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Rule 5160-3-01 | Nursing facilities (NFs): definitions.
Effective:
September 22, 2018
Except as otherwise provided in Chapter 5160-3 of
the Administrative Code, and in addition to the definitions in section 5165.01
of the Revised Code: (A) "Allowable costs" has the
same meaning as in section 5165.01 of the Revised Code and are determined in
accordance with the following reference material, in the following
priority: (1) Title 42 Code of
Federal Regulations (C.F.R.) Chapter IV (October 1, 2017). (2) The centers for
medicare and medicaid services (CMS) publication 15-1 entitled "The
Provider Reimbursement Manual - Part 1" (rev. 9/21/17). (3) Generally accepted
accounting principles in accordance with standards prescribed by the
"American Institute of CPAs" (AICPA) as in effect June 26,
2018. (B) "Intermediate care facility for individuals with
intellectual disabilities" (ICF-IID) has the same meaning as in section
5124.01 of the Revised Code. (C) "Minimum data set" (MDS) is the resident
assessment instrument approved by CMS as described in rule 5160-3-43.1 of the
Administrative Code. The MDS provides the resident assessment data that is used
to classify a resident into a resource utilization group in the RUG case mix
classification system as described in rule 5160-3-43.2 of the Administrative
Code. (D) "Patient" includes resident or
individual. (E) "Quarterly facility average case mix score"
is a facility average case mix score based on data submitted for one reporting
quarter. (F) "Related party" has the same meaning as in
section 5165.01 of the Revised Code. In cases of a change of provider (CHOP), the
following apply: (1) The amount of indirect ownership is
determined by multiplying the percentage of ownership interest at each level
(e.g., forty per cent interest in corporation "A" which owns fifty
per cent of corporation "B" results in a twenty per cent indirect
interest in corporation "B"). (2) If a provider transfers an interest
or leases an interest in a facility to another provider who is a related party,
the capital cost basis shall be adjusted for a sale of a facility to or a lease
to a provider that is not a related party if all of the following conditions
are met: (a) For a NF transfer: (i) The related party is
a relative of owner. (ii) The provider making
the transfer retains no interest in the facility except through the exercise of
the creditor's rights in the event of default. (iii) ODM determines that
the transfer is an arm's length transaction if all the following
apply: (a) Once the transfer goes into effect, the provider that made
the transfer has no direct or indirect interest in the provider that acquires
the facility or the facility itself, including interest as an owner, officer,
director, employee, independent contractor, or consultant, but excluding
interest as a creditor. If the provider making the transfer maintains an
interest as a creditor, the interest rate of the creditor shall not exceed the
lesser of: (i) The prime rate, as
published by the "Wall Street Journal" (June 26, 2018) on the first
business day of the calendar year, plus four per cent; or (ii) Fifteen per
cent. (b) The provider that made the transfer does not reacquire an
interest in the facility except through the exercise of a creditor's
rights in the event of a default. If the provider reacquires an interest in the
facility in this manner, ODM shall treat the facility as if the transfer never
occurred when ODM calculates its reimbursement rates for capital
costs. (c) The provider transferring their facility shall provide ODM
with certified appraisal(s) at least ninety days prior to the actual change of
provider agreement(s). The certified appraisal(s) shall be conducted no earlier
than one hundred eighty days prior to the actual change of provider
agreement(s) for each facility transferred to a related party. (iv) Except in the case
of hardship caused by a catastrophic event, as determined by ODM, or in the
case of a provider making the transfer who is at least sixty-five years of age,
not less than twenty years have elapsed since, for the same facility, the
capital cost basis was determined or adjusted most recently; or actual,
allowable cost of ownership was determined most recently. (b) For a NF lease: (i) The related party is
a relative of the owner. (ii) The lessor retains
an ownership interest in only real property and any improvements on the real
property except when a lessor retains ownership interest through the exercise
of a lessor's rights in the event of default. (iii) ODM determines that
the lease is an arm's length transaction if all the following
apply: (a) Once the lease goes into effect, the lessor has no direct or
indirect interest in the lessee or, except as provided in this rule, the
facility itself, including interest as an owner, officer, director, employee,
independent contractor, or consultant, but excluding interest as a
lessor. (b) The lessor does not reacquire an interest in the facility
except through the exercise of a lessor's rights in the event of a
default. If the lessor reacquires an interest in the facility in this manner,
ODM shall treat the facility as if the lease never occurred when ODM calculates
its reimbursement rates for capital costs. (c) A lessor that proposes to lease a facility to a relative of
owner shall obtain a certified appraisal(s) for each facility leased. The
lessor of the facility shall provide ODM with certified appraisal(s) at least
ninety days prior to the actual change of provider agreement(s). The certified
appraisal(s) shall be conducted no earlier than one hundred eighty days prior
to the actual change of provider agreement(s) for each facility leased to a
related party. (iv) Except in the case
of hardship caused by a catastrophic event, as determined by ODM, or in the
case of a lessor who is at least sixty-five years of age, not less than twenty
years have elapsed since, for the same facility, the capital cost basis was
determined or adjusted most recently; or actual, allowable cost of ownership
was determined most recently. (v) The provisions set
forth in this paragraph do not apply to leases of specific items of
equipment. (c) The provider shall notify ODM in writing and shall supply
sufficient documentation demonstrating compliance with the provisions of this
rule no less than ninety days before the anticipated date of completion of the
transfer or lease. If the provider does not supply any of the required
information, the provider shall not qualify for a rate adjustment. ODM shall
issue a written decision determining whether the transfer meets the
requirements of this rule within sixty days after receiving complete
information as determined by ODM. (d) Any rate adjustments which result from the provisions
contained in paragraph (G)(2) of this rule shall take effect as specified in
rule 5160-3-24 of the Administrative Code, following a determination by ODM
that the requirements of paragraph (G)(2) of this rule are met. (G) "Replacement beds" are beds that are
relocated to a new building or portion of a building attached to and/or
constructed outside of the original licensed structure of a NF. Replacement
beds may originate from within the licensed structure of a NF or from another
NF. (H) "RUG" is the resource utilization groups
system of classifying NF residents into case mix groups as described in rule
5160-3-43.2 of the Administrative Code.
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Rule 5160-3-02 | Nursing facilities (NFs): provider agreements.
In addition to provisions in Chapters 5164. and
5165. of the Revised Code regarding provider agreements, and provisions in
rules 5160-3-02.1 and 5160-3-02.2 of the Administrative Code, execution and
maintenance of a provider agreement between the Ohio department of medicaid
(ODM) and the operator of a NF also are contingent upon compliance with
requirements set forth in this rule. (A) Definitions. (1) "Closure"
means the discontinuance of the use of the building or part of the building
that houses the facility as a NF, and that results in the relocation of the
facility's residents who continue to require NF services. If the building
is converted to a different use and acquires a new type of license, residents
who require services offered under the new license type may
remain. (a) A facility's closure occurs regardless of whether there
is a replacement of the facility whereby the operator completely or partially
replaces the facility's physical plant through the construction of a new
physical plant or the transfer of the facility's license from one physical
plant location to another. (b) Facility closure occurs regardless of whether residents of
the closing facility elect to be relocated to the operator's replacement
facility or to another NF. (c) A facility closure occurs regardless of action taken by the
Ohio department of health (ODH) related to the facility's certification
under Title XIX of the Social Security Act, 42 U.S.C. 1396 (April 16, 2015),
that may result in the transfer of part of the facility's survey findings
to a replacement facility, or related to retention of a license as a NF under
Chapter 3721. of the Revised Code. (d) The last effective date of the provider agreement of a closed
facility will be the date of the relocation of the last resident. (2) "Continuing
care" and "life care" refer to the living setting that provides
the individual with different types of care based on a resident's need
over time and may include an apartment or lodging, meals, maintenance services,
and when necessary, nursing home care. All services are provided on the
premises of the continuing care or life care community. The individual signs a
contract that identifies the continuum of services to be covered by the
individual's initial entrance fee and subsequent monthly charges. If a
continuing care or life care contract provides for a living arrangement that
specifically states that all health care services including nursing home
services are met in full, medicaid payment cannot be made for those services
covered by the contract. If a continuing care or life care contract provides
for only a portion of the resident's health care services, that portion
shall be deducted from the actual cost of nursing home care and medicaid shall
pay the difference up to the medicaid maximum per diem. An individual who
entered into a life care or continuing care contract may be eligible for
medicaid under the conditions in rule 5160:1-3-05.1 of the Administrative
Code. (3) "Failure to
pay" means that an individual has failed, after reasonable and appropriate
notice, to pay or to have the medicare or medicaid program pay on the
individual's behalf, for the care provided by the NF. An individual shall
be considered to have failed to have the individual's care paid for when
the individual has a medicaid application in pending status, if both of the
following are the case: (a) The individual's application, or a substantially similar
previous application, has been denied by the county department of job and
family services (CDJFS); and (b) If the individual appealed the denial pursuant to division
(C) of section 5101.35 of the Revised Code, the director of ODM upheld the
denial. (4) "Medicaid
eligible" means an individual has been determined eligible by the CDJFS
under Chapter 5160:1-3 of the Administrative Code and has been issued an
effective date of health care coverage for the time period in
question. (5) "Operator"
means the individual, partnership, association, trust, corporation, or other
legal entity that operates a NF. (6) "Voluntary
withdrawal" means that the operator of a NF, in compliance with section
1919(c)(2)(F) of the Social Security Act, voluntarily elects to withdraw from
participation in the medicaid program but chooses to continue providing
services of the type provided by NFs. (B) A provider of a NF
shall: (1) Execute the provider
agreement in the format provided by ODM. (2) Apply for and
maintain a valid license to operate if required by law. (3) Comply with the
provider agreement and all applicable federal, state, and local laws and
rules. (4) Keep records and file
cost reports as required in rule 5160-3-20 of the Administrative
Code. (5) Open all records
relating to the costs of its services for inspection and audit by ODM and
otherwise comply with rule 5160-3-20 of the Administrative Code. (6) Supply to ODM such
information as the department requires concerning NF services to individuals
who are medicaid eligible or who have applied to be medicaid
recipients. (7) Unless the conditions
described in paragraph (H) of this rule are applicable, retain as a resident
any individual who is medicaid eligible, becomes medicaid eligible, or applies
for medicaid eligibility. Residents in a NF who are medicaid eligible, become
medicaid eligible, or apply for medicaid eligibility are considered residents
in the NF during any absence for which bed-hold days are reimbursed in
accordance with rule 5160-3-16.4 of the Administrative Code. (8) Unless the conditions
described in paragraph (H) of this rule are applicable, admit as a resident an
individual who is medicaid eligible, whose application for medicaid is pending,
or who is eligible for both medicare and medicaid, and whose level of care
determination is appropriate for the admitting facility. This applies unless at
least twenty-five per cent of the NF's medicaid certified beds are
occupied by medicaid recipients at the time the individual would otherwise be
admitted, in accordance with section 5165.08 of the Revised Code. (a) In order to comply with these provisions, the NF admission
policy shall be designed to admit individuals sequentially based on the
following: (i) The requested
admission date. (ii) The date and time of
receipt of the request. (iii) The availability of
the level of care or range of services necessary to meet the needs of the
applicants. (iv) Gender: sharing a
room with a resident of the same sex (except married couples who agree to share
the same room). (b) The NF shall maintain a written list of all requests for each
admission. The list shall include the name of the potential resident; date and
time the request was received; the requested admission date; and the reason for
denial if not admitted. This list shall be made available upon request to the
staff of ODM, the CDJFS, and ODH. (c) The following are exceptions to paragraph (B)(8) of this
rule: (i) Bed-hold days are
exhausted. Medicaid eligible residents of NFs who are
on hospital stays, visiting with family and friends, or participating in
therapeutic programs and have exhausted coverage for bed-hold days under rule
5160-3-16.4 of the Administrative Code must be readmitted to the first
available semi-private bed in accordance with the provisions of rule
5160-3-16.4 of the Administrative Code. (ii) Facility is a county
home. Any county home organized under Chapter
5155. of the Revised Code may admit individuals exclusively from the county in
which the county home is located. (iii) Facility has a
religious sponsor. Any religious or denominational NF that is
operated, supervised, or controlled by a religious organization may give
preference to persons of the same religion or denomination. (iv) NF has continuing
care or life care contracts. A NF may give preference to individuals
with whom it has contracted to provide continuing care or life care. (v) Prolonged
"medicaid pending" application status. A NF may decline to admit a medicaid
applicant if that facility has a resident whose application was pending upon
admission and has been pending for more than sixty days, as verified by the
CDJFS. The NF shall submit the necessary documentation in a timely manner as
required in rules 5160-3-15.1 and 5160-3-15.2 of the Administrative
Code. (9) Provide the
following necessary information to ODM and the CDJFS to process records for
payment and adjustment: (a) Submit the ODM 09401 "Facility/CDJFS Transmittal"
(7/2014) to the CDJFS to inform the CDJFS of any information regarding a
specific resident for maintenance of current and accurate records at the CDJFS
and the facility. (b) Submit claims to ODM as required in rule 5160-3-39.1 of
the Administrative Code. (10) Permit access to the
facility and the facility's records for inspection by ODM, ODH, the CDJFS,
representatives of the office of the state long-term care ombudsman, and any
other state or local government entity having authority to inspect, to the
extent of that entity's authority. (11) In the case of a
change of operator as defined in section 5165.01 of the Revised Code, follow
the procedures in paragraphs (B)(11)(a) to (B)(11)(d) of this
rule. (a) The exiting operator or owner and entering operator must
provide a written notice to ODM, as provided in section 5165.51 of the Revised
Code, at least forty-five days prior to the effective date of any actions that
constitute a change of operator for the NF, but at least ninety days if
residents are to be relocated. An exiting operator that does not give proper
notice is subject to the penalties specified in section 5165.42 of the Revised
Code. (b) The entering operator must submit documentation of any
transaction (e.g., sales agreement, contract, or lease) as requested by ODM to
determine whether a change of operator has occurred as specified in section
5165.51 of the Revised Code. (c) The entering operator shall submit an application for
participation in the medicaid program and a written statement of intent to
abide by ODM rules, the provisions of the assigned provider agreement, and any
existing CMS 2567 "Statement of Deficiencies and Plan of Correction"
(rev. 2/1999) submitted by the exiting operator. (d) An entering operator is subject to the same survey findings
as the exiting operator unless the entering operator does not accept assignment
of the exiting operator's provider agreement. Refusal to accept assignment
results in termination of certification on the last day of the exiting
operator's participation in medicaid. An entering operator who refuses
assignment may reapply for medicaid participation and must undergo a complete
initial certification survey by ODH. There may be gaps in medicaid coverage at
the facility. (12) Ensure the security
of all personal funds of residents in accordance with rule 5160-3-16.5 of the
Administrative Code. (13) Comply with Title VI
and Title VII of the Civil Rights Act of 1964, 42 U.S.C. 1971 (July 27, 2006)
and the Americans with Disabilities Act of 1990, 42 U.S.C. 12101 et seq (March
15, 2011), and shall not discriminate against any resident on the basis of
race, color, age, sex, creed, national origin, or disability. (14) Provide notice to
ODM within thirty days of any bankruptcy or receivership pertaining to the
provider. Notice shall be mailed to: "Office of Legal Services, Ohio
Department of Medicaid, P.O. Box 182709, Columbus, Ohio 43218" and to:
"Office of the Attorney General, 30 East Broad Street, 14th Floor,
Columbus, Ohio 43215". (15) Provide a statement
to the individual explaining the individual's obligation to reimburse the
cost of care provided during the medicaid application process if it is not
covered by medicaid. (16) Comply with the
requirements in rule 5160-3-04.1 of the Administrative Code to repay ODM the
federal share of payments under the circumstances required by sections 5165.71
and 5165.85 of the Revised Code. (17) During a closure or
voluntary withdrawal from the medicaid program, provide ODM, the resident or
guardian, and the residents' sponsors a written notice at least ninety
days prior to the closure or voluntary withdrawal. A NF that does not issue the
proper notice is subject to the penalties specified in section 5165.42 of the
Revised Code. (18) Comply with the
following requirements when voluntarily withdrawing from the medicaid
program: (a) Continue to provide NF services to residents of the
facility who were residing in the facility on the day before the effective date
of the withdrawal (including those residents who were not entitled to medical
assistance as of such day). (i) A NF operator's
voluntary withdrawal from participation in the medicaid program is not an
acceptable basis for the transfer or discharge of these residents. (ii) Nothing in this
provision invalidates other legal grounds for NF-initiated discharge of
medicaid residents after the effective date of withdrawal. (b) Provide residents admitted after the effective date of
withdrawal with information that the facility is not participating in the
medicaid program with respect to those residents. (c) Provide notice to ODM within fourteen days after the
last medicaid funded resident has been relocated. (C) A provider of a NF shall not: (1) Charge fees for the
application process of a medicaid individual or applicant. (2) Charge a medicaid
individual an admission fee. (3) Charge a medicaid
individual an advance deposit. However, a NF may charge an individual whose
medicaid eligibility is pending, typically in the form of a pre-admission
deposit or payment for services after admission. A NF that has charged a
resident for services between the first month of eligibility established by the
state and the date notice of eligibility is received is obligated to refund any
payments received for that period less the state's determination of any
resident's share of the NF costs for that same period. (4) Require a third party
to accept personal responsibility for paying the facility charges out of his or
her own funds. However, the facility may require a representative who has legal
access to an individual's income or resources available to pay for
facility care to sign a contract, without incurring personal financial
liability, to provide facility payment from the individual's income or
resources if the individual's medicaid application is denied and if the
individual's cost of care is not being paid by medicare or another
third-party payor. A third-party guarantee is not the same as a third-party
payor (i.e., an insurance company), and this provision does not preclude the
facility from obtaining information about medicare and medicaid eligibility or
the availability of private insurance. The prohibition against third-party
guarantees applies to all individuals and prospective individuals in all
certified NFs regardless of payment source. This provision does not prohibit a
third party from voluntarily making payment on behalf of an
individual. (D) ODM shall: (1) Execute a provider
agreement in accordance with the certification provisions set forth by the
secretary of health and human services (HHS) and ODH. (2) In the case of a
change of operator, issue an assigned provider agreement to the entering
operator contingent upon the entering operator's compliance with paragraph
(B)(11)(c) of this rule. (3) Provide access on the
ODM website to a listing of the rules ODM has filed for adoption, admendment,
or rescission under section 119.03 or 111.15 of the Revised Code. (4) Make payments in
accordance with Chapter 5165. of the Revised Code and Chapter 5160-3 of the
Administrative Code to the NF for services to individuals eligible and approved
for payment under the medicaid program. (E) ODM may terminate, suspend, not enter into, or not
revalidate, the provider agreement upon thirty days written notice to the
provider for violations of Chapters 5164. and 5165. of the Revised Code;
Chapters 5160-1 and 5160-3 of the Administrative Code; and if applicable,
subject to Chapter 119. of the Revised Code. (F) Any NF violating provisions defined in paragraphs
(B)(7) and (B)(8) of this rule will be subject to a penalty in accordance with
provisions of section 5165.99 of the Revised Code. (G) The CDJFS shall use the ODM 09401 to communicate with
NFs regarding the assessment of payment for specific individuals. (H) Exclusions. The provisions of paragraphs (B)(7) and (B)(8) of
this rule do not require an individual to be admitted or retained at the NF if
the individual meets one of the following conditions: (1) The individual
requires a level of care or range of services that the NF is not certified or
otherwise qualified to provide. (2) The individual has a
medicaid application in pending status and meets the definition of
"failure to pay" in this rule.
