Ill. Admin. Code tit. 89, § 146.225 - Reimbursement for Medicaid Residents
Supportive Living Programs (SLPs) shall accept the reimbursement provided in this Section as payment in full for all services provided to Medicaid residents.
a) The
Department has established the rate methodology for SLP providers as follows:
1) Prior to July 1, 2014, the Department
shall establish its portion of the reimbursement for Medicaid residents by
calculating 60 percent of the weighted average (weighted by Medicaid patient
days) nursing facility rates for the geographic grouping as defined in Section
146.290. Each
SLP shall be paid 60 percent of the weighted average nursing facility
geographic group rate, based upon the nursing facility geographic group in
which it is located. The rates paid to SLPs shall be updated semi-annually on
April 1 and on October 1 to assure that the rates coincide with 60 percent of
weighted average nursing facility geographic group rates. Notwithstanding the
provisions of this subsection, the supportive living program rates shall remain
at the level in effect on April 30, 2011.
2) Notwithstanding the provisions set forth
in 89 Ill. Adm. Code
153.126,
and subject to federal CMS approval, as of July 1, 2014, supportive living
program rates shall no longer be 60 percent of the weighted average nursing
facility rates for the geographic group rate, based upon the nursing facility
geographic group in which it is located.
3) Notwithstanding the provisions set forth
in 89 Ill. Adm. Code 153.126, and subject to federal CMS approval, for dates of
service on or after July 1, 2014, rates effective on June 30, 2014 shall be
increased 8.85 percent.
4)
Notwithstanding the provisions set forth in 89 Ill. Adm. Code 153.126, and
subject to federal CMS approval of the imposition of the assessment in 89 Ill.
Adm. Code
140.86,
for dates of service on or after July 1, 2014, rates effective July 1, 2014
shall be increased an additional 9.09 percent.
5) Notwithstanding the provisions set forth
in 89 Ill. Adm. Code 153.126, for dates of service on or after July 1, 2017,
rates effective on June 30, 2017 shall be increased by 2.8 percent.
b) The payment rate received by
the SLP from the Department for services, with the exception of meals, provided
in accordance with Section
146.230 shall constitute
the full and complete charge for services rendered. Additional payment, other
than patient credits authorized by the Department, may not be accepted. Meals
are included in the room and board amount paid by the resident.
c) Single Occupancy: Each Medicaid resident
of an SLP shall be allotted a minimum of $90 per month as a deduction from his
or her income as a protected amount for personal use. The SLP may charge each
Medicaid resident no more than the current SSI rate for a single individual
less a minimum of $90 for room and board charges. Any income remaining after
deduction of the protected minimum of $90 and room and board charges shall be
applied first towards medical expenses not covered under the Department's
Medical Assistance Program. Any income remaining after that shall be applied to
the charges for SLP services paid by the Department.
d) Double Occupancy: In the event a Medicaid
eligible resident chooses to share an apartment, the Medicaid resident of an
SLP shall be allotted a minimum of $90 per month as a deduction from his or her
income as a protected amount for personal use. The SLP may charge each Medicaid
resident no more than the resident's share of the current SSI rate for a couple
less a minimum of $90 for room and board charges. The room and board rate for
two Medicaid eligible individuals sharing an apartment cannot exceed the SSI
rate for a married couple even if the two individuals sharing an apartment are
unrelated. Any income of an individual remaining after deduction of the
protected minimum of $90 and room and board charges shall be applied first
towards that individual's medical expenses not covered under the Department's
Medical Assistance Program. Any income of an individual remaining after that
shall be applied to that individual's charges for SLP services paid by the
Department. If one, or both, of the individuals sharing an apartment is not
Medicaid eligible, the SLP may negotiate its own rate with the non-Medicaid
individual or individuals.
e) The
room and board charge for Medicaid residents shall only be increased when the
SSI amount is increased. Any room and board charge increase shall not exceed
the amount of the SSI increase.
f)
Payment shall be made by the Department for up to 30 days per State fiscal year
during a Medicaid resident's temporary absence from the SLP when the absence is
due to situations such as hospitalizations or vacations. The resident shall
continue to be responsible for room and board charges during any absence.
Involuntary discharge criteria relating to temporary absence are found at
Section
146.255(b) and
(d)(7). Nursing facilities that have a
distinct part certified as an SLP shall consider converted beds in the nursing
facility's licensed capacity when calculating the 93 percent occupancy level
for bed reserve payments pursuant to 89 Ill. Adm. Code
140.523.
1) The day a resident is transferred to the
hospital is the first day of the temporary absence.
2) For all other temporary absences, except a
long-term care admission, the day after resident leaves the SLP is the first
day of the temporary absence.
3)
The day before resident returns to the SLP is the last day of the temporary
absence.
4) The Department does not
pay for temporary absence due to admission to a long-term care facility. In
this instance, an SLP shall discharge the resident from the Department's
database. An SLP may choose to hold an apartment while a resident is in a
long-term care facility.
5) By
agreement between the SLP and a resident, an SLP may continue to hold an
apartment when a resident has exceeded the 30 days payable by the
Department.
Notes
Amended at 36 Ill. Reg. 13885, effective August 27, 2012
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