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1 | AN ACT concerning public aid.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Public Aid Code is amended by | ||||||
5 | changing Section 5-5.4h as follows: | ||||||
6 | (305 ILCS 5/5-5.4h) | ||||||
7 | Sec. 5-5.4h. Medicaid reimbursement for medically complex | ||||||
8 | for the developmentally disabled facilities licensed under the | ||||||
9 | MC/DD Act long-term care facilities for persons under 22 years | ||||||
10 | of age . | ||||||
11 | (a) Facilities licensed as medically complex for the | ||||||
12 | developmentally disabled facilities long-term care facilities | ||||||
13 | for persons under 22 years of age that serve severely and | ||||||
14 | chronically ill pediatric patients shall have a specific | ||||||
15 | reimbursement system designed to recognize the characteristics | ||||||
16 | and needs of the patients they serve. | ||||||
17 | (b) For dates of services starting July 1, 2013 and until a | ||||||
18 | new reimbursement system is designed, medically complex for the | ||||||
19 | developmentally disabled facilities long-term care facilities | ||||||
20 | for persons under 22 years of age that meet the following | ||||||
21 | criteria: | ||||||
22 | (1) serve exceptional care patients; and | ||||||
23 | (2) have 30% or more of their patients receiving |
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1 | ventilator care; | ||||||
2 | shall receive Medicaid reimbursement on a 30-day expedited | ||||||
3 | schedule.
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4 | (c) Subject to federal approval of changes to the Title XIX | ||||||
5 | State Plan, for dates of services starting July 1, 2014 through | ||||||
6 | March 31, 2019, medically complex for the developmentally | ||||||
7 | disabled facilities and until a new reimbursement system is | ||||||
8 | designed, long-term care facilities for persons under 22 years | ||||||
9 | of age which meet the criteria in subsection (b) of this | ||||||
10 | Section shall receive a per diem rate for clinically complex | ||||||
11 | residents of $304. Clinically complex residents on a ventilator | ||||||
12 | shall receive a per diem rate of $669. Subject to federal | ||||||
13 | approval of changes to the Title XIX State Plan, for dates of | ||||||
14 | services starting April 1, 2019, medically complex for the | ||||||
15 | developmentally disabled facilities must be reimbursed an | ||||||
16 | exceptional care per diem rate, instead of the base rate, for | ||||||
17 | services to residents with complex or extensive medical needs. | ||||||
18 | Exceptional care per diem rates must be paid for the conditions | ||||||
19 | or services specified under subsection (f) at the following per | ||||||
20 | diem rates: Tier 1 $326, Tier 2 $546, and Tier 3 $735. | ||||||
21 | (d) For To qualify for the per diem rate of $669 for | ||||||
22 | clinically complex residents on a ventilator pursuant to | ||||||
23 | subsection (c) or subsection (f) , facilities shall have a | ||||||
24 | policy documenting their method of routine assessment of a | ||||||
25 | resident's weaning potential with interventions implemented | ||||||
26 | noted in the resident's medical record. |
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1 | (e) For services provided prior to April 1, 2019 and for | ||||||
2 | For the purposes of this Section, a resident is considered | ||||||
3 | clinically complex if the resident requires at least one of the | ||||||
4 | following medical services: | ||||||
5 | (1) Tracheostomy care with dependence on mechanical | ||||||
6 | ventilation for a minimum of 6 hours each day. | ||||||
7 | (2) Tracheostomy care requiring suctioning at least | ||||||
8 | every 6 hours, room air mist or oxygen as needed, and | ||||||
9 | dependence on one of the treatment procedures listed under | ||||||
10 | paragraph (4) excluding the procedure listed in | ||||||
11 | subparagraph (A) of paragraph (4). | ||||||
12 | (3) Total parenteral nutrition or other intravenous | ||||||
13 | nutritional support and one of the treatment procedures | ||||||
14 | listed under paragraph (4). | ||||||
15 | (4) The following treatment procedures apply to the | ||||||
16 | conditions in paragraphs (2) and (3) of this subsection: | ||||||
17 | (A) Intermittent suctioning at least every 8 hours | ||||||