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Rule 5160-3-02.1 | Nursing facilities (NFs): length and type of provider agreements.
(A) Definitions. (1) "Reasonable
assurance period" means a certain period of time, determined by the
centers for medicare and medicaid services (CMS), for which a nursing facility
operator whose provider agreement has been involuntarily terminated is required
to operate without recurrence of the deficiencies that were the basis for
termination. Participation in the medicare and medicaid programs may resume
only following that period. If corrections were made before submission of a new
request for participation, the period of compliance before the new request is
counted as part of the period. (2) "State survey
agency" means the agency that is under contract with the state medicaid
agency and that inspects nursing facilities for the purposes of survey and
certification. The state survey agency in Ohio is the Ohio department of health
(ODH). The state medicaid agency in Ohio is the Ohio department of medicaid
(ODM). (B) Effective dates. (1) Initial certification
of NFs and skilled nursing facilities/nursing facilities
(SNF/NFs). (a) Effective dates of NF and SNF/NF provider agreements
generally are assigned by the state survey agency on the basis of findings of
compliance or substantial compliance with standards of
certification. (b) The effective date shall not be earlier than the date on
which compliance is documented via the state survey agency's onsite visits
to the facility. (c) The effective date of a provider agreement of a nursing
facility that participates in the medicaid program as a SNF/NF shall be the
same as that of the facility's medicare provider agreement. (2) NFs subsequently
approved to operate as SNF/NFs. (a) Upon approval from CMS of a NF to participate in the medicare
program as a SNF/NF, ODM shall issue a SNF/NF provider agreement. (b) The effective date of this provider agreement shall be the
same as that of the facility's medicare provider agreement. (3) Re-entry into the
program following involuntary termination. (a) Following involuntary termination of the medicaid provider
agreement for a nursing facility, the provider agreement effective date of a
facility re-entering the medicaid program shall be the same effective date as
the date CMS issues for the facility's medicare provider
agreement. (b) Re-entry may occur only after the successful completion of a
reasonable assurance period as determined by CMS. (C) Term limits. (1) A NF or SNF/NF
provider agreement shall expire no later than five years from the effective
date of the agreement in accordance with section 5164.32 of the Revised Code.
The process for revalidation of a NF or SNF/NF provider agreement is specified
in rule 5160-1-17.4 of the Administrative Code (2) The term of a NF or SNF/NF provider
agreement shall be determined by the period of certification established by the
state survey agency, which is based upon compliance with certification
standards. The term of a NF or SNF/NF provider agreement may be less than, but
shall not exceed, five years.
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Rule 5160-3-02.2 | Nursing facilities (NFs): termination, denial, and non-revalidation of provider agreements.
(A) Written notice. (1) The Ohio department
of medicaid (ODM) may terminate, deny, or not revalidate a NF provider
agreement upon thirty days written notice to the NF. (2) Notices and
termination orders must comply with provisions set forth in sections 5164.38
and 5165.77 of the Revised Code. (B) Reasons for which ODM may terminate,
deny, or not revalidate a NF provider agreement. (1) In accordance with
section 5164.33 of the Revised Code, ODM may terminate, deny, or not revalidate
a NF provider agreement if ODM determines such an agreement is not in the best
interests of the state or the medicaid residents of the NF. (2) ODM may terminate,
deny, or not revalidate a NF provider agreement on the basis of best interest
including, but not limited to, the following reasons: (a) The provider has not fully and accurately disclosed
information to ODM as required by the provider agreement or any rule contained
in Chapter 5160-3 of the Administrative Code. (b) The provider has failed to abide by or to have the capacity
to comply with the terms and conditions of the provider agreement and/or rules
and regulations promulgated by ODM (c) The provider has been found liable by a court for negligent
performance of professional duties. (d) The provider has failed to file cost reports as required in
rule 5160-3-20 of the Administrative Code. (e) The provider has made false statements or has altered
records, documents, or charts. Alteration does not include properly documented
correction of records. (f) The provider has failed to cooperate or provide requested
records or documentation for purposes of an audit or review of any provider
activity by any federal, state, or local agency. (g) The provider has been found in violation of section 504 of
the Rehabilitation Act of 1973, 29 U.S.C 794 (March 24, 2014), the Civil Rights
Act of 1964, 42 U.S.C. 1971 (July 27, 2006) or the Americans with Disabilities
Act of 1990, 42 U.S.C. 12101 et seq (March 15, 2011) in relation to the
employment of individuals, the provision of services, or the purchase of goods
and services. (h) The attorney general, auditor of state, or any board, bureau,
commission, or department has recommended ODM terminate the provider agreement
where the reason for the request bears a reasonable relationship to the
administration of the medicaid program or the integrity of state and/or federal
funds. (i) In accordance with rule 5160-1-13.1 of the Administrative
Code, the provider has violated the prohibition against billing medicaid
residents for covered services, or has requested the resident to share in the
cost of covered services through deductibles, coinsurance, co-payments, or
other similar charges, other than medicaid co-payments as defined in rule
5160-1-09 of the Administrative Code. (j) The facility has been found by the Ohio department of health
(ODH) during a survey of the facility to have an emergency that is the result
of a deficiency or cluster of deficiencies, and that constitutes immediate
jeopardy. (k) The provider fails to pay the full amount of a
franchise permit fee (FPF) installment when due pursuant to section 5168.52 of
the Revised Code. (C) Reasons for which ODM shall
terminate, deny, or not revalidate a NF provider agreement. (1) ODM shall terminate,
deny, or not revalidate a NF provider agreement for, but not limited to, the
following reasons: (a) The provider has been terminated, suspended, or
excluded by the medicare program and/or by the United States centers for
medicare and medicaid services (CMS) and that action is binding on
participation in the medicaid program or renders federal financial
participation unavailable for participation in the medicaid program. Under
these conditions, medicaid termination and payment sanction dates shall be the
same as medicare termination and payment sanction dates. (b) The facility has been decertified by ODH and/or the
United States department of health and human services. (c) The provider has pled guilty to or been convicted of a
criminal activity materially related to either the medicare or medicaid
program. (d) Any license, permit, or certificate that is required by
ODM or the terms of the provider agreement has been denied, suspended, revoked,
or not renewed. (2) ODM shall terminate, deny, or not
revalidate a NF provider agreement for, but not limited to, the following
reasons set forth in Chapters 5164. and 5165. of the Revised Code, and Chapters
5160-1 and 5160-3 of the Administrative Code: (a) In accordance with division (D) of section 5164.35 of
the Revised Code, there has been a conviction of, or the entry of a judgment in
either a criminal or civil action against the provider or its owner, officer,
authorized agent, associate, manager, or employee in an action brought pursuant
to section 109.85 of the Revised Code. (b) The provider has committed medicaid fraud as defined in
rule 5160-1-29 of the Administrative Code. (c) In accordance with section 5165.073 of the Revised
Code, the provider does not comply with the requirements of section 3721.071 of
the Revised Code for the installation of fire extinguishing and fire alarm
systems. (d) Any of the scenarios specified under division (B) of
section 5165.771 of the Revised Code regarding the special focus facility
program apply to the provider. (e) In accordance with section 5165.106 of the Revised
Code, the provider fails to file a cost report required by section 5165.10 of
the Revised Code by the date it is due or by the date, if any, to which the due
date is extended pursuant to division (D) of section 5165.10 of the Revised
Code, unless the provider submits a complete and adequate cost report within
thirty days after notice of termination by ODM. (f) The provider has failed to ensure a nursing
facility's full participation in the medicare program as a skilled nursing
facility (SNF) pursuant to section 5165.082 of the Revised Code and rule
5160-3-02.4 of the Administrative Code. (g) In accordance with section 5165.072 of the Revised
Code, the provider fails to maintain eligibility for the provider agreement as
set forth in section 5165.06 of the Revised Code. (h) In accordance with division (B)(1) of section 5164.32
of the Revised Code, the provider fails to file a complete application for
revalidation within the time and in the manner required by the revalidation
process as specified by ODM. (3) If ODH terminates certification of a
nursing facility, ODM shall terminate the facility's provider agreement
pursuant to section 5164.38 and section 5165.79 of the Revised
Code. (D) Adjudication order. (1) In accordance with
section 5164.38 of the Revised Code, the director of ODM shall terminate, deny,
or not revalidate an existing NF provider agreement by issuing an order
pursuant to an adjudication conducted in accordance with Chapter 119. of the
Revised Code, unless such action occurred as the result of events described in
division (E) of section 5164.38 of the Revised Code. (2) In accordance with
division (E) of section 5165.77 of the Revised Code, if ODM issues a
termination order as the result of events set forth in paragraph (B)(2)(j) of
this rule, the termination may take effect prior to or during the pendency of
the proceeding under Chapter 119. of the Revised Code. (E) Impact of provider actions on
CMS-imposed reasonable assurance periods. (1) When seeking reentry
to the medicaid program, providers are subject to procedures set forth in CMS
publication 100-07 entitled "State Operations Manual" at Chapter 7
section 7321 (6/12/14) for SNFs and NFs, to comply with the provisions at 42
CFR 489.57 (October 1, 2015) that govern reinstatement after termination, and
require that the reason for termination of the previous agreement has been
removed and there is reasonable assurance that it will not recur. (2) After CMS has
initiated involuntary termination action for a dually certified SNF/NF, or
after ODH has initiated involuntary termination action for a medicaid-certified
NF, a provider of a NF who is permitted to voluntarily terminate, voluntarily
withdraw, or undergoes a change of operator, or the subsequent operator of the
same facility, shall be subject to reasonable assurance requirements set by CMS
when seeking reentry to the medicaid program. (3) CMS or ODH initiates a termination
action when it sends a provider the initial notice certifying noncompliance and
proposing termination.
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Rule 5160-3-02.3 | Nursing facilities (NFs): institutions eligible to participate in medicaid as NFs.
(A) Definitions. (1) "Certification" means the process by which the
state survey agency certifies its findings to the federal centers for medicare
and medicaid services (CMS) or the Ohio department of medicaid (ODM) with
respect to a facility's compliance with health, safety, and resident
rights requirements of divisions (a), (b), (c), and (d) of section 1919 of the
Social Security Act, 42 U.S.C. 1396r (December 20, 2006). (2) "Certified
beds" mean beds that are counted in a provider facility that meets
medicaid standards. A count of facility beds may differ depending on whether
the count is used for certification, licensure, eligibility for medicare or
medicaid payment formulas, or other purposes. (3) "Distinct
part" means a portion of an institution or institutional complex that is
certified to provide skilled nursing facility (SNF) and/or nursing facility
(NF) services. A distinct part shall be physically distinguishable from the
larger institution and fiscally separate for cost reporting purposes. A
distinct part may be a separate building, wing, floor, hallway, or one side of
a corridor. A hospital-based SNF or NF is a distinct part by definition. A long
term care facility with both SNF and NF distinct parts is one facility, even
though the distinct parts are certified separately for medicare and medicaid.
"Distinct part", when applied to NFs or SNF/NFs, has the same
definition and requirements as in 42 C.F.R. 483.5 (October 1,
2015). (4) "Dually
participating" means simultaneous participation of an institution or
institutional complex in both the medicare and medicaid programs. (5) "Dually
participating long term care facility" means an institution that
participates as both a SNF under the medicare program, and as a NF under the
medicaid program. Such a facility is referred to as a SNF/NF. (6) "Facility"
means the entity subject to certification and approval in order for the
provider to be approved for medicaid payment. A facility may be an entire
institution such as a free-standing nursing home, or may be a distinct part of
an institution such as a hospital or continuing care retirement
community. (7) "Long term care facility"
means a NF, SNF, or dually participating SNF/NF. (8) "Long term care institutional
services" means those medicaid funded, institutional medical, health,
psycho-social, habilitative, rehabilitative, and/or personal care services that
may be provided to eligible individuals in a NF or SNF/NF. (9) "NF services" means those
services available in institutions, or parts of institutions, that are
certified as nursing facilities by the Ohio department of health (ODH) or by
the state survey agency of another state. (10) "Religious non-medical health
care institution" (RNHCI) means an institution as defined in section
1861(ss)(1) of the Social Security Act, 42 U.S.C. 1395x (ss) (1) (August 5,
1997), such as the "Christian Science RNHCIs" accredited by the
"Commission for Accreditation of Christian Science Nursing
Organizations/Facilities, Inc." RNHCIs are subject to conditions of
participation in the medicaid program according to 42 C.F.R. 403 subpart G
(October 1, 2015). (11) "State survey agency" means
the agency designated as the state health standard setting authority, and state
health survey agency responsible for certifying and determining compliance of
long term care facilities with the requirements for participation in the
medicaid program. The state survey agency in Ohio is ODH. (B) Types of long term care institutional
services. (1) The types of long
term care institutional services covered in compliance with the provisions of
Chapter 5160-3 of the Administrative Code are NF services provided to eligible
residents requiring either a skilled level of care or an intermediate level of
care as set forth in rule 5160-3-08 of the Administrative Code. (2) Institutions not
eligible for participation are: (a) An institution licensed or approved as a tuberculosis
hospital. (b) A prison, juvenile criminal facility, or an institution used
to incarcerate individuals involuntarily who have committed a violation of a
criminal or civil law. (c) An institution for mental diseases, as defined in rule
5160-3-06.1 of the Administrative Code, for persons under sixty-five years
old. (C) Requirements for
participation. To participate in the Ohio medicaid program and
receive payment from ODM for long term care institutional services to eligible
residents, operators of long term care facilities shall meet all of the
following requirements: (1) Operate an
institution that meets the licensure, registration, and other applicable state
standards as set forth in this rule. (2) Operate an
institution certified by ODH or by the state survey agency of another state as
being in compliance with applicable federal regulations for medicaid
participation as a NF with a minimum of four NF certified beds. (3) Operate an
institution for which a current, completed, and signed ODM 03623 "Ohio
Medicaid Provider Agreement for Long Term Care Facilities (NFs, SNF/NFs and
ICFs-IID)" (rev. 4/2014) is on file with ODM. (D) Qualified types of Ohio
NFs. To be eligible for certification as a NF, an
institution shall qualify as one of the following: (1) A nursing home
licensed by ODH under section 3721.02 of the Revised Code, or a nursing home
licensed by a political subdivision certified under section 3721.09 of the
Revised Code. Licensed nursing homes eligible for medicaid certification
include: (a) RHNCIs. (b) Veterans' homes operated under Chapter 5907. of the
Revised Code. (2) A county home, county
nursing home, or district home owned by the county and operated by the county
commissioners in accordance with Chapter 5155. of the Revised Code, or operated
by the board of county hospital trustees in accordance with section 5155.011 of
the Revised Code; or (3) A unit of any
hospital registered under section 3701.07 of the Revised Code that contains
beds categorized before August 5, 1989, as skilled nursing facility beds in
accordance with section 3702.521 of the Revised Code; or (4) A unit of any
hospital registered under section 3701.07 of the Revised Code that contains
beds categorized as long term care beds as defined in section 3702.51 of the
Revised Code. (E) Mandatory dual
participation. To participate as a NF, all Ohio facilities shall
comply with the provisions in section 5165.082 of the Revised Code and in rule
5160-3-02.4 of the Administrative Code regarding dual participation in the
medicare program as a SNF/NF. (F) Certification of NFs and beds subject to certification
survey. (1) Certification. A facility's certification as a NF by ODH
or by the state survey agency of another state governs the types of services
the operator of the facility may provide. (2) Provider
agreements. (a) A provider agreement with the operator of an Ohio NF or
SNF/NF shall include any part of the facility that meets standards for
certification of compliance with federal and state laws and rules for
participation in the medicaid program. (b) Exceptions to this provision are NFs or SNFs that between
July 1, 1987 and July 1, 1993 added beds licensed as nursing home beds under
Chapter 3721. of the Revised Code. Such facilities are not required to include
those beds in a provider agreement, unless otherwise required by federal law.
This exception continues to apply if such facilities subsequently undergo a
change of operator. (3) Beds subject to
certification survey. (a) All beds in a medicaid participating NF or SNF/NF, except
those licensed nursing home beds added between July 1, 1987 and July 1, 1993,
shall be surveyed to determine compliance with the applicable certification
standards and, if certifiable, included in the provider agreement as NF or
SNF/NF beds. (b) Beds that could quality as NF or SNF/NF beds and were added
between July 1, 1987 and July 1, 1993 may be surveyed for compliance at the
discretion of the operator. Such facilities are not required to include those
beds in a provider agreement, unless otherwise required by federal
law. (c) All other beds that meet NF or SNF/NF standards shall be
certified as NF or SNF/NF beds. (4) The only other basis
for allowing nonparticipation of a portion of an Ohio NF or SNF/NF that is not
hospital-based is certification of noncompliance by ODH. (G) Requirements for out-of-state providers of long term care
institutional services. (1) To participate in the
Ohio medicaid program and receive payment from ODM for long term care
institutional services to eligible Ohio residents, an operator of a long term
care facility located outside Ohio shall meet all of the following requirements
in their state of origin: (a) The operator of the facility shall hold a valid
state-required license, registration, or equivalent from the respective state
that specifies the level(s) of care the facility is qualified to
provide. (b) The operator of the facility shall hold a valid and current
medicaid provider agreement from the respective state as a NF or SNF/NF
provider type. (2) Additionally,
out-of-state providers shall meet the following Ohio requirements: (a) The operator of the facility shall have a current, completed
and signed ODM 03623 on file with ODM. (b) The operator of the facility shall obtain resident-specific
and date-specific prior authorization from ODM in accordance with rule
5160-1-11 of the Administrative Code.
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Rule 5160-3-02.4 | Nursing facilities (NFs): mandatory dual participation in the medicare program.
(A) Definitions. (1) For purposes of this
rule, the terms "certified beds," "dually participating,"
"facility," and "religious non-medical health care
institution" (RNHCI) are defined in rule 5160-3-02.3 of the Administrative
Code. (2) For purposes of this
rule, the term "reasonable assurance period" is defined in rule
5160-3-02.1 of the Administrative Code. (3) "Fully
participating" means participation of an institution in its entirety,
either in the medicare or medicaid program, or both. A fully participating
skilled nursing facility (SNF) is one in which every bed is certified for
participation in medicare. A fully participating nursing facility (NF) is one
in which every bed is certified for participation in medicaid. A fully
participating SNF/NF is one in which every bed is certified for participation
in both medicare and medicaid. (B) Mandatory medicare participation and
exceptions. (1) Operators of Ohio NFs
shall have all medicaid-certified beds as counted in the medicaid provider
agreement also certified under medicare as SNF beds, in accordance with section
5165.082 of the Revised Code and the provisions of this rule. (2) Exceptions to
mandatory medicare participation are: (a) RNHCIs. (b) Veteran's homes operated under Chapter 5907. of the
Revised Code. (c) Out-of-state providers of long term care institutional
services in accordance with the criteria specified in paragraph (G) of rule
5160-3-02.3 of the Administrative Code. (d) Hospital beds re-categorized as skilled nursing beds
after August 5, 1989 in accordance with section 3702.521 of the Revised Code.
