Nursing facilities receive a per diem (a single comprehensive payment per day per resident). The per diem is specific to each facility and is the sum of three separately calculated components – nursing, support and capital.
Support and capital rates are set based on information provided by facilities through cost reports submitted to the Department. The nursing component is a function of the health care needs of the facility’s residents, as measured by the Minimum Data Set (MDS) completed by each facility. The MDS-based reimbursement methodology goes into effect January 1, 2007.
Reimbursement rates were frozen on January 18, 1994. Since implementation of the rate freeze, exceptions allow for adjustments to the facility per diem based upon specific changes in facility costs. These exceptions can be found at 89 Ill. Adm. Code 153.100. Additionally, facility rates have increased or decreased since the freeze based on statutory authority. The history of those increases or decreases can be found at 89 Ill. Adm. Code 153.125 and 153.126.
Each Medicare and Medicaid certified nursing facility shall complete, and transmit quarterly to the Department, a full Minimum Data Set (MDS) for each resident who resides in a certified bed, regardless of payment source. 89 Ill. Adm. Code 147. Table A identifies MDS items that are used to calculate a profile on each Medicaid-eligible resident within each facility. The profile for each Medicaid-eligible resident will be blended to determine the nursing component of the nursing facility's Medicaid rate. Each MDS item in Table A includes a description of the item and the variable time. The variable time assigned to each level represents the type of staff that should be delivering the service (unlicensed, licensed, social worker and activity) and the number of minutes allotted to that service item.