18 | and room air mist or oxygen as needed. | ||||||
19 | (B) Continuous intravenous therapy including | ||||||
20 | administration of therapeutic agents necessary for | ||||||
21 | hydration or of intravenous pharmaceuticals; or | ||||||
22 | intravenous pharmaceutical administration of more than | ||||||
23 | one agent via a peripheral or central line, without | ||||||
24 | continuous infusion. | ||||||
25 | (C) Peritoneal dialysis treatments requiring at | ||||||
26 | least 4 exchanges every 24 hours. |
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1 | (D) Tube feeding via nasogastric or gastrostomy | ||||||
2 | tube. | ||||||
3 | (E) Other medical technologies required | ||||||
4 | continuously, which in the opinion of the attending | ||||||
5 | physician require the services of a professional | ||||||
6 | nurse. | ||||||
7 | (f) Complex or extensive medical needs for exceptional care | ||||||
8 | reimbursement. The conditions and services used for the | ||||||
9 | purposes of this Section have the same meanings as ascribed to | ||||||
10 | those conditions and services under the Minimum Data Set (MDS) | ||||||
11 | Resident Assessment Instrument (RAI) and specified in the most | ||||||
12 | recent manual. Instead of submitting minimum data set | ||||||
13 | assessments to the Department, medically complex for the | ||||||
14 | developmentally disabled facilities must document within each | ||||||
15 | resident's medical record the conditions or services using the | ||||||
16 | minimum data set documentation standards and requirements to | ||||||
17 | qualify for exceptional care reimbursement. | ||||||
18 | (1) Tier 1 reimbursement is for residents who are | ||||||
19 | receiving at least 51% of their caloric intake via a | ||||||
20 | feeding tube. | ||||||
21 | (2) Tier 2 reimbursement is for residents who are | ||||||
22 | receiving tracheostomy care without a ventilator. | ||||||
23 | (3) Tier 3 reimbursement is for residents who are | ||||||
24 | receiving tracheostomy care and ventilator care. | ||||||
25 | (g) For dates of services starting April 1, 2019, | ||||||
26 | reimbursement calculations and direct payment for services |
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1 | provided by medically complex for the developmentally disabled | ||||||
2 | facilities are the responsibility of the Department of | ||||||
3 | Healthcare and Family Services instead of the Department of | ||||||
4 | Human Services. Appropriations for medically complex for the | ||||||
5 | developmentally disabled facilities must be shifted from the | ||||||
6 | Department of Human Services to the Department of Healthcare | ||||||
7 | and Family Services. Nothing in this Section prohibits the | ||||||
8 | Department of Healthcare and Family Services from paying more | ||||||
9 | than the rates specified in this Section. The rates in this | ||||||
10 | Section must be interpreted as a minimum amount. Any | ||||||
11 | reimbursement increases applied to providers licensed under | ||||||
12 | the ID/DD Community Care Act must also be applied in an | ||||||
13 | equivalent manner to medically complex for the developmentally | ||||||
14 | disabled facilities. | ||||||
15 | (h) The Department of Healthcare and Family Services shall | ||||||
16 | pay the rates in effect on March 31, 2019 until the changes | ||||||
17 | made to this Section by this amendatory Act of the 100th | ||||||
18 | General Assembly have been approved by the Centers for Medicare | ||||||
19 | and Medicaid Services of the U.S. Department of Health and | ||||||
20 | Human Services. | ||||||
21 | (i) The Department of Healthcare and Family Services may | ||||||
22 | adopt rules as allowed by the Illinois Administrative Procedure | ||||||
23 | Act to implement this Section; however, the requirements of | ||||||
24 | this Section must be implemented by the Department of | ||||||
25 | Healthcare and Family Services even if the Department of | ||||||
26 | Healthcare and Family Services has not adopted rules by the |
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1 | implementation date of April 1, 2019. | ||||||
2 | (Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14.)
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3 | Section 99. Effective date. This Act takes effect upon | ||||||
4 | becoming law.
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