These beds are not permitted to be covered by a medicaid provider
agreement. (C) Dual and full
participation. (1) Operators of Ohio NFs
currently holding a medicaid provider agreement under which all
medicaid-certified beds are also medicare-certified are in compliance with the
requirement for NFs to be both dually and fully participating
SNF/NFs. (2) Pursuant to rule
5160-3-02.2 of the Administrative Code, the Ohio department of medicaid (ODM)
shall terminate or not revalidate an operator's provider agreement if the
provider fails to ensure a nursing facility's full participation in the
medicare program as a SNF. (D) Enrollment of new facilities. (1) Operators of Ohio
facilities requesting participation in the medicaid NF program must provide
documentation that they have requested full participation in the medicare SNF
program. (2) Operators of Ohio
facilities requesting participation in the medicaid NF program that have been
recommended for medicaid certification by the Ohio department of health (ODH)
and that have provided documentation that they have requested full
participation in the medicare SNF program, may be issued a fully participating
NF medicaid provider agreement with an effective date determined in accordance
with rule 5160-3-02.1 of the Administrative Code. (3) After ODM is notified
by the centers for medicare and medicaid services (CMS) that a facility
operator's request for medicare certification has been approved, a SNF/NF
provider agreement may be issued by ODM using the medicare SNF's effective
date of certification in accordance with rule 5160-3-02.1 of the Administrative
Code. (4) If ODM is notified by
CMS that a facility operator's request for medicare participation has been
denied and all appeals have been exhausted, ODM shall terminate the NF's
provider agreement in accordance with rule 5160-3-02.2 of the Administrative
Code. (E) Readmission to the medicaid program. (1) A facility operator
requesting readmission to the medicaid program must provide documentation of
the request for admission or readmission, and of full participation in the
medicare SNF program. (2) If a facility's
participation in the medicaid program ends due to voluntary withdrawal from
participation by the operator, and the operator requests readmission to the
medicaid NF program, enrollment will be processed in the same manner as for a
new facility as set forth in paragraph (D) of this rule. (3) If a facility's
participation in the medicaid program ends due to involuntary termination,
cancellation, or non-revalidation by ODM, and ODH recommends that the facility
receive certification, ODM may issue a provider agreement that begins on or
after the effective date of medicare certification or recertification. If CMS
has imposed a reasonable assurance period prior to re-entry to the medicare
program, the reasonable assurance period also shall be imposed for medicaid
enrollment purposes. (F) Change of operator. If a SNF/NF undergoes a change of operator that
results in a change of provider agreement, the entering operator must either
accept assignment of the exiting operator's provider agreement and survey
results, or refuse assignment and undergo a new certification survey. An
operator may accept or refuse assignment of the medicare provider agreement
and/or the medicaid provider agreement. (1) If an entering
operator of a SNF/NF accepts assignment of both the medicare and medicaid
provider agreements of the exiting operator, ODM shall issue a SNF/NF provider
agreement to the entering operator. The entering operator must continue to
operate a dually participating facility that fully participates in both the
medicare and medicaid programs. (2) If an entering
operator of a SNF/NF refuses to accept assignment of the exiting
operator's medicare provider agreement, but does accept assignment of the
exiting operator's medicaid provider agreement, the entering operator must
meet requirements for medicare participation in the same manner as for a new
facility as set forth in paragraph (D) of this rule. (3) If an entering
operator of a SNF/NF refuses to accept assignment of the exiting
operator's medicaid provider agreement, ODM shall terminate the agreement
of the exiting operator. To enter the medicaid program, the entering operator
must apply for medicaid participation as a new facility. Upon notice of
certification approval from ODH, ODM may issue a medicaid provider agreement to
the entering operator in the same manner as for new facilities as set forth in
paragraph (D) of this rule.
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Rule 5160-3-02.7 | Nursing facilities (NFs): emergency and disaster plan, resident relocation, and required notifications.
(A) Purpose. The purpose of this rule is to set forth
provisions for the preparation for, response to, and recovery from an emergency
or disaster at a NF. The provisions of this rule are in addition to the
requirements set forth in sections 5165.77, 5165.80, and 5165.81 of the Revised
Code, and in rule 3701-17-25 of the Administrative Code. (B) Emergencies and
disasters. "Emergencies and disasters" are
unexpected situations or sudden occurrences of a serious or urgent nature that
create a substantial likelihood that one or more of a facility's residents
may be harmed and/or may need to be relocated. Events that may constitute an
emergency or disaster include, but are not limited to, the following: (1) Tornado, severe wind,
severe storm, flood, or other natural disaster. (2) Fire. (3) Explosion. (4) Loss of electrical
power. (5) Release of hazardous
chemicals or other hazardous material. (6) Outbreak of
contagious disease. (7) Civil disturbance
such as a riot. (8) A labor strike that
suddenly causes the number of staff members in a facility to be below that
necessary for resident care. (9) A missing resident,
where there is the liklihood that the resident may be harmed while absent from
the facility. (C) Emergency and disaster
plan. (1) In accordance with 42
C.F.R. 483.75(m) (October 1, 2015), each facility shall have a detailed written
plan of procedures to be followed in the event of an emergency or disaster. The
emergency and disaster plan shall include the following components regarding
resident relocation: (a) Procedures for securing emergency shelter, including
resident identification and tracking. (b) Procedures for resident care, including supplies,
equipment, and staffing. (c) Procedures for contacting physicians, family,
guardians, other individuals responsible for residents, and government
agencies. (d) Procedures for resident transportation,
hospitalization, therapy, and other appropriate services, including
post-emergency transportation. (e) Procedures for records transfer. (2) In accordance with 42
C.F.R. 483.75(m), each facility shall train all employees in the
facility's emergency and disaster procedures when they begin to work in
the facility, periodically review the procedures with existing staff, and carry
out unannounced staff drills using those procedures. (D) Notification. (1) In the event of any
emergency or disaster, the provider shall notify each resident's family,
guardian, sponsor, next of kin, or other person responsible for the
resident. (2) In cases where residents are relocated, within one
working day after the relocation of residents, the provider shall give
notification of the following to the Ohio department of health (ODH):
(a) The name and location
of the facility experiencing the emergency or disaster. (b) The nature of the
emergency or disaster. (3) In cases where residents are
relocated, within one working day after the relocation of residents, the
provider shall give notification of the following to the county department of
job and family services (CDJFS), the Ohio department of medicaid (ODM) bureau
of long term care services and supports (BLTCSS) designated emergency
relocation coordinator, and all applicable managed care plans: (a) The name and location
of the facility experiencing the emergency or disaster. (b) The nature of the emergency or disaster. (c) Any significant injuries to residents related to the
emergency or disaster that result in hospitalization. (d) The new location of residents. (e) The plans for restoration or rehabilitation of the
facility to allow residents to re-occupy the facility. (f) An estimated timeframe for the resumption of facility
operations, if applicable. (4) In cases where residents are
relocated, the provider shall submit weekly updates to the ODM BLTCSS emergency
relocation coordinator, all applicable managed care plans, and ODH until the
facility is permanently closed or all relocated residents are
returned. (E) Compliance and reimbursement. In cases where residents are relocated, the
provider should consult with the ODM BLTCSS emergency relocation coordinator
regarding nursing facility functions that may be impacted by the temporary
relocation of residents, including the following: (1) Level of care and
pre-admission reviews. (2) Claims
processing. (3) Minimum data sets
(MDS) assessments and reporting. (4) Personal needs
allowance (PNA) accounts. (5) Transportation. (6) Cost
reporting. (F) Termination of NF services. Pursuant to section 5165.01 of the Revised Code,
a NF closure does not occur if all of the facility's residents are
relocated due to an emergency evacuation and one or more of the residents
return to a medicaid-certified bed in the facility not later than thirty days
after the evacuation occurs.
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Rule 5160-3-03.2 | Nursing facilities (NFs): resident protection fund and collection of fines.
Effective:
August 15, 2020
(A) Definitions. (1) "Fines"
means civil money penalties (CMPs) and other assessments imposed against a NF
as a remedy for deficiencies or a cluster of deficiencies that were not
substantially corrected before a survey. (2) "Interest"
means the interest rate determined by the tax commissioner on the fifteenth day
of October each year by rounding the federal short-term rate to the nearest
whole number per cent and adding three per cent. This is the interest rate per
annum used in computing the interest that accrues during the following calendar
year. (B) Procedure for collection of fines
imposed by the centers for medicare and medicaid services (CMS). (1) If CMS has been
unable to collect a CMP fine directly and notifies the Ohio department of
medicaid (ODM), ODM will attempt to collect the fine. (2) ODM will inform the
NF, via certified mail, of the following available payment
options: (a) Lump sum payment. A lump sum payment, including any interest
accrued, from the provider; or (b) Periodic payments. Periodic payments, including any interest
accrued, in accordance with a schedule approved by ODM for a period not to
exceed twelve months; or (c) Medicaid payment offset. Following the date on which the fine plus
interest becomes due, an appropriate reduction to medicaid payments made to the
provider for care rendered to medicaid eligible residents in accordance with a
schedule approved by ODM for a period not to exceed twelve months; or (d) Attorney general's office (AGO). If the facility is no longer active in the
medicaid program, the fine may be referred to the AGO for collection in
accordance with section 131.02 of the Revised Code. (3) Not later than ten
days after notification, the NF is responsible for selecting a payment option
and advising ODM in writing. (4) If the NF fails to
adhere to the terms of the payment agreement or fails to select a payment
option within ten days, ODM will immediately implement collection from an
actively participating facility by medicaid payment offset(s). If a facility is
not actively participating in the medicaid program, the fine will be referred
to the AGO for collection. (5) The fine and any
interest collected from the NF will be retained in the resident protection
fund. (6) ODM will notify CMS
in writing when the CMP fine has been collected in full. (C) Uses of the resident protection
fund. (1) Proceeds from all
fines, including interest collected, are deposited in the state treasury to the
credit of the resident protection fund. (2) ) Monies in the
resident protection fund may only be used in accordance with 42 CFR 488.433 and
488.442 (October 1, 2019) for activities that protect or improve the quality of
care or quality of life for residents of NFs. (D) Management of the resident protection
fund. ODM will provide budgetary, accounting, and other
related management functions for the resident protection fund. When medicaid
payment offset is used as a means of collection, the amount equal to the
reduction in medicaid payments will be deposited to the credit of the resident
protection fund. (E) Disbursement of funds. Upon CMS approval of disbursement of monies in
accordance with paragraph (C)(2) of this rule, a purchase order will be created
by ODM against which invoices or intrastate transfer vouchers are submitted,
or, in the event of an emergency at a nursing facility, a state issued payment
card will be used. (F) The provisions of this rule are
applicable only to the extent that monies are available in the resident
protection fund.
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Rule 5160-3-04 | Nursing facilities (NFs): payment during the Ohio department of medicaid (ODM) administrative appeals process for denial or termination of a provider agreement.
Effective:
December 10, 2017
(A) When ODM is required to provide an
adjudicatory hearing pursuant to Chapter 119. of the Revised Code, payment
shall continue for medicaid-covered services provided to eligible residents
during the appeal of, and the proposed termination or non-revalidation of, a
nursing facility (NF) provider agreement. Payment shall not be made under this
provision for services rendered on or after the effective date of ODM issuance
of a final order of adjudication pursuant to Chapter 119. of the Revised Code,
except as provided in paragraph (B) of this rule. (B) Payment may be provided up to thirty
days following the effective date of termination or non-revalidation of a NF
provider agreement; or after an administrative hearing decision that upholds
the ODM termination or non-revalidation action. Payment will be available if
both of the following conditions are met: (1) Residents were
admitted to the NF before the effective date of termination or expiration;
and (2) The NF cooperates
with the state, local, and federal entities in the effort to transfer residents
to other NFs, institutions, or community programs that can meet the
residents' needs. (C) When ODM acts under instructions from
the United States department of health and human services, payment ends on the
termination date specified by that agency.
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Rule 5160-3-04.1 | Nursing facilities (NFs): payment during the survey agency's administrative appeals process for termination or non-renewal of medicaid certification.
Effective:
December 10, 2017
(A) For the purposes of this rule, the
following definitions shall apply: (1) "State survey
agency" means for the purpose of medicaid certification, the Ohio
department of health (ODH). (2) "Effective date
of termination" means the date set by the state survey agency or the
United States department of health and human services for the termination of
certification. (B) When medicaid certification is either
terminated or not renewed, the Ohio department of medicaid (ODM) must also
either terminate or not revalidate the medicaid provider
agreement. (C) The following requirements
apply: (1) During the appeals
process provided by the state survey agency for the proposed termination or
non-renewal of certification, payment for covered services provided to eligible
residents is available if: (a) Payment is for those residents admitted prior to the
effective date of an order issued under section 5165.72, 5165.74, 5165.77, or
5165.84 of the Revised Code, denying medicaid payments to the facility for all
medicaid eligible residents admitted after the effective date of the order;
and (b) The appeal is conducted prior to the effective date of
termination or non-renewal. (2) If the NF appeal
process results in an adjudication order that upholds the ODH action or if the
administrative hearing is not completed prior to the certification
termination/non-renewal date, payment for services provided to eligible
residents may be available for an additional thirty days if: (a) The eligible resident was admitted prior to the effective
date of an order that was issued as specified in paragraph (C)(1)(a) of this
rule; and (b) The NF cooperates with the state, local, and federal entities
in the effort to transfer residents to other NFs, institutions, or community
programs that can meet the residents' needs. (3) If a NF's appeal
of the termination or non-renewal of its certification is upheld, payment for
covered services provided to eligible residents is resumed. If the appeal
decision is reached after the termination/ non-renewal date, payment is made
retroactive to the date of termination. (4) When the state survey
agency certifies that there is jeopardy to residents' health and safety by
issuing an order under Chapter 5165. of the Revised Code, or when it fails to
certify that there is no jeopardy, payment will end on the effective date of
termination. (5) When ODM acts under
instructions from the United States department of health and human services,
payment ends on the date specified by that agency.
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Rule 5160-3-05 | Level of care definitions.
Effective:
March 19, 2012
(A) This rule contains the definitions used in the process of making a determination of an individual's level of care. The definitions in this rule apply unless a term is otherwise defined in a specific rule. (B) Definitions. (1) "Active Treatment" means a continuous treatment program including aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services for individuals with mental retardation and/or other developmental disabilities that are directed toward the following: (a) The acquisition of the behaviors necessary for the individual to function with as much self determination and independence as possible; and (b) The prevention or deceleration of regression or loss of current optimal functional status. (2) "Activity of daily living (ADL)" means a personal or self-care task that enables an individual to meet basic life needs. For purposes of this rule, the term "ADL" includes the following defined activities: (a) "Bathing" means the ability of an individual to cleanse one's body by showering, tub, or sponge bath, or any other generally accepted method. (b) "Dressing" means the ability of an individual to complete the activities necessary to dress oneself and includes the following two components: (i) Putting on and taking off an item of clothing or prosthesis; and (ii) Fastening and unfastening an item of clothing or prosthesis. (c) "Eating" means the ability of an individual to feed oneself. Eating includes the processes of getting food into one's mouth, chewing, and swallowing, and/or the ability to use and self-manage a feeding tube. (d) "Grooming" means the ability of an individual to care for one's appearance and includes the following three components: (i) Oral hygiene; (ii) Hair care; and (iii) Nail care. (e) "Mobility" means the ability of an individual to use fine and gross motor skills to reposition or move oneself from place to place and includes the following three components: (i) "Bed mobility" means the ability of an individual to move to or from a lying position, turn from side to side, or otherwise position the body while in bed or alternative sleep furniture; (ii) "Locomotion" means the ability of an individual to move between locations by ambulation or by other means; and (iii) "Transfer" means the ability of an individual to move between surfaces, including but not limited to, to and from a bed, chair, wheelchair, or standing position. (f) "Toileting" means the ability of an individual to complete the activities necessary to eliminate and dispose of bodily waste and includes the following four components: (i) Using a commode, bedpan, or urinal; (ii) Changing incontinence supplies or feminine hygiene products; (iii) Cleansing self; and (iv) Managing an ostomy or catheter. (3) "Adverse level of care determination" means a determination that an individual does not meet the criteria for a specific level of care. (4) "Alternative form" means a form that is used in place of and contains all of the data elements of, the JFS 03697, "Level of Care Assessment" (rev. 4/2003) to request a level of care determination from the Ohio department of job and family services (ODJFS) or its designee. (5) "Assistance" means the hands-on provision of help in the initiation and/or completion of a task. (6) "Authorized representative" has the same meaning as in rule 5101:1-37-01 of the Administrative Code. (7) "CBDD" means a county board of developmental disabilities as established under Chapter 5126. of the Revised Code. (8) "Current diagnoses" means a written medical determination by the individual's attending physician, whose scope of practice includes diagnosis, listing those diagnosed conditions that currently impact the individual's health and functional abilities. (9) "Delayed face-to-face visit" means an in-person visit that occurs within a specified period of time after a desk review has been conducted that includes the elements of a long-term care consultation, in accordance with Chapter 173-43 of the Administrative Code, for the purposes of exploring home and community-based services (HCBS) options and making referrals to the individual as appropriate. (10) "Desk review" means a level of care determination process that is not conducted in person. (11) "Developmental delay" means that an individual age birth through five has not achieved developmental milestones as expected for the individual's chronological age as measured, documented, and determined by qualified professionals using generally accepted diagnostic instruments or procedures. (12) "Face-to-face" means an in-person level of care assessment and determination process with the individual for the purposes of exploring nursing facility services or HCBS options and making referrals to the individual as appropriate, that is not conducted by a desk review only. (13) "Habilitation" in accordance with 42 U.S.C. 1396n(c)(5) as in effect December 27, 2005, means services designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings. (14) "ICF-MR" means an intermediate care facility for persons with mental retardation. (15) "ICF-MR-based level of care" means the levels of care as described in rules 5101:3-3-07, 5101:3-3-15.3, and 5101:3-3-15.5 of the Administrative Code. (16) "Individual" means a medicaid recipient or person with pending medicaid eligibility. (17) "Instrumental activity of daily living (IADL)" means the ability of an individual to complete community living skills. For the purposes of this rule, the term "IADL" includes the following defined activities: (a) "Community access " means the ability of an individual to use available community services and supports to meet one's needs and includes the following three components: (i) "Accessing transportation" means the ability to get and use transportation. (ii) "Handling finances" means the ability of an individual to manage one's money and does not include transportation. Handling finances includes all of the following: (a) Knowing where money is; (b) Knowing how to get money; (c) Paying bills; and (d) Knowing how to get and use benefits and services, including but not limited to: (i) Health benefits and insurance; (ii) Social benefits; and (iii) Home utilities. (iii) "Telephoning" means the ability to make and answer telephone calls or use technology to connect to community services and supports. (b) "Environmental management" means the ability of an individual to maintain the living arrangement in a manner that ensures the health and safety of the individual and includes the following three components: (i) "Heavy chores" means the ability to move heavy furniture and appliances for cleaning, turn mattresses, and wash windows and walls; and (ii) "House cleaning" means the ability to make beds, clean the bathroom, sweep and mop floors, dust, clean and store dishes, pick up clutter, and take out trash; (iii) "Yard work and/or maintenance" means the ability to care for the lawn, rake leaves, shovel snow, complete minor home repairs, and paint. (c) "Meal preparation" means the ability of an individual to prepare or cook food for oneself. (d) "Personal laundry" means the ability of an individual to wash and dry one's clothing and household items by machine or by hand. (e) "Shopping" means the ability to obtain or purchase one's necessary items. Necessary items include, but are not limited to, groceries, clothing, and household items. Shopping does not include handling finances or accessing transportation. (18) "Less than twenty-four hour support" means that an individual requires the presence of another person, or the presence of a remote monitoring device that does not require the individual to initiate a response, during a portion of a twenty-four hour period of time. (19) "Level of care determination" means an assessment and evaluation by ODJFS or its designee of an individual's physical, mental, social, and emotional status, using the processes described in rules 5101:3-3-15, 5101:3-3-15.3, and 5101:3-3-15.5 of the Administrative Code, to compare the criteria for all of the possible levels of care as described in rules 5101:3-3-06 to 5101:3-3-08 of the Administrative Code, and make a decision about whether an individual meets the criteria for a level of care. (20) "Level of care validation" means the verification process for ODJFS or its designee to review and enter an individual's current level of care in the electronic records of the individual that are maintained by ODJFS. (21) "Long-term services and supports" means institutional or community-based medical, health, psycho-social, habilitative, rehabilitative, or personal care services that may be provided to medicaid-eligible individuals. (22) "Major life area" has the same meaning as in rule 5101:3-3-07 of the Administrative Code. (23) "Manifested" means a condition is diagnosed and interferes with the individual's ability to develop or maintain functioning in at least one major life area. (24) "Medication administration" means the ability of an individual to prepare and self-administer all forms of over-the-counter and prescription medication. (25) "Need" means the inability of an individual to complete a necessary and applicable task independently, safely, and consistently. An individual does not have a need when: (a) The individual is not willing to complete a task or does not have the choice to complete a task. (b) The task can be completed with the use of available assistive devices and accommodations. (26) "Nursing facility (NF)" has the same meaning as in section 5111.20 of the Revised Code. A facility that has submitted an application packet for medicaid certification to ODJFS is considered to be in the process of obtaining its initial medicaid certification by the Ohio department of health and shall be treated as a NF for the purposes of this rule. (27) "NF-based level of care" means the intermediate and skilled levels of care, as described in rule 5101:3-3-08 of the Administrative Code. (28) "NF-based level of care program" means a NF, a home and community-based services medicaid waiver that requires a NF-based level of care, or other medicaid program that requires a NF-based level of care. (29) "PASRR" means the preadmission screening and resident review requirements mandated by section 1919(e)(7) of the Social Security Act and implemented in accordance with rules 5101:3-3-14, 5101:3-3-15.1, 5101:3-3-15.2 and 5122-21-03 and 5123:2-14-01 of the Administrative Code. (30) "Physician" means a person licensed under Chapter 4731. of the Revised Code or licensed in another state as defined by applicable law, to practice medicine and surgery or osteopathic medicine and surgery. (31) "Psychiatrist" means a physician licensed under Chapter 4731. of the Revised Code or licensed in another state as defined by applicable law, to practice psychiatry. (32) "Psychologist" means, a person licensed in Ohio as a psychologist or school psychologist, or licensed in another state as a psychologist as defined by applicable law. (33) The terms "psychologist," "the practice of psychology," "psychological procedures," "school psychologist," "practice of school psychology," "licensed psychologist," "licensed school psychologist," and "certificated school psychologist" have the same meanings as in section 4732.01 of the Revised Code. (34) "Skilled nursing services" means specific tasks that must, in accordance with Chapter 4723. of the Revised Code, be provided by a licensed practical nurse (LPN) at the direction of a registered nurse or by a registered nurse directly. (35) "Skilled rehabilitation services" means specific tasks that must, in accordance with Title 47 of the Revised Code, be provided directly by a licensed or other appropriately certified technical or professional health care personnel. (36) "Sponsor" means an adult relative, friend, or guardian of an individual who has an interest in or responsibility for the individual's welfare. (37) "Substantial functional limitation" means the inability of an individual to independently, adequately, safely, and consistently perform age-appropriate tasks as associated with the major life areas and as referenced in paragraph (B)(4) of this rule, without undue effort and within a reasonable period of time. An individual who has access to and is able to perform the tasks independently, adequately, safely, and consistently with the use of adaptive equipment or assistive devices is not considered to have a substantial functional limitation. (38) "Supervision" means either of the following: (a) Reminding an individual to perform or complete an activity; or (b) Observing while an individual performs an activity to ensure the individual's health and safety. (39) "Twenty-four hour support" means that an individual requires the continuous presence of another person throughout the course of the entire day and night during a twenty-four hour period of time. (40) "Unstable medical condition" means clinical signs and symptoms are present in an individual and a physician has determined that: (a) The individual's signs and symptoms are outside of the normal range for that individual; (b) The individual's signs and symptoms require extensive monitoring and ongoing evaluation of the individual's status and care and there are supporting diagnostic or ancillary testing reports that justify the need for frequent monitoring or adjustment of the treatment regimen; (c) Changes in the individual's medical condition are uncontrollable or unpredictable and may require immediate interventions; and (d) A licensed health professional must provide ongoing assessments and evaluations of the individual that will result in adjustments to the treatment regimen as medically necessary. The adjustments to the treatment regimen must happen at least monthly, and the designated licensed health professional must document that the medical interventions are medically necessary.
