Section 146.225 Reimbursement for Medicaid Residents

Section 146

Section 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

n 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

ent'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)

e 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.