rates based on the MDS nursing component methodology in excess of the funding in effect on December 31, 2006:(i) For rates taking effect January 1, 2007,     $60,000,000.(ii) For rates taking effect January 1, 2008,     $110,000,000.(iii) For rates taking effect January 1, 2009,     $194,000,000.(iv) For rates taking effect April 1, 2011, or the     first day of the month that begins at least 45 days after the effective date of this amendatory Act of the 96th General Assembly, $416,500,000 or an amount as may be necessary to complete the transition to the MDS methodology for the nursing component of the rate. Increased payments under this item (iv) are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act.Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the support component of the rates taking effect on January 1, 2008 shall be computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006.For facilities licensed by the Department of Public Health under the  Nursing Home Care Act as Intermediate Care for the Developmentally Disabled  facilities or Long Term Care for Under Age 22 facilities, the rates taking  effect on April 1, 2002 shall include a statewide increase of 2.0%, as  defined by the Department.  This increase terminates on July 1, 2002;  beginning July 1, 2002 these rates are reduced to the level of the rates  in effect on March 31, 2002, as defined by the Department.For facilities licensed by the Department of Public Health under the  Nursing Home Care Act as skilled nursing facilities or intermediate care  facilities, the rates taking effect on July 1, 2001 shall be computed using the most recent cost reports  on file with the Department of Public Aid no later than April 1, 2000,  updated for inflation to January 1, 2001.  For rates effective July 1, 2001  only, rates shall be the greater of the rate computed for July 1, 2001  or the rate effective on June 30, 2001.Notwithstanding any other provision of this Section, for facilities  licensed by the Department of Public Health under the Nursing Home Care Act  as skilled nursing facilities or intermediate care facilities, the Illinois  Department shall determine by rule the rates taking effect on July 1, 2002,  which shall be 5.9% less than the rates in effect on June 30, 2002.Notwithstanding any other provision of this Section, for facilities  licensed by the Department of Public Health under the Nursing Home Care Act as  skilled nursing  facilities or intermediate care facilities, if the payment methodologies required under Section 5A-12 and the waiver granted under 42 CFR 433.68 are approved by the United States Centers for Medicare and Medicaid Services, the rates taking effect on July 1, 2004 shall be 3.0% greater than the rates in effect on June 30, 2004. These rates shall take  effect only upon approval and  implementation of the payment methodologies required under Section 5A-12.Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, the rates taking effect on January 1, 2005 shall be 3% more than the rates in effect on December 31, 2004.Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January  1, 2009, the per diem support component of the rates effective on January 1, 2008, computed using the most recent cost reports on file with the Department of Healthcare and Family Services no later than April 1, 2005, updated for inflation to January 1, 2006, shall be increased to the amount that would have been derived using standard Department of Healthcare and Family Services methods, procedures, and inflators.Notwithstanding any other provisions of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as intermediate care facilities that are federally defined as Institutions for Mental Disease, or facilities licensed by the Department of Public Health under the Specialized Mental Health Rehabilitation Act of 2013, a socio-development component rate equal to 6.6% of the facility's nursing component rate as of January 1, 2006 shall be established and paid effective July 1, 2006. The socio-development component of the rate shall be increased by a factor of 2.53 on the first day of the month that begins at least 45 days after January 11, 2008 (the effective date of Public Act 95-707). As of August 1, 2008, the socio-development component rate shall be equal to 6.6% of the facility's nursing component rate as of January 1, 2006, multiplied by a factor of 3.53. For services provided on or after April 1, 2011, or the first day of the month that begins at least 45 days after the effective date of this amendatory Act of the 96th General Assembly, whichever is later, the Illinois Department may by rule adjust these socio-development component rates, and may use different adjustment methodologies for those facilities participating, and those not participating, in the Illinois Department's demonstration program pursuant to the provisions of Title 77, Part 300, Subpart T of the Illinois Administrative Code, but in no case may such rates be diminished below those in effect on August 1, 2008.For facilities  licensed  by the  Department of Public Health under the Nursing Home Care Act as Intermediate  Care for  the Developmentally Disabled facilities or as long-term care facilities for  residents under 22 years of age, the rates taking effect on July 1,  2003 shall  include a statewide increase of 4%, as defined by the Department.For facilities licensed by the Department of Public Health under the  Nursing Home Care Act as Intermediate Care for the Developmentally Disabled  facilities or Long Term Care for Under Age 22 facilities, the rates taking  effect on the first day of the month that begins at least 45 days after the effective date of this amendatory Act of the 95th General Assembly shall include a statewide increase of 2.5%, as  defined by the Department.Notwithstanding any other provision of this Section, for facilities licensed by the Department of Public Health under the Nursing Home Care Act as skilled nursing facilities or intermediate care facilities, effective January 1, 2005, facility rates shall be increased by the difference between (i) a facility's per diem property, liability, and malpractice insurance costs as reported in the cost report filed with the Department of Public Aid and used to establish rates effective July 1, 2001 and (ii) those same costs as reported in the facility's 2002 cost report.  These costs shall be passed through to the facility without caps or limitations, except for adjustments required under normal auditing procedures.Rates established effective each July 1 shall govern payment  for services rendered throughout that fiscal year, except that rates  established on July 1, 1996 shall be increased by 6.8% for services  provided on or after January 1, 1997.  