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SB 3365

MEDICARE/MEDICAID DUAL ELIGIBL

104th Regular Session Introduced by Dee Avelar and 3 co-sponsors

Extends MMAI to include FIDE-SNPs and any dual-eligible plan, and updates nursing home per diem payments (RUG-IV based) plus add-ons for MCOs.

Placed on Calendar 2nd Reading - Short Debate
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Bill Summary · SB 3365

Summary of SB3365 (104th General Assembly, Illinois)

Purpose and intent

  • To amend the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home Residents' Managed Care Rights Law within the Illinois Public Aid Code.
  • The bill extends the scope of the MMAI framework to include fully integrated dual eligible special needs plans (FIDE-SNPs) and any managed care plan serving individuals who are dually eligible for Medicare and Medicaid.
  • It requires the Department of Healthcare and Family Services (HFS) to provide each managed care organization (MCO) with specific per diem payments for nursing home residents under contract, replacing or updating the current per diem components used in calculating reimbursements.

Key provisions and changes

  • Section scope (5F-10): The Article applies to:
    • Nursing home components of MMAI and the Managed Long-Term Services and Supports Program (MLTSS),
    • Fully integrated dual eligible special needs plans (FIDE-SNPs),
    • Any managed care plan for people dually eligible for Medicare and Medicaid.
    • It preserves existing duties of MCOs under other federal/state laws and under MMAI/MLTSS contracts.
  • Definitions (5F-15): The bill expands definitions to cover:
    • Demonstration Project as including FIDE-SNPs and any dual-eligible managed care plan.
    • Enrollee, health care services, managed care organization, medical professionals, nursing homes, and other terms to align with MMAI and dual-eligible demonstrations.
    • Resident-related terms (e.g., transition period, resident, RA I Manual reference, SNFist) to reflect dual-eligible nursing home care arrangements.
  • Reimbursement changes (5F-35): The Department must provide each MCO with:
    • The quarterly facility-specific nursing component per diem using RUG-IV (Resource Utilization Groups IV) as the basis, plus any add-ons for enhanced care services,
    • The per diem for the “support component” and the capital per diem, effective for each nursing home under contract with the MCO.
  • Effective date: Immediate upon becoming law.

Who/what is affected

  • Affects Medicaid-managed care arrangements and nursing home vendor relationships under MMAI and MLTSS.
  • Expands to include FIDE-SNPs and other MCOs serving dually eligible Medicare-M Medicaid enrollees in Illinois.
  • Nursing homes participating in these demonstrations and contracts with MCOs will receive updated per diem payments (nursing component, support component, capital component), with per-diem rates based on the quarterly facility-specific RUG-IV classification (plus add-ons).

Procedural and timeline aspects

  • The act is effective immediately upon becoming law.
  • The bill underwent standard Illinois legislative process in 2025-2026, including committee referrals and multiple sponsor support steps; it passed the House and is moving through committee as of the latest action.
  • Revisions pertain to administrative rules and contract administration between HFS, MCOs, and nursing homes, with an emphasis on alignment with MMAI and dual-eligible demonstration parameters.

Practical impact and considerations

  • For enrollees: Potentially more integrated and streamlined management of care in nursing homes under dual-eligible arrangements, with clarified rights and processes under the MMAI framework.
  • For nursing homes: Updated per diem reimbursements tied to RUG-IV with additional add-ons; this could affect payment stability and incentives for enhanced care services, support, and capital needs.
  • For MCOs and FIDE-SNPs: Expanded obligation to operate under MMAI and dual-eligible plans, requiring coordination with HFS, CMS, and nursing facilities; potential administrative changes to billing and reimbursements consistent with RUG-IV and add-ons.

If you’d like, I can summarize the bill’s potential fiscal impact estimates (if provided in fiscal notes) or compare these provisions to current Illinois law for a quick before/after view.

Compiled from official sources — confirm details with the bill’s official record.

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