Last updated March 18, 2024 at 4:06 PM
Supplemental Information
Authorized By:
–
Amplifies:
–
Five Year Review Date:
Prior Effective Dates:
4/7/1977, 10/14/1977, 7/1/1980, 11/10/1983, 8/1/1984, 4/16/1992, 12/24/1993, 12/31/1993, 1/20/2002, 7/1/2008
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Rule 5160-3-06 | Criteria for the protective level of care.
Effective:
March 19, 2012
(A) This rule describes the criteria for an individual to meet the protective level of care. (B) The criteria for the protective level of care is met when: (1) The individual's needs for long-term services and supports (LTSS), as defined in rule 5101:3-3-05 of the Administrative Code, are less than the criteria for the intermediate or skilled levels of care, as described in paragraphs (B)(4), (C), and (D)(4) of rule 5101:3-3-08 of the Administrative Code. (2) The individual's LTSS needs are less than the criteria for the ICF-MR-based level of care, as defined in rule 5101:3-3-05 of the Administrative Code. (3) The individual has a need for: (a) Less than twenty-four hour support, as defined in rule 5101:3-3-05 of the Administrative Code, in order to prevent harm due to a cognitive impairment, as diagnosed by a physician or other licensed health professional acting within his or her applicable scope of practice, as defined by law; or (b) Supervision, as defined in rule 5101:3-3-05 of the Administrative Code, of one activity of daily living (ADL), as defined in rule 5101:3-3-05 of the Administrative Code and as described in paragraph (C) of this rule, or supervision of medication administration, as defined in rule 5101:3-3-05 of the Administrative Code; and (c) Assistance, as defined in rule 5101:3-3-05 of the Administrative Code, with three instrumental activities of daily living (IADL), as defined in rule 5101:3-3-05 of the Administrative Code and as described in paragraph (D) of this rule. (C) For the purposes of meeting the criteria described in paragraph (B)(3) of this rule, an individual has a need in an ADL when: (1) The individual requires supervision of mobility in at least one of the following three components: (a) Bed mobility; (b) Locomotion; or (c) Transfer. (2) The individual requires supervision of bathing. (3) The individual requires supervision of grooming in all of the following three components: (a) Oral hygiene; (b) Hair care; and (c) Nail care. (4) The individual requires supervision of toileting in at least one of the following four components: (a) Using a commode, bedpan, or urinal; (b) Changing incontinence supplies or feminine hygiene products; (c) Cleansing self; or (d) Managing an ostomy or catheter. (5) The individual requires supervision of dressing in at least one of the following two components: (a) Putting on and taking off an item of clothing or prosthesis; or (b) Fastening and unfastening an item of clothing or prosthesis. (6) The individual requires supervision of eating. (D) For the purposes of meeting the criteria described in paragraph (B)(3) of this rule, an individual has a need in an IADL when: (1) The individual requires assistance with meal preparation. (2) The individual requires assistance with environmental management in all of the following three components: (a) Heavy chores; (b) House cleaning; and (c) Yard work and/or maintenance. (3) The individual requires assistance with personal laundry. (4) The individual requires assistance with community access in at least one of the following three components: (a) Accessing transportation; (b) Handling finances; or (c) Telephoning. (5) The individual requires assistance with shopping.
Last updated March 18, 2024 at 4:06 PM
Supplemental Information
Authorized By:
–
Amplifies:
–
Five Year Review Date:
Prior Effective Dates:
12/24/1993, 7/1/2008
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Rule 5160-3-06.1 | Institutions for mental diseases (IMDs).
Effective:
August 17, 2017
(A) The purpose of this rule is to set forth the process by which the Ohio department of medicaid (ODM) shall identify nursing facilities (NFs) that are at risk of becoming IMDs, the preventive measures to be taken by ODM when such facilities have been identified, and the course of action to be taken if a NF is identified as an IMD. Medicaid payment is not available for services provided to individuals in an IMD who are age twenty-one and over, and in certain circumstances age twenty-two and over, and under age sixty-five, except as permitted in 42 C.F.R. 438.6(e) (October 1, 2016). (B) Definitions. (1) "At risk facility". A NF is considered to be an at risk facility if it meets two or more of the IMD evaluation criteria set forth in paragraph (C)(2)(b) of this rule but has not been determined to meet the definition of IMD set forth in paragraph (B)(2) of this rule. (2) "Institution for mental diseases (IMD)" means a hospital, nursing facility, or other institution of more than sixteen beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services. A NF is considered to be an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An intermediate care facility for the mentally retarded (ICF-MR) is not an IMD. (3) "Mental diseases" means diseases listed as mental disorders in the "International Classification of Diseases, Tenth Revision, Clinical Modification," or the most recent edition, with the exception of mental retardation, senility, and organic brain syndrome. This publication is available on the internet via the website http://www.cdc.gov/nchs/icd/icd10cm.htm. (4) "Potentially at risk of becoming an IMD". A NF is considered to be potentially at risk of becoming an IMD if any one of the following applies: (a) The NF is licensed as a mental nursing home as defined in rule 3701-17-01 of the Administrative Code; (b) The NF was identified as an at risk facility during a prior IMD review; or (c) Forty-five per cent or more of the NF's residents have been determined to need specialized services for serious mental illness by the Ohio department of mental health and addiction services (ODMHAS) in accordance with rules 5160-3-15.1, 5160-3-15.2, and 5122-21-03 of the Administrative Code. (C) Identification of at risk facilities and IMDs. (1) ODM shall identify and maintain a list of NFs that are potentially at risk of becoming IMDs. (2) IMD reviews shall be conducted for any potentially at risk facility on the list. (a) IMD reviews shall be scheduled as follows: (i) ODM shall schedule and complete an initial on-site IMD review of any NF that is newly identified as meeting the criteria set forth in paragraphs (B)(4)(a) and/or (B)(4)(c) of this rule. Initial reviews shall be completed within sixty calendar days following the identification of the NF's potentially at risk status; (ii) ODM shall conduct annual on-site IMD reviews in each potentially at risk facility for at least two consecutive years after it is identified as potentially at risk of becoming an IMD. (b) IMD review criteria. The following criteria shall be used to evaluate the overall character of a NF: (i) Whether the NF is licensed as a psychiatric facility. For purposes of this rule, this includes licensure as a mental nursing home in accordance with rule 3701-17-01 of the Administrative Code; (ii) Whether the NF is accredited as a psychiatric facility by the "Joint Commission," which accredits and certifies health care organizations and programs in the United States; (iii) Whether the NF is under the jurisdiction of the ODMHAS; (iv) Whether the NF specializes in providing psychiatric and/or psychological care and treatment, as evidenced by any of the following indicators: (a) Fifty per cent or more of individuals residing in the NF have medical records indicating that they are receiving psychiatric/psychological care and treatment; (b) Fifty per cent or more of the NF's staff have specialized psychiatric/psychological training; or (c) Fifty per cent or more of individuals residing in the NF are receiving psychopharmacological drugs; and (v) Whether the current need for institutionalization for more than fifty per cent of all the individuals residing in the NF results from mental diseases. In determining whether this criterion is met, the reviewer must consider whether more than fifty per cent of individuals residing in the NF have serious mental illness (as defined in rule 5160-3-15 of the Administrative Code) and have been determined by ODMHAS to need specialized services for serious mental illness in accordance with rule 5160-3-15.1 or 5160-3-15.2, and rule 5122-21-03 of the Administrative Code. (c) IMD review results. At the conclusion of each IMD review, ODM shall make one of the following determinations: (i) The NF is not at risk of becoming an IMD; (ii) The NF is an at risk facility as defined in paragraph (B)(1) of this rule; or (iii) The facility is determined to be an IMD. (D) ODM action pursuant to IMD review results. Upon completion of the IMD review, ODM shall proceed with the follow-up activities corresponding to the determination that was made for the NF: (1) For NFs determined not to be at risk of becoming an IMD: (a) Any NF that is determined not to meet the criteria for potential risk shall be notified and removed from the list of facilities that are potentially at risk of becoming an IMD. (b) Any NF determined to be potentially at risk of becoming an IMD but that does not meet at least two of the IMD review criteria set forth in paragraph (C)(2)(b) of this rule shall be notified of its status as a potentially at risk facility and that it shall continue to be subject to annual IMD reviews, and retained on the list of facilities that are potentially at risk of becoming an IMD. (2) NFs determined to be at risk of becoming an IMD shall be notified of the determination, offered the opportunity to receive technical assistance to prevent them from becoming IMDs, and shall be monitored closely by ODM following the at risk determination. Such monitoring may include the performance of additional, unannounced, on-site IMD reviews by ODM. (3) For NFs determined to be an IMD: (a) The NF shall be notified by certified mail of the determination, that eligibility to receive medicaid vendor payment shall be terminated with respect to all individuals residing in that NF who are under age sixty-five and age twenty-one and over, and, in certain circumstances age twenty-two and over, except as permitted in 42 C.F.R. 438.6(e), and that it has thirty days from the date the notice was mailed to exercise its reconsideration rights pursuant to paragraph (D) of rule 5160-70-02 of the Administrative Code; (b) If the facility requests a reconsideration pursuant to paragraph (D) of rule 5160-70-02 of the Administrative Code, eligibility to receive vendor payment will continue until the issuance of a final decision by ODM. (c) On the thirty-first day following the date the IMD determination notice was mailed to the NF, or upon issuance of a final decision by ODM, if the IMD determination is upheld on reconsideration, ODM shall notify the county department of job and family services (CDJFS) in writing, to initiate the process for termination of the vendor payment and a redetermination of the residents' continued eligibility for medicaid and to provide notice of all applicable appeal rights to all affected residents of that IMD in accordance with Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. (E) A NF which has been determined to be an IMD may, following a period of not less than six months, submit a written request that ODM conduct a redetermination survey when changes have been made in its overall character such that the administrator of the facility believes it would no longer qualify as an IMD. ODM shall respond to such requests by conducting a redetermination survey within sixty days of the receipt of the request. (1) If the redetermination survey finds that the NF no longer meets the definition of an IMD set forth in paragraph (B)(2) of this rule, ODM shall: (a) Follow the procedures set forth in paragraph (D)(1) or (D)(2) of this rule; and (b) Notify the CDJFS in writing, of the effective date of the determination that the facility is not an IMD, to initiate vendor payment, regardless of the age of the individual and in accordance with rule 5160-3-15 of the Administrative Code, on behalf of medicaid eligible individuals seeking medicaid payment of their stay in that NF. (2) If the redetermination survey finds that the NF continues to be an IMD, the NF shall be notified by certified mail of the determination, the basis for the determination, that it has thirty days from the date the notice was mailed to exercise its reconsideration rights pursuant to paragraph (D) of rule 5160-70-02 of the Administrative Code, and that if the NF does not exercise its reconsideration rights within that time it may not request another redetermination survey for at least six months from the date of the determination.
Last updated March 18, 2024 at 4:06 PM
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Rule 5160-3-08 | Criteria for nursing facility-based level of care for an adult.
Effective:
March 19, 2012
(A) This rule describes the criteria for an individual to meet the nursing facility (NF)-based level of care. The NF-based level of care includes the intermediate and skilled levels of care. An individual is determined to meet the NF-based level of care when the individual meets the criteria as described in paragraphs (B) to (D) of this rule. (B) The criteria for the intermediate level of care is met when: (1) The individual's needs for long-term services and supports (LTSS), as defined in rule 5101:3-3-05 of the Administrative Code, exceed the criteria for the protective level of care, as described in paragraph (B)(3) of rule 5101:3-3-06 of the Administrative Code. (2) The individual's LTSS needs are less than the criteria for the skilled level of care, as described in paragraph (D)(4) of this rule. (3) The individual's LTSS needs do not meet the criteria for the ICF-MR-based level of care, as defined in rule 5101:3-3-05 of the Administrative Code. (4) The individual has a need for a minimum of one of the following: (a) Assistance, as defined in rule 5101:3-3-05 of the Administrative Code, with the completion of a minimum of two activities of daily living (ADL), as defined in rule 5101:3-3-05 of the Administrative Code and as described in paragraph (C) of this rule; (b) Assistance with the completion of a minimum of one ADL as described in paragraph (C) of this rule, and assistance with medication administration, as defined in rule 5101:3-3-05 of the Administrative Code; (c) A minimum of one skilled nursing service or skilled rehabilitation service, as defined in rule 5101:3-3-05 of the Administrative Code; or (d) Twenty-four hour support, as defined in rule 5101:3-3-05 of the Administrative Code, in order to prevent harm due to a cognitive impairment, as diagnosed by a physician or other licensed health professional acting within his or her applicable scope of practice, as defined by law. (C) For the purposes of meeting the criteria described in paragraph (B)(4) of this rule, an individual has a need in an ADL when: (1) The individual requires assistance with mobility in at least one of the following three components: (a) Bed mobility; (b) Locomotion; or (c) Transfer. (2) The individual requires assistance with bathing. (3) The individual requires assistance with grooming in all of the following three components: (a) Oral hygiene; (b) Hair care; and (c) Nail care. (4) The individual requires assistance with toileting in at least one of the following four components: (a) Using a commode, bedpan, or urinal; (b) Changing incontinence supplies or feminine hygiene products; (c) Cleansing self; or (d) Managing an ostomy or catheter. (5) The individual requires assistance with dressing in at least one of the following two components: (a) Putting on and taking off an item of clothing or prosthesis; or (b) Fastening and unfastening an item of clothing or prosthesis. (6) The individual requires assistance with eating. (D) The criteria for the skilled level of care is met when: (1) The individual's LTSS needs exceed the criteria for the protective level of care, as described in paragraph (B)(3) of rule 5101:3-3-06 of the Administrative Code. (2) The individual's LTSS needs exceed the criteria for the intermediate level of care as described in paragraph (B)(4) of this rule. (3) The individual's LTSS needs exceed the criteria for the ICF-MR-based level of care. (4) The individual requires a minimum of one of the following: (a) One skilled nursing service within the day on no less than seven days per week; or (b) One skilled rehabilitation service within the day on no less than five days per week. (5) The individual has an unstable medical condition, as defined in rule 5101:3-3-05 of the Administrative Code. (E) When an individual meets the criteria for a skilled level of care, as described in paragraph (D) of this rule, the individual may request placement in an intermediate care facility for persons with mental retardation (ICF-MR) that provides services to individuals who have a skilled level of care. When an individual with a skilled level of care requests placement in an ICF-MR, the following requirements apply: (1) The individual may be determined to meet the criteria for the ICF-MR-based level of care; and (2) The ICF-MR must provide written certification that the services provided in the facility are appropriate to meet the needs of an individual who meets the criteria for a skilled level of care.
Last updated March 18, 2024 at 4:06 PM
Supplemental Information
Authorized By:
–
Amplifies:
–
Five Year Review Date:
Prior Effective Dates:
12/24/1993
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Rule 5160-3-14 | Process and timeframes for a level of care determination for nursing facility-based level of care programs.
