Section 305 ILCS 5/5-5.4h - Medicaid reimbursement for medically complex for the developmentally disabled facilities licensed under the MC/DD Act(a) Facilities licensed as medically complex for the developmentally disabled facilities that serve severely and chronically ill patients shall have a specific reimbursement system designed to recognize the characteristics and needs of the patients they serve.(b) For dates of services starting July 1, 2013 and until a new reimbursement system is designed, medically complex for the developmentally disabled facilities that meet the following criteria: (1) serve exceptional care patients; and(2) have 30% or more of their patients receiving ventilator care; shall receive Medicaid reimbursement on a 30-day expedited schedule.
(c) Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting July 1, 2014 through March 31, 2019, medically complex for the developmentally disabled facilities which meet the criteria in subsection (b) of this Section shall receive a per diem rate for clinically complex residents of $304. Clinically complex residents on a ventilator shall receive a per diem rate of $669. Subject to federal approval of changes to the Title XIX State Plan, for dates of services starting April 1, 2019, medically complex for the developmentally disabled facilities must be reimbursed an exceptional care per diem rate, instead of the base rate, for services to residents with complex or extensive medical needs. Exceptional care per diem rates must be paid for the conditions or services specified under subsection (f) at the following per diem rates: Tier 1 $326, Tier 2 $546, and Tier 3 $735. Subject to federal approval, on and after January 1, 2024, each tier rate shall be increased 6% over the amount in effect on the effective date of this amendatory Act of the 103rd General Assembly. Any reimbursement increases applied to the base rate to providers licensed under the ID/DD Community Care Act must also be applied in an equivalent manner to each tier of exceptional care per diem rates for medically complex for the developmentally disabled facilities.(d) For residents on a ventilator pursuant to subsection (c) or subsection (f), facilities shall have a policy documenting their method of routine assessment of a resident's weaning potential with interventions implemented noted in the resident's medical record.(e) For services provided prior to April 1, 2019 and for the purposes of this Section, a resident is considered clinically complex if the resident requires at least one of the following medical services: (1) Tracheostomy care with dependence on mechanical ventilation for a minimum of 6 hours each day.(2) Tracheostomy care requiring suctioning at least every 6 hours, room air mist or oxygen as needed, and dependence on one of the treatment procedures listed under paragraph (4) excluding the procedure listed in subparagraph (A) of paragraph (4).(3) Total parenteral nutrition or other intravenous nutritional support and one of the treatment procedures listed under paragraph (4).(4) The following treatment procedures apply to the conditions in paragraphs (2) and (3) of this subsection:(A) Intermittent suctioning at least every 8 hours and room air mist or oxygen as needed.(B) Continuous intravenous therapy including administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals; or intravenous pharmaceutical administration of more than one agent via a peripheral or central line, without continuous infusion.(C) Peritoneal dialysis treatments requiring at least 4 exchanges every 24 hours.(D) Tube feeding via nasogastric or gastrostomy tube.(E) Other medical technologies required continuously, which in the opinion of the attending physician require the services of a professional nurse.(f) Complex or extensive medical needs for exceptional care reimbursement. The conditions and services used for the purposes of this Section have the same meanings as ascribed to those conditions and services under the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) and specified in the most recent manual. Instead of submitting minimum data set assessments to the Department, medically complex for the developmentally disabled facilities must document within each resident's medical record the conditions or services using the minimum data set documentation standards and requirements to qualify for exceptional care reimbursement. (1) Tier 1 reimbursement is for residents who are receiving at least 51% of their caloric intake via a feeding tube.(2) Tier 2 reimbursement is for residents who are receiving tracheostomy care without a ventilator.(3) Tier 3 reimbursement is for residents who are receiving tracheostomy care and ventilator care.(g) For dates of services starting April 1, 2019, reimbursement calculations and direct payment for services provided by medically complex for the developmentally disabled facilities are the responsibility of the Department of Healthcare and Family Services instead of the Department of Human Services. Appropriations for medically complex for the developmentally disabled facilities must be shifted from the Department of Human Services to the Department of Healthcare and Family Services. Nothing in this Section prohibits the Department of Healthcare and Family Services from paying more than the rates specified in this Section. The rates in this Section must be interpreted as a minimum amount. Any reimbursement increases applied to providers licensed under the ID/DD Community Care Act must also be applied in an equivalent manner to medically complex for the developmentally disabled facilities.(h) The Department of Healthcare and Family Services shall pay the rates in effect on March 31, 2019 until the changes made to this Section by this amendatory Act of the 100th General Assembly have been approved by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.(i) The Department of Healthcare and Family Services may adopt rules as allowed by the Illinois Administrative Procedure Act to implement this Section; however, the requirements of this Section must be implemented by the Department of Healthcare and Family Services even if the Department of Healthcare and Family Services has not adopted rules by the implementation date of April 1, 2019.Amended by P.A. 103-0102,§ 75-5, eff. 1/1/2024.Amended by P.A. 100-0646,§ 20, eff. 7/27/2018.Amended by P.A. 098-0651,§ 55-15, eff. 6/16/2014.Added by P.A. 098-0104,§ 11-45, eff. 7/22/2013.