Such rates will be based  upon the rates calculated for the year beginning July 1, 1990, and for  subsequent years thereafter until June 30, 2001 shall be based on the  facility cost reports  for the facility fiscal year ending at any point in time during the previous  calendar year, updated to the midpoint of the rate year.  The cost report  shall be on file with the Department no later than April 1 of the current  rate year.  Should the cost report not be on file by April 1, the Department  shall base the rate on the latest cost report filed by each skilled care  facility and intermediate care facility, updated to the midpoint of the  current rate year.  In determining rates for services rendered on and after  July 1, 1985, fixed time shall not be computed at less than zero.  The  Department shall not make any alterations of regulations which would reduce  any component of the Medicaid rate to a level below what that component would  have been utilizing in the rate effective on July 1, 1984.(2) Shall take into account the actual costs incurred by facilities  in providing services for recipients of skilled nursing and intermediate  care services under the medical assistance program.(3) Shall take into account the medical and psycho-social  characteristics and needs of the patients.(4) Shall take into account the actual costs incurred by facilities in  meeting licensing and certification standards imposed and prescribed by the  State of Illinois, any of its political subdivisions or municipalities and by  the U.S. Department of Health and Human Services pursuant to Title XIX of the  Social Security Act.The Department of Healthcare and Family Services    shall develop precise standards for  payments to reimburse nursing facilities for any utilization of  appropriate rehabilitative personnel for the provision of rehabilitative  services which is authorized by federal regulations, including  reimbursement for services provided by qualified therapists or qualified  assistants, and which is in accordance with accepted professional  practices.  Reimbursement also may be made for utilization of other  supportive personnel under appropriate supervision.The Department shall develop enhanced payments to offset the additional costs incurred by a          facility serving exceptional need residents and shall allocate at least $4,000,000 of the funds          collected from the assessment established by Section 5B-2 of this Code for such payments. For          the purpose of this Section, "exceptional needs" means, but need not be limited to, ventilator care and traumatic brain injury care. The enhanced payments for exceptional need residents under this paragraph  are not due and payable, however, until (i) the methodologies described in this paragraph are approved by the federal government in an appropriate State Plan amendment and (ii) the assessment imposed by Section 5B-2 of this Code is determined to be a permissible tax under Title XIX of the Social Security Act.Beginning January 1, 2014 the methodologies for reimbursement of nursing facility services as provided under this Section 5-5.4 shall no longer be applicable for services provided on or after January 1, 2014.No payment increase under this Section for the MDS methodology, exceptional care residents, or the socio-development component rate established by Public Act 96-1530 of the 96th General Assembly and funded by the assessment imposed under Section 5B-2 of this Code shall be due and payable until after the Department notifies the long-term care providers, in writing, that the payment methodologies to long-term care providers required under this Section have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services and the waivers under 42 CFR 433.68 for the assessment imposed by this Section, if necessary, have been granted by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services. Upon notification to the Department of approval of the payment methodologies required under this Section and the waivers granted under 42 CFR 433.68, all increased payments otherwise due under this Section prior to the date of notification shall be due and payable within 90 days of the date federal approval is received.On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval, the rates taking effect for services delivered on or after August 1, 2019 shall be increased by 3.5% over the rates in effect on June 30, 2019.  The Department shall adopt rules, including emergency rules under subsection (ii) of Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval, the rates taking effect on the latter of the approval date of the State Plan Amendment for these facilities or the Waiver Amendment for the home and community-based services settings shall include an increase sufficient to provide a $0.26 per hour wage increase to the base wage for non-executive staff. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of  this Section, including wage increases for direct care staff.For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment and the Waiver Amendment for the home and community-based services settings, the rates taking effect for the services delivered on or after July 1, 2020 shall include an increase sufficient to provide a $1.00 per hour wage increase for non-executive staff. For services delivered on or after January 1, 2021, subject to federal approval of the State Plan Amendment and the Waiver Amendment for the home and community-based services settings, shall include an increase sufficient to provide a $0.50 per hour increase for non-executive staff. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section, including wage increases for direct care staff.For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for the residential services delivered on or after July 1, 2021, shall include an increase sufficient to provide a $0.50 per hour increase for aides in the rate methodology.  For facilities licensed by the Department of Public Health under the ID/DD Community Care Act as ID/DD Facilities and under the MC/DD Act as MC/DD Facilities, subject to federal approval of the State Plan Amendment, the rates taking effect for the residential services delivered on or after January 1, 2022 shall include an increase sufficient to provide a $1.00 per hour increase for aides in the rate methodology.  In addition, for residential services delivered on or after January 1, 2022 such rates shall include an increase sufficient to provide wages for all residential non-executive direct care staff, excluding aides, at the federal Department of Labor, Bureau of Labor Statistics' average wage as defined in rule by the Department. The Department shall adopt rules, including emergency rules as authorized by Section 5-45 of the Illinois Administrative Procedure Act, to implement the provisions of this Section. (Source: P.A. 101-10, eff. 6-5-19; 101-636, eff. 6-10-20; 102-16, eff. 6-17-21.)