(A) This rule describes the processes
and timeframes for a level of care determination, as defined in rule 5160-3-05
of the Administrative Code, for a nursing facility (NF)-based level of care
program, as defined in rule 5160-3-05 of the Administrative Code. (1) The processes
described in this rule will not be used for a determination for an
ICF-IID-based level of care, as defined in rule 5160-3-05 of the Administrative
Code. (2) A level of care
determination may occur face-to-face, by a desk review, or by telephone, as
defined in rule 5160-3-05 of the Administrative Code, and is one component of
medicaid eligibility in order to: (a) Authorize medicaid payment to a NF; or (b) Approve medicaid payment of a NF-based home and
community-based services (HCBS) waiver or other NF-based level of care
program. (3) An individual who is seeking a NF
admission is subject to both a preadmission screening and resident review
(PASRR) process, as described in rules 5160-3-15, 5160-3-15.1, 5160-3-15.2,
5122-21-03, and 5123-14-01 of the Administrative Code, and a level of care
determination process. (a) The preadmission screening process must be completed before
a level of care determination or a level of care validation can be
issued. (b) In order for the Ohio department of medicaid (ODM) to
authorize payment to a NF, the individual must have received a non-adverse
PASRR determination and subsequent NF-based level of care
determination. (i) ODM may authorize
payment to the NF effective on the date of the PASRR
determination. (ii) The level of care
effective date cannot precede the date that the PASRR requirements were
met. (iii) If a NF receives
medicaid payment from ODM or its designee for an individual who does not have a
NF-based level of care, the NF is subject to the claim adjustment for
overpayments process described in rule 5160-1-19 of the Administrative
Code. (B) Level of care request. (1) In order for ODM or
its designee (hereafter referred to as ODM) to make a level of care
determination, ODM must receive a complete level of care request. A level of
care request is considered complete when all necessary data elements are
included and completed on the ODM 03697, "Level of Care Assessment"
(rev. 7/2014) or alternative form, as defined in rule 5160-3-05 of the
Administrative Code, and any necessary supporting documentation is submitted
with the ODM 03697 or alternative form, as described in paragraphs (B)(2) to
(B)(4) of this rule. (2) Necessary data
elements on the ODM 03697 or alternative form: (a) Individual's legal name; (b) Individual's medicaid case number, or a pending medicaid
case number; (c) Date of original admission to the facility, if
applicable; (d) Individual's current address, including county of
residence; (e) Individual's current diagnoses; (f) Date of onset for each diagnosis, if available; (g) Individual's medications, treatments, and required
medical services; (h) A description of the individual's activities of daily
living and instrumental activities of daily living; (i) A description of the individual's current mental and
behavioral status; and (j) Type of service setting requested. (3) Certification on the
ODM 03697 or alternative form. (a) A certification means a signature from a physician as
defined in rule 5160-3-05 of the Administrative Code, nurse practitioner as
defined in Chapter 4723. of the Revised Code, or physician assistant as defined
in Chapter 4730. of the Revised Code and date on the ODM 03697 or alternative
form. ODM will allow an electronic signature for the certification or standard
cerification via mail. (b) A certification must be obtained within thirty calendar days
of submission of the ODM 03697 or alternative form. (c) Exceptions to the certification: (i) When an individual
resides in the community and ODM determines that the individual's health
and welfare is at risk and that it is not possible for the submitter of the ODM
03697 or alternative form to obtain a physician, nurse practitioner, or
physician assistant signature and date at the time of the submission of the ODM
03697 or alternative form, a verbal certification is acceptable. (ii) ODM must obtain a
certification within thirty days of the verbal certification. (4) Necessary supporting
documentation with the ODM 03697 or alternative form when the individual is
subject to a preadmission screening process: (a) A copy of the ODM 03622, "Preadmission
Screening/Resident Review (PAS/RR) Identification Screen" (rev. 8/2014)
and ODM 07000, "Hospital Exemption from Preadmission Screening
Notification" (rev. 7/2014), as applicable, in accordance with rules
5160-3-15.1 and 5160-3-15.2 of the Administrative Code; and (b) Any preadmission screening results and assessment
forms. (C) Process when ODM receives a complete
level of care request. (1) When ODM determines
that a level of care request is complete, ODM will: (a) Issue a level of care determination. (b) Inform the individual, and/or the sponsor and the authorized
representative, as applicable, about the individual's PASRR
results. (c) Notify the individual, and/or the sponsor and the authorized
representative, as applicable, as defined in rule 5160-3-05 of the
Administrative Code, of the level of care determination. (d) When there is an adverse level of care determination, inform
the individual, the sponsor, and the authorized representative, as applicable,
about the individual's hearing rights in accordance with division 5101:6
of the Administrative Code. (2) In accordance with
rules 5160:1-2-01 and 5160:1-6-03.1 of the Administrative Code, the county
department of job and family services (CDJFS) will determine medicaid
eligibility and issue proper notice and hearing rights to the
individual. (D) Process when ODM receives an
incomplete level of care request. (1) When ODM determines
that a level of care request is not complete, ODM will: (a) Notify the submitter that a level of care determination
cannot be issued due to an incomplete ODM 03697 or alternative
form. (b) Specify the necessary information the submitter must provide
on or with the ODM 03697 or alternative form. (c) Notify the submitter that the level of care request will be
denied if the submitter does not submit the necessary information to ODM within
fourteen calendar days. (i) When the submitter
provides a complete level of care request to ODM within the fourteen-calendar
day timeframe, ODM will perform the steps described in paragraph (C) of this
rule. (ii) When the submitter
does not provide a complete level of care request to ODM within the
fourteen-calendar day timeframe, ODM may deny the level of care request and
document the denial in the individual's electronic record maintained by
ODM. (2) In accordance with
rules 5160:1-2-01 and 5160:1-6-03.1 of the Administrative Code, the CDJFS will
determine medicaid eligibility and issue proper notice and hearing rights to
the individual. (E) Desk review level of care
determination. (1) A desk review level
of care determination is required within one business day from the date of
receipt of a complete level of care request when: (a) ODM determines that an individual is seeking admission or
re-admission to a NF from an acute care hospital or hospital emergency
room. (b) A CDJFS requests a level of care determination for an
individual who is receiving adult protective services, as defined in rule
5101:2-20-01 of the Administrative Code, and the CDJFS submits a ODM 03697 or
alternative form at the time of the level of care request. (2) A desk review level
of care determination is required within five calendar days from the date of
receipt of a complete level of care request when: (a) ODM determines that an individual who resides in a NF is
requesting to change from a non-medicaid payor to medicaid payment for the
individual's continued NF stay. (b) ODM determines that an individual who resides in a NF is
requesting to change from medicaid managed care to medicaid fee-for-service as
payment for the individual's continued NF stay. (c) ODM determines that an individual is transferring from one
NF to another NF. (F) Face-to-face level of care
determination. ODM will allow telephonic, video conference or desk review in
lieu of a face-to-face, unless the individual's needs require a
face-to-face visit. ODM will conduct face-to-face visits for all adverse level
of care determinations as described in paragraph (F)(1)(b) of this
rule. (1) A level of care
determination is required within ten calendar days from the date of receipt of
a complete level of care request when: (a) An individual or the authorized representative of an
individual requests a face-to-face level of care determination. (b) ODM makes an adverse level of care determination, as defined
in rule 5160-3-05 of the Administrative Code, during a desk review level of
care determination. When a desk review results in an adverse level of care
determination, a face-to-face assessment will follow to verify the findings of
the desk review. (c) ODM determines that the information needed to make a level of
care determination through a desk review is inconsistent. (d) An individual resides in the community and ODM verifies that
the individual does not have a current NF-based level of care. (e) ODM determines that an individual has a pending disenrollment
from a NF-based HCBS waiver due to the individual no longer having a NF-based
level of care. (2) A level of care
determination is required within two business days from the date of a level of
care request from a CDJFS for an individual who is receiving adult protective
services when the CDJFS does not submit a ODM 03697 or alternative form at the
time of the level of care request. (G) Level of care validation. ODM may conduct a level of care validation, as
defined in rule 5160-3-05 of the Administrative Code, in lieu of a face-to-face
level of care determination within one business day from the date of a level of
care request for: (1) An individual who is
enrolled on a NF-based HCBS waiver and is seeking admission to a
NF. (2) An individual who is
a NF resident and is seeking readmission to the same NF after a
hospitalization.
Last updated March 18, 2024 at 4:06 PM
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Rule 5160-3-15 | Preadmission screening and resident review (PASRR) definitions.
Effective:
December 30, 2019
(A) The purpose of this rule is to set forth the
definitions for terms contained in rules 5160-3-15.1, 5160-3-15.2, 5122-21-03
and 5123-14-01 of the Administrative Code. (B) Definitions: (1) "Adverse determination"
means a determination made in accordance with rules 5160-3-15.1, 5160-3-15.2,
5122-21-03 and 5123-14-01 of the Administrative Code, that an individual does
not require the level of services provided by a nursing facility or that the
individual does or does not require specialized services. (2) "Attending
Physician" means the physician to whom a person, or the family of a
person, has assigned primary responsibility for the treatment or care of the
person or, if the person or the person's family has not assigned that
responsibility, the physician who has accepted that
responsibility. (3) "Categorical determination"
means a preadmission level II determination which may be made for an individual
without a face to face assessment for an individual diagnosed with a serious
mental illness (SMI) and/or developmental disability (DD) as defined in
paragraphs (B)(6) and (B)(28) of this rule when the individual's
circumstances fall within one of the following two categories: (a) The individual requires an 'emergency nursing
facility stay', as defined in paragraph (B)(7) of this rule; (b) The individual is seeking admission to a nursing
facility for a 'respite nursing facility stay' as defined in
paragraph (B)(26) of this rule. (4) "Community"
for PASRR purposes means a new admission from a setting other than a nursing
facility, Ohio hospital or a unit of a hospital that is not operated by or
licensed by the Ohio department of mental health and addiction services
(OhioMHAS). (5) "Current
diagnoses" means a written medical determination by the individual's
attending physician, whose scope of practice includes diagnosis, listing those
diagnosed conditions which currently impact the individual's health and
functional abilities. To be considered current, the written documentation of
the diagnoses must reflect the diagnoses assigned by the individual's
attending physician within one hundred eighty calendar days of submission for
the preadmission screening review certifying that the listed diagnoses are an
accurate reflection of the individual's current condition. (6) "Developmental disability
(DD)." An individual is considered to have a DD when he or she meets the
conditions described in rule 5123-14-01 of the Administrative
Code. (7) "Emergency nursing facility
stay" refers to the temporary admission of an individual to a nursing
facility pending further assessment in emergency situations requiring
protective services as defined in rule 5101:2-20-01 of the Administrative Code,
with placement in a nursing facility not to exceed seven days. (8) "Guardian" has the same
meaning as in section 2111.01 of the Revised Code. (9) "Hospital discharge
exemption," also known as hospital exemption means an exemption from the
preadmission screening as defined in paragraph (B)(21) of this rule, when an
individual meets the hospital discharge exemption criteria in rule 5160-3-15.1
of the Administrative Code. (10) "Indications of developmental
disabilities (DD)." An individual shall be considered to have indications
of developmental disabilities when the individual meets the criteria specified
in rule 5123-14-01 of the Administrative Code or the individual receives
services from a county board of DD. (11) "Indications of serious mental
illness (SMI)." An individual shall be considered to have indications of
an SMI when the individual meets the criteria specified in rule 5122-21-03 of
the Administrative Code. (12) "Individual," for the
purposes of this rule, means a person, regardless of payment source, who is
seeking admission, readmission or transfer to a medicaid certified nursing
facility, or who resides in a medicaid certified nursing facility or facility
in the process of becoming medicaid certified as a nursing
facility. (13) "Level I"
or "level I screening" refers to the initial screening that must be
given to all individuals seeking new admission as defined in paragraph (B)(17)
of this rule to a medicaid-certified nursing facility, regardless of payor
source, for the purpose of identifying individuals who may have or are
suspected to have indications of a DD as defined in paragraph (B)(10) of this
rule and/or a SMI as defined in paragraph (B)(11) of this rule. (14) "Level II
entities" refers to the state level II authorities which is the OhioMHAS
and the Ohio department of developmental disabilities (DODD). (15) "Level II"
or "level II evaluation" refers to the in-depth evaluation of an
individual that has been identified as having indications or suspected of
having indications of a DD and/or a SMI as defined in paragraphs (B)(10) and
(B)(11) of this rule by the level I screening outcome. The level II entity must
confirm or disconfirm the existence of a DD and/or a SMI and make a written
determination of the following: (a) The individual's need or continued need for
nursing facility services as defined in paragraph (B)(19) of this rule;
and (b) If the nursing facility is or continues to be the most
appropriate setting to meet the individual's long-term care needs; and
(c) Identification and recommendation for specialized
services as defined in paragraphs (B)(30) and/or (B)(31) of this rule, if any,
that would be needed for the individual during the individual's nursing
facility stay. (16) "Long-term resident" means
an individual who has continuously resided in a nursing facility or a
consecutive series of nursing facilities and/or medicare skilled nursing
facilities for at least thirty months prior to the first resident review
determination in which the individual was found not to require the level of
services provided by a nursing facility, but to require specialized services as
defined in paragraphs (B)(30) and (B)(31) of this rule. The thirty months may
include temporary absences for hospitalization, therapeutic leave, or visits
with family or friends as defined in rule 5160-3-16.4 of the Administrative
Code. (17) "New admission" means the
admission to an Ohio medicaid certified nursing facility of an
individual: (a) Who was not a resident of any nursing facility
immediately preceding: (i) The current nursing
facility admission; or (ii) A hospital stay for
which the individual is to be admitted directly to a nursing
facility; (b) Seeking admission or admitted to a nursing facility
from another state, regardless of prior residence; or (c) Is transferred or readmitted from a nursing facility
following an: (i) Adverse level II or a
resident review determination; or (ii) Overruled appeal of
an adverse level II determination. (d) For PASRR purposes only and effective on the date the
facility submits its application packet for medicaid certification to the Ohio
department of medicaid, individuals seeking admission to, or who are currently
residing in, a facility that is in the process of obtaining its initial
medicaid certification by Ohio department of health, and (e) With the exception of those circumstances specified in
paragraphs (B)(17)(a) to (B)(17)(c) of this rule, nursing facility transfers
and readmissions as defined in paragraphs (B)(20) and (B)(24) of this rule are
not considered to be new admissions for the purposes of this rule. (18) "Nursing facility" has the
same meaning as in section 5111.20 of the Revised Code. A long term care
facility that has submitted an application packet for medicaid certification to
the Ohio department of medicaid is considered to be in the process of obtaining
its initial medicaid certification by the Ohio department of health and shall
be treated as a nursing facility for the purposes of this rule. (19) "Nursing facility level of
service" for the purposes of PASRR means a determination made by the DODD
and/or OhioMHAS in accordance with rules 5123-14-01 and 5122-21-03 of the
Administrative Code as required by section 1919(e)(7) of the Social Security
Act, as in effect July 1, 2019 that the individual's need for treatment
does not exceed the level of services which can be delivered by the nursing
facility to which the individual is seeking admission or is currently admitted
to either through nursing facility services alone or, where necessary, through
nursing facility services supplemented by specialized services provided by or
arranged for by the state. (20) "Nursing facility
transfer." A nursing facility transfer occurs when an individual is
transferred from any Ohio medicaid certified nursing facility to another Ohio
medicaid certified nursing facility, with or without an intervening hospital
stay. (21) "Preadmission screening"
refers to the level I screening as defined in paragraph (B)(13) of this rule
and when applicable the completion of the level II evaluation as defined in
paragraph (B)(15) of this rule that results in a PASRR determination from the
DODD and/or OhioMHAS administered prior to the individuals admission to the
nursing facility. (22) "PASRR" means the
preadmission screening and resident review of individuals for the purposes of
identifying individuals with serious mental illness as defined in rule
5122-21-03 of the Administrative Code and/or a developmental disability as
defined in rule 5123-14-01 of the Administrative Code and required by the
"Social Security Act," 42 U.S.C 1396r(e)(7). (23) "Physician" means a doctor
of medicine or osteopathy who is licensed to practice medicine. (24) "Readmission" means the
individual is readmitted to the same nursing facility from a hospital to which
he or she was sent for the purpose of receiving care. (25) "Resident review " is a
post admission level II evaluation as defined in paragraph (B)(15) of this rule
that results in a determination for nursing facility residents which must be
implemented upon a significant change in condition as defined in paragraph
(B)(29) of this rule and in accordance with section 1919(e)(7) of the Social
Security Act, as in effect on July 1, 2019, which must be implemented in
accordance with rules 5160-3-15.2, 5122-21-03 and 5123-14-01 of the
Administrative Code. (26) "Respite nursing facility
stay" means the admission of an individual to a nursing facility for a
maximum of fourteen days in order to provide respite to in-home caregivers to
whom the individual is expected to return following the respite
stay. (27) "Ruled out" means a
determination made by the DODD and/or the OhioMHAS that the individual is not
subject to further review. An individual may be ruled out at any time during
the PASRR assessment when it is determined that the individual: (a) Does not have a DD and/or SMI; or (b) Has a primary diagnosis of dementia (including
alzheimer's disease or a related disorder); or (c) Has a non-primary diagnosis of dementia without a
primary diagnosis that is a SMI, and does not have a diagnosis of a DD or a
related condition. (28) "Serious mental illness"
means an individual meets the conditions described in rule 5122-21-03 of the
Administrative Code. (29) "Significant change of
condition" means any major decline or improvement in the individual's
physical or mental condition, as described in 42 C.F.R. 483.20, as in effect on
July 1, 2019 and when at least one of the following criteria is
met: (a) There is a change in the individual's current
diagnosis(es), mental health treatment, functional capacity, or behavior such
that, as a result of the change, the individual who did not previously have
indications of a SMI, or who did not previously have indications of a DD, now
has such indications; or (b) The change is such that it may impact the mental health
treatment or placement options of an individual previously identified as having
SMI and/or may result in a change in the specialized services needs of an
individual previously identified as having a DD. (30) "Specialized services for
serious mental illness" means those services specified by the level II or
the resident review determination for an individual with a SMI which are
arranged by OhioMHAS in accordance with rule 5122-21-03 of the Administrative
Code and may be provided under the behavioral health services as described in
rules 5160-8-05 and 5160-27-02 of the Administrative Code, which when combined
with services by the nursing facility, results in the continuous and aggressive
implementation of an individualized plan of care in accordance with 42 CFR
483.120, as in effect July 1, 2019. (31) 'Specialized services for
developmental disabilities' means the services or supports specified by
the level II or the resident review determination for an individual with a DD
which is provided or arranged for by the county board of DD in accordance with
rule 5123-14-01 of the Administrative Code.
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Rule 5160-3-15.1 | Preadmission screening requirements for individuals seeking admission to nursing facilities.
