(305 ILCS 5/5-5.4h)
Sec. 5-5.4h. Medicaid reimbursement for long-term care facilities for persons under 22 years of age.
(a) Facilities licensed as long-term care facilities for persons under 22 years of age that serve severely and chronically ill pediatric 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, long-term care facilities for persons under 22 years of age 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 and until a new reimbursement system is designed, long-term care facilities for persons under 22 years of age 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.
(d) To qualify for the per diem rate of $669 for clinically complex residents on a ventilator pursuant to subsection (c), 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 record.
(e) 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.
(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14.)
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Last modified: February 18, 2015