Provider Notice issued 02/18/14

Nursing Facility Ventilator Rates

On January 14, 2014, JCAR objected to and suspended Section 147.335(a)(7)(B), and repealed Section 147.355(b) of the Department of Healthcare and Family Services' (HFS) emergency rule titled "Reimbursement for Nursing Costs for Geriatric Facilities" (89 Ill. Adm. Code 147; 38 Ill. Reg. 1205). In their objection, JCAR stated that "HFS has not shown sufficient cause for reducing the enhanced care add-on rate for ventilator care to a level that covers only the cost of supplies when the add-on rate had previously included the cost of ventilator care services."

HFS did not reduce the ventilator rate to include "only" the cost of supplies, while excluding the cost of ventilator care services. HFS did retain the supply add-on at $174, the level in effect since 2011. HFS eliminated the add-on static payment that existed for ventilator care services prior to Resource Utilization Groups (RUGs) reform because this add-on is a duplicate payment under the RUGs methodology. It is critical to understand that the service spending for the vent-dependent Medicaid individuals residing in the 23 nursing homes which elect to serve this population will increase under the new RUGs methodology by approximately $10 million, from $20 million to $30+ million. This $10 million increase is directly attributable to ventilator care services.

JCAR's action indicates that its members intended to increase the rates for the 23 nursing homes beyond the $10 million increase for ventilator care services spent through the new RUGs methodology. It is the opinion of the HFS General Counsel that JCAR action – by objecting to and suspending the new section, and un-repealing the old section – will not accomplish the purpose intended by the Committee. Despite the fact that the nursing home lobby has stated otherwise, HFS believes that it is not possible to pay the ventilator add-on ($174) plus the value of services ($30-$34) paid under the old methodology in the manner directed by JCAR.

HFS would like to resolve this impasse in an amicable manner and move forward to implement the RUGs methodology, as mandated in statute.  Accordingly, HFS intends to file a new emergency rule for Section 147.335(a)(7)(B) quickly to increase the vent add-on for supplies and services to $208, to be effective January 1st, 2014, if so approved by JCAR.

As a reminder, HFS would like to take this opportunity to reinforce some of the clinical requirements which must be met in order for a nursing facility to serve and receive reimbursement, including the vent supply add-on, for ventilator-dependent residents. Ventilators are defined as any type of electrical or pneumatically powered closed mechanical system for residents who are, or who may become, unable to support their own respiration. It does not include Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway Pressure (BiPAP) devices. When ventilators are used to deliver CPAP or BiPAP, they shall not be counted as ventilator services for enhanced rates. Ventilators set to Positive End-Expiratory Pressure (PEEP) or CPAP to aid in weaning a resident from the ventilator are included. The weaning process shall be documented in the clinical record. Pursuant to 89 IL. Admin. Code 147.335 (a), all requirements and the defined criteria for in-service training must be met to be eligible for enhanced care rates, including the vent supply-add on.

Written policy and procedures shall include, but are not limited to, assessment and prevention of pressure ulcers, assessment and monitoring of pain, assessment of risk factors relating to immobility, assessment of residents risk for infection, and assessment to determine risk for social isolation. The facility shall identify a method of tracking ventilator associated pneumonia and tracking of hospitalization for ventilator residents. The nursing facility shall also correctly code Section S (S0600). Residents for whom a ventilator add-on rate is requested may be cross-referenced with the appropriate MDS assessment(s) Section S designation.

In order for an applicable rate to be assigned to a ventilator-dependent resident, the nursing facility shall notify the Department by submitting Form HFS 106, Nursing Facility Ventilator Notification. This form must be submitted initially to identify residents on a ventilator when a ventilator-dependent resident is admitted, placed on a ventilator, discharged from the facility, removed from a ventilator, or upon death. Notification in any instance, other than initial identification, shall occur within five days of the admission, discharge, removal from the ventilator or death. Discharge is defined as the resident leaving the facility with no intention of returning and does not mean a temporary absence due to a hospital admission. Incomplete form(s) submitted without required physician order sheet identifying need for ventilator services will be returned. The form should be sent to the Department even if the Recipient Database (RDB) has not been updated with the resident's admission. The form will be held until an admission to the RDB is completed. This process allows enhanced payment for each day a ventilator-dependent resident is in the facility and receiving ventilator services.

The form must be faxed to 217-557-5061 or mailed to the following address:

Illinois Department of Healthcare and Family Services

Bureau of Long Term Care

201 S. Grand Avenue East

Springfield, IL 62763

Claim submittal timeframes in accordance with P.A. 98-0104 require Form HFS 106 to be submitted no later than 180 days from date of service to be approved.

Questions can be directed to the Bureau of Long Term Care at 217-782-0545.

Theresa A. Eagleson, Administrator

Division of Medical Programs