(A) The purpose of this rule is to set
forth the level I and level II preadmission screening requirements pursuant to
section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019, to
ensure that individuals seeking admission, as defined in rule 5160-3-15 of the
Administrative Code, to a medicaid-certified nursing facility (NF) who have
serious mental illness (SMI) and/or a developmental disability (DD) as defined
in rules 5122-21-03 and 5123-14-01 of the Administrative Code are identified
and not admitted to a NF unless a thorough evaluation indicates that such
placement is appropriate and adequate services will be provided regardless of
payor source. (B) A level I screening as defined in rule 5160-3-15 of the
Administrative Code is required: (1) Prior to any new
admission, as defined in rule 5160-3-15 of the Administrative Code, to a
NF. (2) Prior to a
categorical determination, as defined in rule 5160-3-15 of the Administrative
Code. (3) When an individual is
directly admitted to a NF from any of the following: (a) A hospital that is maintained, operated, managed or governed
by the Ohio department of mental health and addiction services (OhioMHAS) under
section 5119.14 of the Revised Code for the care and treatment of mentally ill
persons; or (b) A free standing hospital, or unit of a hospital licensed by
OhioMHAS under section 5119.33 of the Revised Code; or (c) An out-of state psychiatric hospital or unit of such
hospital. (4) When a non Ohio
resident is seeking admission to an Ohio NF from an out-of-state
NF. (a) If the non Ohio resident has been determined or suspected to
have a SMI and/or DD by the other state, the other state's level II
evaluation(s) of the individual and any additional supporting documentation
should be submitted with the preadmission request. (b) Submission of the required forms and documentation does not
constitute completion of the level I process. (c) The NF can not admit an individual until the PASRR screening
process as defined in rule 5160-3-15 of the Administrative Code is complete and
a determination for the individual is received by the NF pursuant to section
1919(e)(7) of the Social Security Act, as in effect July 1, 2019. (C) Level I screening
requirements. (1) Level I will be
administered by the Ohio department of medicaid (ODM) or its designee, OhioMHAS
or its designee, the Ohio department of developmental disability (DODD) or its
designee, social worker, professional counselor, hospital discharge planners or
one of the professionals listed in paragraph (H)(6) of this rule. (2) The level I has to be
submitted via the electronic system designated by ODM. (3) The submitter of the
level I is responsible for gathering information from the individual, family,
legal guardian and available medical records to ensure an accurate level I and,
when applicable, level II determination outcomes. (4) The submitter is
expected to include any necessary supporting documentation within the
electronic system designated by ODM for validation. (5) The submitter of the level I has to
certify that the level I information that is submitted is true, accurate and
complete to the best of their knowledge. The absence of such certification by
the submitter will result in an incomplete level I submission. (6) For an individual seeking medicaid
payment, the ODM approved level of care (LOC) assessment will be completed in
accordance with rule 5160-3-14 of the Administrative Code, unless the
individual is enrolled in a medicaid managed care plan as defined in rule
5160-26-01 of the Administrative Code. (7) The NF is responsible for ensuring
every individual residing in the NF has completed the PASRR screening process
as defined in rule 5160-3-15 of the Administrative Code prior to NF
admission. (D) Level I screening
outcomes. (1) An individual will be
considered to have indications of DD when the individual meets the criteria
specified in rule 5123-14-01 of the Administrative Code or the individual
receives services from a county board of DD. (a) Individuals with indications of DD will be subject to further
review by DODD in accordance with rule 5123-14-01 of the Administrative
Code. (b) Such individuals will not be considered to have completed the
PASRR screening requirements as defined in rule 5160-3-15 of the Administrative
Code until DODD has issued the level II determination pursuant to section
1919(e)(7) of the Social Security Act, as in effect July 1, 2019 and in
accordance with rule 5123-14-01 of the Administrative Code. (2) An individual will be
considered to have indications of a SMI when the individual meets the criteria
specified in rule 5122-21-03 of the Administrative Code. (a) Individuals with indications of a SMI shall be subject to
further review by OhioMHAS, in accordance with rule 5122-21-03 of the
Administrative Code. (b) Such individuals will not be considered to have completed the
PASRR screening process as defined in rule 5160-3-15 until OhioMHAS has issued
the level II determination pursuant to section 1919(e)(7) of the Social
Security Act, as in effect July 1, 2019 and in accordance with rule 5122-21-03
of the Administrative Code. (3) Individuals
determined to have no indications of a SMI and/or DD are not subject to a level
II evaluation. (a) Such individuals are considered to have met PASRR screening
requirements effective on the date an accurate and complete level I screening
was submitted. (b) The printed result letter generated via the electronic
system designated by ODM is evidence of PASRR compliance. (4) Individuals with indications of both
SMI and DD will be subject to further review by both OhioMHAS and DODD in
accordance with rules 5122-21-03 and 5123-14-01 of the Administrative Code.
Such individuals will not be considered to have met PASRR screening
requirements as defined in rule 5160-3-15 of the Administrative Code until both
OhioMHAS and DODD have issued the level II determination. (5) Any individual who has been
determined by DODD or OhioMHAS to be ruled out, in accordance with rules
5122-21-03 and 5123-14-01 of the Administrative Code as defined in rule
5160-3-15 of the Administrative Code, is not subject to further PASRR
review. (E) ODM or its designee, OhioMHAS and/or
DODD, are the only entities that have the authority to render level I screening
result outcomes. The individual must not be admitted into the NF until
prescreening requirements as defined in rule 5160-3-15 of the Administrative
Code have been met pursuant to section 1919(e)(7) of the Social Security Act,
as in effect July 1, 2019. (F) Categorical determination
requirements. (1) Consists of a level I
with sufficient documentation that the individual meets one of the following
categories: (a) Emergency NF stay when the individual is temporarily admitted
to a NF pending further assessment in emergency situations requiring protective
services, not to exceed seven days; or (b) Respite NF stay when the individual is being admitted to a NF
for a maximum of fourteen days in order to provide respite to in-home
caregivers to whom the individual is expected to return following the respite
stay. (2) A face to face
assessment is not required for a categorical determination provided there is
enough data to determine that the individual meets the categorical
requirements. (3) The NF has to submit
the request for a categorical determination via the electronic system
designated by ODM. (4) The NF has to
initiate a resident review as defined in rule 5160-3-15 of the Administrative
Code for residents admitted under a categorical determination that require a
stay longer than the specified time limit for the category. (5) The NF can not admit
an individual requesting a categorical determination until the NF receives a
determination for the individual from the appropriate level II
entity. (G) Hospital discharge exemption
requirements. (1) An individual does
not qualify for admission using the hospital discharge exemption
unless: (a) The individual is being admitted to a NF directly from an
Ohio hospital or a unit of a hospital that is not operated by or licensed by
OhioMHAS under section 5119.14 or section 5119.33 of the Revised Code, after
receiving acute inpatient care at that hospital; or (b) The individual is an Ohio resident seeking admission to a NF
directly from an out-of-state hospital that is not an out-of-state psychiatric
hospital or psychiatric unit within an out-of-state hospital, after receiving
acute inpatient care at that hospital; and (c) The individual requires the level of services provided by a
NF for the condition for which he or she was treated in the hospital;
and (d) The individual's attending physician provides written
certification that is signed and dated no later than the date of discharge from
the hospital that the individual is likely to require the level of services
provided by a NF for less than thirty days. (2) The discharging
hospital has to request a hospital discharge exemption via the electronic
system designated by ODM. (3) When the NF accepts
the placement of the individual, the NF acknowledges that the individual meets
the criteria described in paragraph (G) of this rule. (4) The admitting NF is
expected to maintain the hospital discharge exemption documentation in the
resident's record at the NF. (5) The NF has to
initiate a resident review, as defined in rule 5160-3-15.2 of the
Administrative Code, prior to the individual's thirtieth day in the NF
when an individual requires a continued stay beyond thirty days. (6) When an individual is
admitted under the hospital discharge exemption and is subsequently admitted to
a hospital or transfers to another NF during the first thirty days of the
individual's NF stay, the days in the hospital or previous NF count
towards the individual's thirty day hospital discharge exemption time
period. A new hospital discharge exemption can not be granted during the
existing exemption time period. (7) When an adverse
determination has been issued by OhioMHAS or DODD within the last sixty
calendar days prior to the new NF admission, the individual is not eligible for
a hospital discharge exemption. A level I screening has to be initiated in
accordance with paragraph (C) of this rule. (H) Level II evaluation and determination
requirements. (1) The new admission of
an individual with a SMI or DD is not permitted unless the individual has
either been determined, in accordance with rules 5122-21-03 and 5123:2-14-01 of
the Administrative Code, to need the level of services provided by a NF, or
qualifies for admission under the hospital discharge exemption provision set
forth in paragraph (G) of this rule, regardless of the individual's payor
source. (2) Individuals
determined by OhioMHAS and/or DODD not to meet NF level of service as defined
in rules 5160-3-15, 5122-21-03 and 5123-14-01 of the Administrative Code will
not be admitted and medicaid payment will not be available for NF
services. (3) The level II evaluation will be
complete and determination made prior to any new admission of an individual to
a NF in the process of obtaining its initial medicaid certification and NF
provider agreement. (4) For current residents
of a facility in the process of obtaining its initial medicaid certification
and NF provider agreement, the level II requirements have to be met prior to
the effective date of the NF provider agreement between ODM and the newly
certified NF or prior to the availability of medicaid payment for the medicaid
eligible individual. (5) The level II determinations are made
by OhioMHAS and/or DODD in accordance with section 1919(e)(7) of the Social
Security Act, as in effect July 1, 2019. (6) Before an adverse determination as
defined in rule 5160-3-15 of the Administrative Code can be issued, both of the
following conditions have to be met: (a) A face-to-face, telephonic, or video conference assessment of
the individual and a review of the medical records accurately reflecting the
individual's current condition are performed by one of the following
professionals within the scope of his/her practice: (i) Medical doctor or
doctor of osteopathic medicine; (ii) Registered nurse
(RN); (iii) Master of science
of nursing; (iv) Clinical nurse
specialist; (v) Certified nurse
practitioner; (vi) Licensed social
worker, under supervision of a licensed independent social worker
(LISW); (vii) Licensed
independent social worker; (viii) Professional
counselor, under supervision of a licensed professional clinical counselor
(PCC); (ix) Professional
clinical counselor; (x) Psychologist; (xi) Qualified mental
health professional as defined in rule 5122-21-03 of the Administrative Code;
or (xii) Qualified intellectual disability professional;
or (xiii) Service and support administrator as defined in section
5126.15 of the Revised Code. (b) Authorized personnel from OhioMHAS and DODD other than the
personnel identified in paragraph (H)(6)(a) of this rule who have conducted the
face-to-face, telephonic, or video conference assessment, have reviewed the
assessment and, made the final determination regarding the need for NF services
and specialized services. (I) NF to NF transfer requirements. (1) The admitting NF is
responsible for ensuring that all individuals have met the PASRR screening
requirements as defined in rule 5160-3-15 of the Administrative Code prior to
entering the NF. (2) The admitting NF will
initiate a referral for a resident review as defined in rule 5160-3-15 of the
Administrative Code for any individual transferred to its facility upon the
discovery of a significant change in the individual's condition as defined
in rule 5160-3-15 of the Administrative Code. (3) The admitting NF is
responsible for ensuring that copies of the resident's most recent level I
screening results letter and, if applicable, level II evaluation and
determination accompany the transferring resident. (4) The admitting NF is expected to
retain the written notification of the level II determinations received from
the transferring NF in the individual's resident record at the
facility. (J) Level I and level II requests for additional
information. (1) ODM or its designee,
OhioMHAS and/or DODD may request any additional information required in order
to make a preadmission screening determination. (2) When ODM or its
designee, OhioMHAS and/or DODD need additional information in order to make the
preadmission screening determination, they will provide written notice to the
NF, the individual, the hospital, the referring entity, and the
individual's representative, if applicable. This notice will specify the
missing forms, data elements and other documentation needed to make the
required determinations. (3) In the event the
individual and/or other entity does not provide the necessary information
within fourteen calendar days, ODM or its designee, OhioMHAS and DODD is
expected to provide written notice to the individual, the individual's
guardian or authorized representative, if applicable, and the NF that the
admission is not permitted due to failure to provide information necessary for
the completion of the preadmission screening process and that the individual
may appeal the determination in accordance with the provisions of division
5101:6 of the Administrative Code. The individual, regardless of payment
source, cannot be admitted to the NF. (4) When the individual
or other entity submits the requested information within the timeframes
specified in the notice, ODM or its designee, OhioMHAS and/or DODD will proceed
with the preadmission screening process. (K) An individual will undergo a new level I screening in
accordance with the provisions of this rule when: (1) The individual
received a completed preadmission screening as defined in rule 5160-3-15 of the
Administrative Code indicating that NF services are needed but the individual
has not been admitted to a NF within one hundred eighty days of the most recent
level II that was not a categorical determination, as defined in rule 5160-3-15
of the Administrative Code; or (2) The individual
received a categorical determination by OhioMHAS and/or DODD that NF services
are needed and the individual has not been admitted to a NF immediately
following discharge from a hospital setting, or within twenty fours hours from
the date of the catergorical emergency determination, or within sixy days from
the date of the categorical respite determination. (L) Level I and level II notification and record
retention. (1) In accordance with
all requirements specified in rule 5101:6-2-32 of the Administrative Code, ODM,
or its designee, has to report the outcome of the level I to the individual,
their guardian, or authorized representative, if applicable, the NF and the
appropriate level II entity. (2) In accordance with all requirements
specified in rule 5101:6-2-32 of the Administrative Code, DODD and OhioMHAS
will provide a printed copy of the level II determination to the individual,
their guardian or authorized representative, if applicable, the
individual's physician and the NF. The level II determination will contain
notice of the individual's right to appeal an adverse determination made
by the level II entities. (3) When an adverse determination is
issued, the facility will provide the individual, their guardian or authorized
representative, if applicable, with notice of the intent to discharge in
accordance with section 3721.16 of the Revised Code. (4) The NF is expected to maintain a
printed copy of the level I result notice and, if applicable, a printed copy of
the level II determination received from OhioMHAS and DODD in the
individual's resident record at the facility (M) Preadmission screening compliance. (1) NFs which, whether
intentionally or otherwise, fail to accept any new admission, readmission, or
NF transfers pursuant to this rule are in violation of their medicaid provider
agreements. This is true regardless of the payment source for the
individual's NF stay. (2) PASRR level I
screening and/or level II determinations will not be backdated. (3) An adverse
determination as the result of a preadmission evaluation performed by OhioMHAS
or DODD may be appealed in accordance with division 5101:6 of the
Administrative Code. (4) Level II
determinations made by OhioMHAS or DODD in accordance with section 1919(e)(7)
of the Social Security Act, as in effect, July 1, 2019 cannot be overturned by
ODM and/or Ohio department of health. Only appeal determinations made in
accordance with division 5101:6 of the Administrative Code may overturn an
adverse PASRR determination. (5) Medicaid payment is not available for
NF stays for individuals who are otherwise medicaid-eligible until the date on
which the preadmission screening requirements as defined in rule 5160-3-15 of
the Administrative Code have been met. (6) ODM has authority to ensure
compliance with the provisions of this rule, including but not limited to the
following: (a) Official notice to the NF of PASRR
noncompliance; (b) Development of a compliance corrective action
plan; (c) Mandatory PASRR training; (d) NF site visits; (e) Recoupment of funds for number of days PASRR requirements
were not met for the resident. (7) NF, local administrators, hospitals
and all state agencies and their designees will comply, with accuracy and
timeliness, to all requests for records and compliance plans issued by
ODM.
Last updated April 8, 2021 at 1:29 PM
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Rule 5160-3-15.2 | Resident review requirements for individuals residing in nursing facilities.
Effective:
December 30, 2019
(A) The purpose of this rule is to set
forth resident review requirements in compliance with section 1919(e)(7) of the
Social Security Act, as in effect on July 1, 2019, which prohibits nursing
facilities (NF) from retaining individuals with serious mental illness (SMI) as
defined in rule 5160-3-15 of the Administrative Code and/or developmental
disabilities (DD) as defined in rule 5160-3-15 of the Administrative Code
unless a thorough evaluation indicates that such placement is appropriate and
adequate services are provided. A resident review will be completed whenever an
individual experiences a significant change in condition as defined in rule
5160-3-15 of the Administrative Code and that change has a material impact on
their functioning as it relates to their mental illness or developmental
disability status. (B) Resident review
requirements. (1) No individual with
SMI or DD can be retained as a resident in a nursing facility (NF), regardless
of payment source, unless it has been determined in accordance with rules
5122-21-03 and 5123:14-01 of the Administrative Code, that: (a) The individual needs the level of services provided by
a NF; or (b) The individual had resided in a NF for at least thirty
months at the time of the first resident review determination that established
that the individual does not require the level of services provided by a NF,
and (i) Requires specialized
services only; and (ii) The individual has
chosen to remain in a NF after being informed of service alternatives to NF
placement. (2) The NF will initiate
and submit a resident review via the electronic system designated by
ODM. (3) The NF will include
supporting documentation of the individual's current condition, including
evidence of the individual's need for services in a NF, when submitting
the resident review. (4) The NF is responsible
for the accurate and timely submission of the resident review request to the
Ohio department of developmental disabilities (DODD) and/or Ohio department of
mental health and addiction services (OhioMHAS) and for ensuring that a copy of
the resident review determination is maintained in the resident's file in
accordance with the provisions of this rule. (C) Resident review will be completed for
an individual who meets any of the following criteria: (1) The individual was
admitted under the hospital discharge exemption as defined in rule 5160-3-15 of
the Administrative Code, and has since been found to require more than thirty
days of services at the NF. The resident review will be submitted no later than
the twenty-ninth day from the date of admission; or (2) The individual had
been in a NF and was admitted directly into a different NF following an
intervening hospital stay for psychiatric treatment, or was readmitted to the
same NF directly following a hospital stay for psychiatric treatment. A
resident review for a significant change in condition will be submitted within
twenty-four hours of the individual's NF admission to a different NF or
readmission to the same NF; or (3) The individual has
experienced a significant change in condition as defined in rule 5160-3-15 of
the Administrative Code. The resident review will be submitted within
seventy-two hours following identification of the significant change;
or (4) The individual was
admitted as a result of a negative level I preadmission screening and there is
subsequent evidence of possible, but previously unrecognized or unreported, SMI
and/or DD; or (5) The individual
received a categorical determination as defined in rule 5160-3-15 of the
Administrative Code, and has since been found to need a stay in a NF that will
exceed the specified time limit for that category. Unless the individual meets
the criteria for a resident review extension described in paragraph (F) of this
rule, the resident review has to be submitted as soon as the NF has reason to
believe the individual may need to remain in a NF beyond the expiration date of
the categorical determination but no later than the expiration date of the
categorical determination; or (6) The individual
received a resident review determination for a specified period of time as
established by DODD or OhioMHAS and has since been found to need a stay in a NF
exceeding the specified period of time. The resident review will be submitted
at least thirty days prior to the expiration of the determination. (D) Resident review
outcomes. (1) Individuals
determined to have no indications of SMI or DD are not subject to further
resident review. (2) Individuals
determined to have indications of SMI or DD will be subject to further resident
review by the OhioMHAS or DODD in accordance with rules 5122-21-03 and
5123-14-01 of the Administrative Code. (3) Individuals
determined to have indications of both SMI and DD will not be considered to
have completed the resident review process until both OhioMHAS and DODD have
issued the resident review determinations. (4) If an individual who
is subject to a resident review has indications of SMI or DD and is discharged
from the NF after submission of the resident review request, but prior to the
determination, or prior to the due date for the request, the NF will notify
OhioMHAS and/or DODD. (5) Individuals
previously determined by OhioMHAS and/or DODD to be ruled out from preadmission
screening in accordance with rules 5122-21-03 and 5123-14-01 of the
Administrative Code are not subject to further review. (E) Resident review placement
determinations. (1) OhioMHAS and DODD may
approve a determination that the level of services provided by the NF will meet
the individual's long term needs and for an unspecified period of
time. (2) OhioMHAS and DODD may
approve a determination that the level of services provided by a NF will meet
the individual's short term needs and for a specified period of
time. (a) OhioMHAS and DODD may approve such a determination for
no more than one hundred eighty days. (b) Unless a resident review extension is requested and
granted in accordance with paragraph (F) of this rule, the NF will initiate a
resident review in accordance with paragraph (C)(4) of this rule when the
individual stay exceeds the specified period of time. (c) In conjunction with local entities, the NF will
initiate and continue discharge planning activities throughout the period of
time specified on the determination notice. (F) Resident review extension request
requirements. (1) A resident review
determination extension may be requested by the NF on behalf of an individual
that received a resident review determination for a specified period of time as
established by the DODD or OhioMHAS and is believed to need a stay in a NF
exceeding the specified period of time. (2) The NF will submit
the resident review extension request for consideration directly to DODD or
OhioMHAS for approval via the electronic system approved by ODM. (3) Extension requests
and approvals cannot exceed ninety days. (4) In order to receive consideration for
an extension to the initial determination, the NF will initiate a resident
review at least thirty days prior to the expiration of the
determination. (a) The NF is responsible for the accurate and timely
submission of the resident review extension request to DODD or OhioMHAS in
accordance with the provisions of this rule. (b) Resident review extension requests submitted after the
expiration of the individual's determination are in violation of this rule
and the NF will be considered out of compliance with PASRR requirements in
accordance with this rule from the day after the expiration of specified date
stated on the initial resident review until the day the resident review
extension is subsequently approved if applicable, by DODD or
OhioMHAS. (c) DODD and OhioMHAS are expected to notify ODM in writing
when instances specified in paragraph (F)(4)(b) of this rule
occur. (5) The NF will include supporting
documentation of the individual's current condition including evidence of
the individual's need for services in a NF past the specified period of
time established by DODD and/or OhioMHAS when submitting the request for an
extension. (6) A request for an extension is
expected to include documentation of discharge planning activities. The written
record of discharge planning activities has to include the alternative settings
and services explored and the steps taken to ensure that a safe and orderly
discharge occurs. (7) DODD and OhioMHAS
will keep a record of all resident review extension requests received by NFs
and approved or denied by DODD or OhioMHAS. (8) DODD and OhioMHAS
will submit a resident review extension summary in the form of a list to ODM on
a monthly basis with the following information: (a) Date extension request was received by DODD or
OhioMHAS; (b) Name of NF; (c) Name of resident; (d) Date of original specified resident
review; (e) The number of previous granted extensions and number of
days currently being requested by the NF; (f) Reason for extension; and (g) Date of approval or denial of extension
request. (9) The NF is expected to maintain a
printed copy of the resident review extension approval and all supporting
documentation in the resident's record at the NF. (G) NF to NF transfers: (1) If an individual is
to be transferred to another Ohio NF after submission of the resident review
request but prior to receipt of the resident review determination: (a) The transferring NF will notify the appropriate level
II entity of the transfer. Written notice will be provided to the level II
entity by the NF no later than the day the individual is transferred. The
transferring NF is expected to provide sufficient contact information to enable
the completion of the resident review process. (b) At or prior to the time the individual is transferred,
the transferring NF will provide the admitting NF with copies of all PASRR
related documents pertaining to the individual and written notice of the
individual's current PASRR status. If known, the notice should include
contact information for the resident review evaluator assigned by OhioMHAS and
DODD. (c) The admitting NF cannot accept the individual as a NF
transfer unless it receives this information at or prior to the time the
individual is admitted to the NF. (d) If the transferring individual is medicaid eligible at
the time of the transfer, the transferring NF will also provide written notice
of the transfer and the current PASRR status of the individual to ODM or its
designee. Such notice will be provided no later than the date on which the
individual is transferred. (H) Resident review requests for
additional information: (1) OhioMHAS and DODD may
request additional information necessary to make a resident review
determination. (2) If OhioMHAS or DODD
request additional information to make the resident review determination, the
agency will provide written notice to the NF, the individual, and the
individual's representative, if applicable. This notice will specify the
missing forms, data elements and other documentation needed to make the
required determinations. (3) In the event the
individual or other entity does not provide the necessary information within
fourteen calendar days, the agency that requested the information will provide
written notice to the individual, the individual's representative, if
applicable, and the NF that a continued stay in the NF is not permitted due to
failure to provide information necessary for the completion of the resident
review process and the individual may appeal the determination in accordance
with the provisions of division 5101:6 of the Administrative Code. (I) Resident review
notification: (1) In accordance with
rule 5101:6-2-32 of the Administrative Code, the appropriate level II entity
will provide written notification of all resident review determinations
made. (a) Such written notice will be provided to: (i) The evaluated
individual and his or her legal representative; (ii) The NF in which the
individual is a resident; (iii) The
individual's attending physician; (iv) The
individual's medicaid managed care plan, if applicable, as defined in rule
5160-26-01 of the Administrative Code. (b) Such written notice has to include all of the following
components: (i) The determination as
to whether and, when applicable, the estimated length of time the individual
requires the level of services provided by a NF; (ii) The determination as
to whether the individual requires specialized services for SMI and/or
DD; (iii) The placement
and/or service options that are available to the individual consistent with
those determinations; and (iv) The
individual's right to appeal the determination(s). (2) Upon receipt of the
written notice of an adverse determination, the NF will provide the individual
with notice of the intent to discharge. When an expiration date is specified in
the written notice, the NF will provide the individual with notice of the
intent to discharge at least thirty days prior to the expiration
date. (3) All individuals who
are subject to a resident review and who do not meet the retention criteria set
forth in paragraph (B)(1) of this rule will be discharged from the NF and
relocated to an appropriate setting in accordance with section 3721.16 of the
Revised Code. (4) The NF will maintain
a written record of discharge planning activities which will include the
alternative settings and services explored and the steps taken to ensure that a
safe and orderly discharge occurs. (5) The NF will retain
the written notification of the resident review determinations received from
OhioMHAS and DODD in the resident's record at the facility. (J) Medicaid payment for
services. (1) Medicaid payment is available for the
provision of NF services to medicaid-eligible individuals subject to resident
review only when the individual has met the criteria for retention set forth in
paragraph (B)(1) of this rule. (2) A resident review determination is
not a level of care determination. Individuals seeking medicaid payment for the
NF stay will meet the level of care requirements in accordance with Chapter
5160-3 of the Administrative Code. (3) For medicaid eligible individuals,
medicaid payment is available through the time period specified in the notice
or during the period an appeal is in progress. (4) When a resident review is not
initiated by the NF within the timeframes specified in paragraph (C) of this
rule, but is performed at a later date, medicaid payment is not available for
services furnished to the eligible individual from the date the resident review
was due through the date in which the resident review determination was
received by the NF. (K) Resident review
compliance. (1) NFs who fail to
initiate a resident review or request a resident review extension pursuant to
this rule are in violation of their medicaid provider agreements. This is true
regardless of the payment source for the individual's NF
stay. (2) Adverse PASRR determinations may be
appealed in accordance with division 5101:6 of the Administrative
Code. (3) Level II resident review
determinations made by OhioMHAS or DODD in accordance with section 1919(e)(7)
of the Social Security Act, as in effect July 1, 2019 cannot be overturned by
ODM or Ohio department of health. Only appeals determinations made in
accordance with division 5101:6 of the Administrative Code may overturn an
adverse PASRR determination. (4) If the individual is subject to
resident review and there is no record of the determination in the medical
record and no indication that they are in progress, the NF will notify OhioMHAS
and/or DODD. (5) OhioMHAS and DODD will utilize
criteria relating to the need for NF care or specialized services that is
consistent with section 1919(e)(7) of the Social Security Act, as in effect
July 1, 2019, and the ODM approved state plan for medicaid, including criteria
consistent with Chapter 5160-3 of the Administrative Code, in making their
determinations whether individuals with SMI and/or DD meet the level of
services provided by a NF. (6) ODM has authority to ensure
compliance with the provisions of this rule, including but not limited to the
following: (a) Official notice to the NF of PASRR
noncompliance; (b) Development of a compliance corrective action
plan; (c) Mandatory PASRR training; (d) NF site visits; (e) Recoupment of funds for number of days PASRR
requirements were not met for the resident in accordance with 42 C.F.R.
483.122.
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Rule 5160-3-16.3 | Nursing facilities (NFs): private rooms.
Effective:
September 9, 2024
(A) A NF may provide private room
accommodations, if available, as follows: (1) For a medicaid
eligible resident if the resident requires a private room due to medical
necessity such as the need for infection control or for therapeutic purposes;
or (2) Semi-private or ward
accommodations are not available; or (3) In accordance with
sections 5165.01 and 5165.158 of the Revised Code. (B) Reimbursement for private
rooms (1) Unless approved for a
private room incentive payment pursuant to section 5165.158 of the Revised
Code, medicaid payment for private rooms permitted under paragraphs (A)(1) and
(A)(2) of this rule will be paid in accordance with section 5165.15 of the
Revised Code. (2) Private room
incentive payments pursuant to section 5165.158 of the Revised Code will only
be available to approved providers and will be paid an amount in addition to
the total per medicaid day payment rate determined for the facility under
section 5165.15 of the Revised Code. (3) Except as otherwise
provided herein, medicaid payment for private rooms is considered payment in
full, and no supplemental payment may be requested or accepted from a resident
or from a resident's authorized representative or family. (4) Unless approved for a
private room incentive payment pursuant to section 5165.158 of the Revised
Code, if semiprivate or ward accommodations are available and are offered to a
resident but the resident or the resident's representative or family
member makes a written request for a private room, the private room will be
considered a non-covered service for which the facility may seek supplemental
payment from the resident or from the resident's authorized representative
or family as follows: (a) The supplemental payment amount will represent no more
than the difference between the charge to a private pay resident for a
semiprivate room and the charge to a private pay resident for a private
room; (b) The charge for the private room cannot include charges
for services covered by medicaid, whether or not medicaid payment meets a
NF's costs for the per diem services; (c) A NF should detail both monthly and annual supplemental
charges, if applicable, on a resident's statement of charges so that the
additional cost of a private room is evident to the resident and to the
resident's authorized representative and family; (d) The written request for a private room will be kept in
the resident's file; and (e) The amount of any supplemental payment will not be
considered when calculating the resident's patient liability. (5) Medicaid bed hold
payments for individuals in a private room approved by the department pursuant
to section 5165.158 of the Revised Code will be paid in accordance with section
5165.34 of the Revised Code. The private room incentive payment will not be
used in determining the bed hold payment rate. (C) Private room incentive payment
(1) Application
process The following information is to be submitted to
the Ohio department of medicaid (department) by a NF seeking a private room
incentive payment to demonstrate that the room meets the prerequisites
identified in section 5165.158 of the Revised Code: (a) Application in the form and manner prescribed by the
department. (b) List of all NF rooms and their corresponding number of
beds, designating the rooms for which private room incentive payment approval
is requested and identifying which rooms are category one and category two
private rooms as defined in section 5165.158 of the Revised Code. (c) Floor plan of the entire facility which identifies and
shows the location of each private room with the designated room number and
designated bathroom. Arrows should indicate the path between each resident room
and the bathroom and each resident room and the hallway. (d) Documentation evidencing the private room meets the
criteria in paragraph (C)(2) of section 5165.158 of the Revised
Code. (e) Attestation in the form and manner prescribed by the
department that the information submitted by the facility is accurate and
truthful. (2) Approval
process Applications will be held in a pending status
in the order received until the centers for medicare and medicaid services
(CMS) approves the private room incentive payments and the department
determines a NF is qualified for the private room incentive payment. (a) The department will review all applications and
supporting information to determine if a NF is eligible to receive the
incentive payment for private rooms. (b) Additional information may be requested by the
department to ensure a NF's eligibility. NFs will have ten business days
from the date of the request to provide this additional information. Failure to
submit the requested information within ten business days will invalidate the
original application submission. NFs with invalidated applications may reapply.
(c) The department reserves the right to conduct on-site
visits as part of this process. (d) Eligible applications will be approved in the order
received until the funding limit identified in the Revised Code is reached.
(e) A NF that is approved will receive written
authorization from the department including the effective date for the
approval. (f) If a private room is created by surrendering beds,
adding space to the NF, or renovating non-bedroom space, the surrender,
addition, or renovation, whichever is applicable, does not have to be completed
at the time of application but will need to be completed before an application
will be approved by the department. (3) Reconsideration (a) A NF that submits an application that is denied in full
or in part by the department may request a reconsideration. (i) If an application is
approved in part and denied in part, a reconsideration request will proceed on
the denied portion only. The approved portion may proceed and is not held
pending the outcome of the reconsideration on the denied portion, (ii) Denied applications
or parts of applications will be held in a pending status in the order received
until the conclusion of the reconsideration process. (b) The reconsideration will be conducted by the department
director, assistant director, or deputy director over the area where the
contestation arose, or their designee, provided the person conducting the
reconsideration was not involved in the original decision. (c) The denial decision will include information about
deadlines and supporting documentation needed for submission of the
reconsideration. (i) Deadlines will be no
fewer than thirty days from the date on the notice of the denial
decision. (ii) Reconsideration
requests and supporting documentation received after the deadline may be
considered at the department's discretion. (d) Reconsideration decisions will not be further
reconsidered. (4) Change of
operator. If a NF notifies the department of its intent
to change operator and an application for private room incentive payments is in
a pending status, the new operator will not need to reapply and will maintain
the NF's order in the pending status. The new operator will need to
attest that the original information submitted by the NF is true and accurate
and disclose any information that is different from the original application
submission.
Last updated September 9, 2024 at 8:50 AM
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Rule 5160-3-16.4 | Nursing facilities (NFs): covered days and bed-hold days.
Effective:
August 17, 2017
(A) Definitions. (1) "Home and community-based services" (HCBS) means services that enable individuals to live in a community setting rather than in an institutional setting such as a NF, an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a hospital. (2) "Hospitalization" means transfer of a NF resident to a medical institution as defined in paragraph (A)(4) of this rule. A NF resident is considered hospitalized if the resident is formally admitted to a medical institution, or is on observation status in a medical institution. (3) "Institution for mental disease" (IMD) means a hospital, NF, or other institution of more than sixteen beds that is engaged primarily in the diagnosis, treatment, and care of persons with mental diseases, and that provides medical attention, nursing care, and related services. An institution is determined to be an IMD when its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. (4) "Medical institution" means an institution other than a NF that meets all of the following criteria: (a) Is organized to provide medical care, including nursing and convalescent care. (b) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health care needs of patients on a continuing basis in accordance with accepted standards. (c) Is authorized under state law to provide medical care. (d) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. Professional medical and nursing services shall include all of the following: (i) Adequate and continual medical care and supervision by a physician. (ii) Registered nurse or licensed practical nurse supervision and services sufficient to meet nursing care needs. (iii) Nurses' aid services sufficient to meet nursing care needs. (iv) A physician's guidance on the professional aspects of operating the institution. (5) "NF admission" means the act that allows an individual who was not considered a resident of any Ohio medicaid certified NF during the time immediately preceding their current NF residence to officially enter a facility to receive NF services. This may include former NF residents who have exhausted their bed-hold days while in the community and/or hospital and returned to the facility. A NF admission may be a new admission or a return admission after an official discharge. A NF admission is distinguished from the readmission of a resident who has not exhaused all bed-hold days.. (6) "NF bed-hold day," also referred to as "NF leave day," means a day for which a bed is reserved for a NF resident while the resident is temporarily absent from the NF for hospitalization, therapeutic leave days, or visitation with friends or relatives. Payment for NF bed-hold days may be made only if the resident has the intent and ability to return to the same NF. A resident on NF bed-hold day status is not considered discharged from the NF. (7) "NF discharge" means the full release of a NF resident from the facility, allowing the resident who leaves the facility to no longer be counted in the NF's census. Reasons for NF discharge include but are not limited to the resident's transfer to another facility, exhaustion of NF bed-hold days, decision to reside in a community-based setting, or death. (8) "NF occupied day" means one of the following: (a) A day of admission or readmission. (b) A day during which a medicaid eligible resident's stay in a NF is eight hours or more, and for which the facility receives the full per resident per day payment directly from medicaid in accordance with Chapter 5165. of the Revised Code. (9) "NF readmission" means the status of a resident who is readmitted to the same NF following a stay in a hospital to which the resident was sent to receive care, or the status of a resident who returns after a therapeutic program or visit with friends or relatives. A NF resident can only be readmitted to a facility if that individual was not officially discharged from the facility during that NF stay. (10) "NF therapeutic leave day" means a day that a resident is temporarily absent from a NF with intent and ability to return, and is in a residential setting other than a long-term care facility, hospital, or other entity eligible to receive federal, state, or county funds to maintain a resident, for the purpose of receiving a regimen or program of formal therapeutic services. (11) "NF transfer" means the events that occur when a person's place of residence changes from one Ohio medicaid certified NF to another, with or without an intervening hospital stay. However, when the person has an intervening IMD admission, or when the person is discharged from a NF during a hospital stay due to exhaustion of available NF bed-hold days and is admitted to a different NF immediately following that hospital stay, the change of residence is not considered a NF transfer. (12) "Skilled nursing facility" (SNF) means a facility certified to participate in the medicare program. (B) Prohibition of preadmission NF bed-hold payment. (1) The Ohio department of medicaid (ODM) shall not make payment to reserve a bed for a medicaid eligible prospective NF resident. (2) A NF provider shall not accept preadmission bed-hold payments from a medicaid eligible prospective NF resident or from any other source on the prospective resident's behalf as a precondition for NF admission. (C) Determination of NF bed-hold day or NF occupied day. To determine whether a specific day during a resident's stay is payable as a NF bed-hold day or a NF occupied day, the following criteria shall be used: (1) The day of NF admission or readmission counts as one occupied day. (2) The day of NF discharge is not counted as either a bed-hold or an occupied day. (3) When NF admission and NF discharge occur on the same day, the day is considered a day of admission and counts as one occupied day, even if the day is less than eight hours. (4) The day a resident leaves on bed-hold status counts as one occupied day for payment purposes if the resident is in the NF for eight hours or more. A day begins at twelve a.m. and ends at eleven fifty-nine p.m. (D) Limits and payment for NF bed-hold days. (1) For medicaid eligible residents in a certified NF, except those described in paragraph (K) of this rule, ODM shall pay the NF provider to reserve a bed only for as long as the resident intends to return to the facility, but for not more than thirty days in any calendar year, and only if the requirements of paragraph (D)(3) of this rule are met. (2) According to section 5165.34 of the Revised Code, payment for NF bed-hold days shall be as follows: (a) Fifty per cent of the NF provider's per diem rate if the facility had an occupancy rate in the preceding calendar year exceeding ninety-five per cent; or (b) Eighteen per cent of the NF provider's per diem rate if the facility had an occupancy rate in the preceding calendar year of ninety-five per cent or less. (3) Payment for NF bed-hold days according to paragraph (D)(2) of this rule shall be considered payment in full, and the NF provider shall not seek supplemental payment from the resident. (4) Payment for NF bed-hold days shall be made for the following reasons: (a) Hospitalization. NF bed-hold days used for hospitalization of NF residents, including NF residents on HCBS waivers, shall be authorized only until: (i) The day the resident's anticipated level of care (LOC) at the time of NF discharge from the hospital changes to a LOC that the NF provider is not certified to provide; or (ii) The day the resident is discharged from the hospital, including discharge resulting in transfer to another hospital-based or free-standing NF or SNF; or (iii) The day the resident decides to go to another NF upon discharge from the hospital and notifies the first NF provider; or (iv) The day the hospitalized resident dies. (b) NF therapeutic leave days. (i) Any plan to use therapeutic leave days must be approved in advance by the resident's primary physician and documented in the resident's medical record. The documentation shall be available for viewing by the county department of job and family services (CDJFS) and ODM staff. (ii) A NF provider shall make arrangements for the resident to receive required care and services while on approved therapeutic leave, but medicaid shall not pay for care and services that are included in medicaid's continued payments, including but not limited to home health care, personal care services, durable medical equipment (DME), and private duty nursing. (iii) NF therapeutic leave days are not payable for NF residents who are on an HCBS waiver and do not count towards the annual leave day limit specified in this rule. (c) Visits with friends or relatives. (i) Any plan for a limited absence to visit with friends or relatives must be approved in advance by the resident's primary physician and documented in the resident's medical record. The documentation shall be available for viewing by the CDJFS and ODM staff. (ii) The number of days per visit is flexible within the maximum NF bed-hold days, allowing for differences in the resident's physical condition, the type of visit, and travel time. (iii) The NF provider shall make arrangements for the resident to receive required care and services while on approved visits, but medicaid shall not pay for care and services that are included in medicaid's continued payments, including but not limited to home health care, personal care services, DME, and private duty nursing. (iv) Leave days for visits with friends or relatives are not payable for NF residents who are on an HCBS waiver and do not count towards the annual leave day limit specified in this rule. (5) The number and frequency of NF bed-hold days used shall be considered in evaluating the continuing need of a resident for NF care. (E) Submission of claims for NF bed-hold days. A NF provider shall submit claims for NF bed-hold days electronically to ODM in accordance with rule 5160-3-39.1 of the Administrative Code. (F) NF admission after depletion of NF bed-hold days. (1) A resident who leaves a facility and has already exhausted their bed-hold days is considered in a NF discharge status. (2) A NF provider shall establish and follow a written policy under which a medicaid resident who has expended their annual allotment of thirty NF bed-hold days, and therefore is no longer entitled to a reserved bed under the medicaid bed-hold limit, and is considered to be discharged, shall be admitted to the first available medicaid certified bed in a semiprivate room. (a) The first available bed means the first unoccupied bed not being held by a resident (regardless of the source of payment) who has elected to make payment to hold that bed. (b) Unless involuntary discharge hearing and notice requirements were issued as set forth in section 3721.16 of the Revised Code for the previous admission span, a resident shall be admitted to the first available medicaid certified bed in a semiprivate room even if the resident has an outstanding balance owed to the NF provider from the previous admission. The admitted NF resident may be discharged if the NF provider can demonstrate that nonpayment of charges exists, and if hearing and notice requirements have been issued as set forth in section 3721.16 of the Revised Code. (3) A medicaid eligible NF resident whose absence from the facility exceeds the bed-hold limit or for whom no bed-hold coverage is available may choose to do one of the following: (a) Return to the NF upon the availability of the first semiprivate bed in the facility. (b) Ensure the timely availability of a specific bed upon return to the facility by making bed-hold payments for any days of absence in excess of the medicaid limit or for which no bed-hold coverage is available. Such payment is separate and distinct from the prohibition of any third party payment guarantee as set forth in rule 5160-3-02 of the Administrative Code. (4) A medicaid eligible resident's NF bed-hold day rights extend only to situations in which the resident leaves the NF for hospitalization, therapeutic leave days, or visits with friends or relatives, and has the intent and ability to return to the same NF. (a) If a resident who has depleted medicaid covered NF bed-hold days is transferred from a NF to a hospital and then undergoes a NF transfer to a second NF because the second NF provider offers services the first NF provider does not, the first NF provider has no obligation to admit the resident. (b) If a resident who has depleted medicaid NF bed-hold days is admitted from a NF to a hospital and then is transferred to a hospital-based NF or SNF, the type of NF or SNF to which the resident is transferred does not change the requirements stated in paragraph (F) of this rule. Therefore, a resident transfer to a hospital-based NF or SNF shall be considered the same as a transfer to any other NF or SNF, and the first NF provider has no obligation to admit the resident. (5) NF admission following the depletion of bed-hold days during a prior stay and subsequent NF discharge requires that a resident has a NF LOC and is eligible for medicaid NF services. (G) Information and notice prior to leave. (1) Prior to a resident's use of NF bed-hold days, a NF provider shall furnish the resident and their family member or legal representative written information about the facility's bed-hold policies, which shall be consistent with paragraph (F) of this rule. (2) At the time a resident is scheduled for a temporary leave of absence, a NF provider shall furnish the resident and their family member or legal representative a written notice that specifies all of the following: (a) The maximum duration of medicaid covered NF bed-hold days as described in this rule. (b) The duration of bed-hold status during which the resident is permitted to return to the NF. (c) Whether medicaid payment will be made to hold a bed and if so, for how many days. (d) The resident's option to make payments to hold a bed beyond the medicaid bed-hold day limit, and the amount of such payments. (H) Emergency hospitalization. (1) In the case of emergency hospitalization, a NF provider shall furnish the resident and a family member or legal representative a written notice as described in paragraph (G) of this rule within twenty-four hours of the hospitalization. (2) This requirement is met if the resident's copy of the notice is sent to the hospital with other documents that accompany the resident. (I) Maximum number of NF bed-hold days. (1) Medicaid payment for covered NF bed-hold days is considered payment for reserving a bed for a resident who intends to return to the same NF and is able to do so. (2) The number of NF inpatient days as defined in section 5165.01 of the Revised Code for the calendar year shall not exceed one hundred per cent of available bed days. (J) Residents eligible for payment of NF bed-hold days. (1) Medicaid payment for NF bed-hold days is available under the provisions specified in this rule if a resident meets all of the following criteria: (a) Is eligible for medicaid services and has met the patient liability and financial eligibility requirements as stated in rule 5160:1-3-04.3 of the Administrative Code. (b) Requires a NF LOC or is using medicare part A SNF benefits as described in paragraph (J)(2) of this rule. (c) Is not a participant of special medicaid programs or assigned special status as outlined in paragraph (K) of this rule. (2) Dual eligible for both medicare and medicaid. (a) If a resident meets all of the criteria in paragraph (J)(1) of this rule and is both medicare part A and medicaid eligible, medicaid payment shall be made for NF bed-hold days up to the bed-hold day limit specified in this rule. Medicaid will, therefore, pay NF bed-hold days during the acute care hospitalization of a medicaid eligible resident who had been receiving medicare part A SNF benefits in the NF immediately prior to and/or following the period of hospitalization. (b) A level of care evaluation is not necessary in the following circumstances: (i) A medicaid eligible resident receives medicare part A SNF benefits in the NF. (ii) A medicaid eligible resident who receives medicare part A SNF benefits in the NF is transferred to the hospital, and the NF bills the hospital bed-hold days to medicaid. (3) Medicaid pending. If a resident meets all of the criteria in paragraph (J)(1) of this rule, and is pending approval of a medicaid application and requires NF bed-hold days, medicaid payment shall be made retroactive to the date the resident became medicaid eligible and approved for NF medicaid payment, through the date the resident returns from a leave or until the maximum number of NF bed-hold days are exhausted. (4) Medicaid eligible. If a resident meets all of the criteria in paragraph (J)(1) of this rule, and is approved for NF medicaid payment, medicaid payment shall be made for NF bed-hold days up to the maximum number of days as specified in this rule. Medicaid eligible residents include low resource utilization residents for whom medicaid payment is made in accordance with section 5165.152 of the Revised Code. (5) HCBS waiver. If a resident using the NF for a short-term stay is enrolled in an HCBS waiver program and is not using short-term respite care as a waiver service, medicaid payment shall be made for NF bed-hold days for hospitalization up to the bed-hold day limit specified in this rule. Payment for NF bed-hold days shall not be made for NF residents who are on an HCBS waiver for purposes other than hospitalization. (K) Exclusions. NF bed-hold days are not available to medicaid eligible NF residents in the following situations: (1) Hospice. A person enrolled in a medicare or medicaid hospice program is not entitled to medicaid covered NF bed-hold days. It is the hospice provider's responsibility to contract with and pay the NF provider. Hospice program provisions and criteria are stated in Chapter 5160-56 of the Administrative Code. (2) IMD. A resident age twenty-one and over, and in some circumstances age twenty-two and over, and under age sixty-five who becomes a patient of an IMD is not entitled to NF bed-hold days, and a NF provider shall not receive reimbursement for NF bed-hold days during the period the person is hospitalized in an IMD except as permitted in 42 C.F.R. 438.6(e) (October 1, 2016). (3) HCBS waiver. NF bed-hold days do not apply to a person enrolled in a HCBS waiver program who is using the NF for short-term respite care as a waiver service. (4) Restricted medicaid coverage. A person who is medicaid eligible but is in a period of restricted medicaid coverage because of an improper transfer of resources is not eligible for NF bed-hold days until the period of restricted coverage has been met. The criteria for the determination of restricted medicaid coverage are specified in rule 5160:1-3-07.2 of the Administrative Code. (5) Facility closure and resident relocation. NF bed-hold days are not available to residents who have relocated due to the facility's anticipated closure, voluntary withdrawal from participation in the medicaid program, or other termination of the facility's medicaid provider agreement. No span of NF bed-hold days shall be approved that ends on a facility's date of closure or termination from participation in the medicaid program. (L) Compliance. (1) Without limiting such other remedies provided by law for noncompliance with the provisions of this rule, ODM may do one or both of the following: (a) Require the provider to submit and implement a corrective action plan approved by ODM on a schedule specified by ODM. (b) Terminate the facility's NF provider agreement. (2) A NF provider shall cooperate with any investigation and shall provide copies of any records requested by ODM.
Last updated February 9, 2024 at 1:18 PM
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Rule 5160-3-16.5 | Nursing facilities (NFs): personal needs allowance (PNA) accounts and other resident funds.
Effective:
October 16, 2017
A NF resident's rights concerning his or her
personal financial affairs shall be in accordance with 42 CFR 483.10 (October
4, 2016). (A) Definitions. (1) "Personal needs allowance (PNA)
account" means an account or petty cash fund that holds the money of a NF
resident and is managed for the resident by the NF provider. (2) "Letters of
administration," also known as letters testamentary, means court papers
allowing a person to take charge of the property of a deceased person in order
to distribute it. (3) "Surety bond" means an
agreement between the principal (i.e., the NF provider), the surety (i.e., the
insurance company), and the obligee (i.e., the resident and/or the Ohio
department of medicaid (ODM) acting on behalf of the resident), wherein the
principal and the surety agree to compensate the obligee for any loss of the
obligee's funds that the principal holds, safeguards, manages, and
accounts for. The purpose of a surety bond is to guarantee
that a NF provider will pay a resident, or ODM on behalf of a resident, for
losses occurring from any failure by the facility to hold, safeguard, manage,
and account for the resident's funds, including losses incurred as a
result of acts of error or negligence, incompetence, or dishonesty. The
principal assumes the responsibility to compensate the obligee for the amount
of the loss up to the entire amount of the surety bond. (B) PNA. (1) A medicaid resident
who receives care in a NF certified to participate in the medicaid program is
eligible to retain a PNA account for the purchase of items and services of his
or her choice. (2) The PNA account is
the exclusive property of the resident, who may use the funds in the account as
he or she chooses to meet personal needs. (3) Unless a medicaid
resident receives additional irregular contributions from another source, all
of his or her personal expenses shall be met through the PNA
account. (C) Management of personal
funds. (1) A NF resident has the
right to manage his or her personal financial affairs. (2) A NF provider shall
not require a resident to deposit his or her PNA funds with the provider.
However, if a resident requests assistance from the NF staff in managing his or
her PNA account, the request shall be in writing. (3) Upon written
authorization from a resident, a NF shall hold, safeguard, manage, and account
for a resident's PNA funds deposited with the provider. (4) A NF provider shall
explain verbally and in writing to the resident or the resident's
representative that PNA funds are for the resident to use as he or she chooses.
If a representative is the payee for the resident's PNA account, the
representative shall be responsible for ensuring that the money is used to meet
the personal needs of the resident. (D) Deposit of PNA account funds and
interest earned. (1) Funds of fifty
dollars or less. If a resident's PNA account funds are
fifty dollars or less, a NF provider may deposit the funds in an
interest-bearing account, a non-interest bearing account, or a petty cash
fund. (2) Funds in excess of
fifty dollars. If a resident's PNA account funds are in
excess of fifty dollars, the NF provider shall deposit the funds in an
interest-bearing account (or accounts) that is separate from any of the NF
provider's operating accounts within five banking days from the date the
balance exceeds fifty dollars. (3) A NF provider shall
credit any interest earned on a resident's PNA funds to the
resident's PNA account balance. If pooled accounts are used, the provider
shall prorate interest per resident on the basis of actual earnings or
end-of-quarter balance. (4) A NF provider shall
not charge a resident a fee for managing the resident's PNA account.
Banks, however, may charge the resident a fee for handling the
account. (E) Accounting and records. (1) A NF provider shall
establish and maintain a system that ensures full, complete, and separate
accounting of each resident's PNA account funds. (2) A NF provider shall
not commingle a resident's accounts or funds with the provider's
accounts or funds, or with the accounts or funds of any individual other than
another NF resident. (3) A NF provider shall
provide a resident with access to petty cash (less than fifty dollars) on an
ongoing basis and shall arrange for the resident to access larger funds (fifty
dollars or more). A NF provider shall give residents a receipt for every
transaction, and the NF provider shall retain a copy. (4) A NF provider shall
obtain a resident's signature upon the resident's receipt of PNA
funds. If the resident is unable to sign his or her name, he or she shall
acknowledge receipt of the money by marking an "X." Two persons shall
verify through signature that they have witnessed the resident's
action. (5) A NF provider shall
maintain an individual ledger account of revenue and expenses for each PNA
account managed by the facility. The ledger account shall meet all the
following criteria: (a) Specify all funds received by or deposited with the NF
provider. For PNA account funds deposited in banks, monies shall be credited to
the resident's bank account within three business days; and (b) Specify the dates and reasons for all expenditures;
and (c) Specify at all times the balance due the resident, including
interest earned as last reported by the bank to the provider; and (d) Be available to the resident or the resident's
representative for review. (6) Upon request, a NF
provider shall provide receipts to a resident or the resident's
representative for purchases made with the resident's PNA
funds. (7) Within thirty days
after the end of the quarter, a NF provider shall provide a written quarterly
statement to each resident or resident's representative of all financial
transactions made by the provider on the resident's behalf. (F) Notification of certain balances or
transactions that may affect medicaid eligibility. (1) Notice to
resident. (a) A NF provider shall give written notification to each
resident who receives medicaid benefits, and whose funds are managed by the NF
provider, when the amount in the resident's PNA account reaches two
hundred dollars less than the supplemental security income resource limit
specified in section 1611(a)(3)(A) or section 1611(a)(3)(B) of the Social
Security Act. (b) The notice shall inform the resident that he or she may lose
medicaid eligibility if the amount in his or her PNA account, in addition to
the value of the other nonexempt resources, reaches the resource limit
amount. (c) A copy of the notice to the resident shall be retained in the
resident's file. (2) Notice to the county
department of job and family services (CDJFS). (a) A NF provider shall report to the CDJFS any PNA account
balance in excess of the resource limit. The CDJFS shall apply the excess
amount to the routine cost of NF care. (3) If a resident is
considering using PNA funds to purchase life insurance, grave space, a burial
account, or other item that may be considered a countable resource, the NF
provider shall refer the resident or the resident's representative to the
CDJFS for an explanation of the effect the purchase may have on the
resident's medicaid eligibility. (G) Release of funds upon
discharge. (1) Upon discharge of a
resident, a NF provider shall release all the resident's funds, up to and
including the maximum resource limit amount. (2) Other than for items
and services that the resident has requested and that may be charged to the
resident's PNA account in accordance with this rule, a NF provider shall
not withhold PNA account funds to pay any outstanding balance a resident owes
the provider at the time of discharge. (H) Conveyance of funds upon
death. (1) First thirty
days. A NF provider shall not retain the money in a
resident's PNA account beyond thirty days following the resident's
death if letters testamentary or letters of administration are issued, or an
application for release from administration is filed under section 2113.03 of
the Revised Code concerning the resident's estate within that thirty-day
period. In these circumstances, the provider shall transfer the funds in the
resident's PNA account and a final accounting of those funds to the
administrator, executor, commissioner, or person who filed the application for
release from administration. If these conditions for release are not met, the
provider shall follow paragraph (H)(2) or (H)(3) of this rule. (2) First sixty
days. If, within sixty days after a resident's
death, letters testamentary or letters of administration are issued, or an
application for release from administration is filed under section 2113.03 of
the Revised Code concerning the resident's estate, the provider shall
transfer the resident's PNA account funds and a final accounting of those
funds to the administrator, executor, commissioner, or person who filed the
application for release from administration. (3) After sixty
days. (a) If, within sixty days after a resident's death, letters
testamentary or letters of administration concerning the resident's estate
are not issued, or an application for release from administration is not filed
under section 2113.03 of the Revised Code concerning the resident's
estate, and if the resident was a recipient of medicaid benefits, the provider
shall transfer all the resident's PNA account funds to ODM no earlier than
sixty and no later than ninety days after the death of the resident, with the
exception listed in paragraph (H)(3)(c) of this rule. (b) PNA account funds transferred to ODM shall be paid by check
or money order made payable to "Attorney General's Office" and
shall be accompanied by a completed ODM 09405 (rev. 4/2017) entitled
"Personal Needs Allowance (PNA) Account Remittance Notice." The
payment and completed ODM 09405 shall be mailed to the Ohio attorney
general's office. (c) If funeral and/or burial expenses for a deceased resident
have not been paid, and all the resident's resources other than the PNA
have been exhausted, the resident's PNA account funds shall be used to pay
the funeral and/or burial expenses. (d) If, sixty-one or more days after a resident dies, letters
testamentary or letters of administration are issued, or an application for
release from administration under section 2113.03 of the Revised Code is filed
concerning the resident's estate, ODM shall transfer all the
resident's PNA account funds received by the department to the
administrator, executor, commissioner, or person who filed the application for
release from administration, unless ODM is entitled to recover the money under
section 5162.21 of the Revised Code. (I) Financial security. A NF provider shall purchase a surety bond or
provide a reasonable alternative as described in this rule in order to protect
all resident funds deposited with and managed by the NF provider. (1) Surety
bond. (a) A surety bond shall be executed by a licensed surety company
pursuant to Chapters 1301., 1341., and 3929. of the Revised Code. (b) At a minimum, surety bond coverage shall protect at all times
the full amount of resident funds deposited with the NF provider, including
interest earned and refundable deposit fees. (c) The surety bond shall provide for repayment of funds lost due
to any failure of the NF provider, whether by commission, bankruptcy, omission,
or otherwise, to hold, safeguard, manage, and account for resident
funds. (d) The surety bond shall designate either the NF provider, or
ODM on behalf of the resident, as the obligee. (e) If an entity purchases a surety bond that covers more than
one of its facilities, the surety bond shall protect the full amount of all
resident funds on deposit in all the entity's facilities. (2) Reasonable
alternative to the surety bond. A reasonable alternative to the surety bond
shall provide protection equivalent to that afforded by a surety bond. Neither
self insurance nor deposit of funds in bank accounts protected by the federal
deposit insurance corporation (FDIC) or a similar entity are acceptable
alternatives to a surety bond. A NF provider electing not to purchase a surety
bond shall submit a proposal for an alternative to ODM for approval. An
acceptable alternative shall meet all of the following criteria: (a) At a minimum, protect at all times the full amount of
resident funds deposited with the NF provider, including interest earned and
refundable deposit fees; and (b) Designate either ODM or the residents of the NF as the entity
or entities that will collect payment for lost funds; and (c) Guarantee repayment of funds lost due to any failure of the
NF provider, whether by commission, bankruptcy, omission, or otherwise, to
hold, safeguard, manage, and account for resident funds; and (d) Be managed by a third party unrelated in any way to the NF
provider or its management; and (e) Not name the NF provider as a beneficiary. (3) Provision of
assurance to ODM. A NF provider or entity that operates multiple
facilities shall submit copies of either the multi-facility surety bond or a
reasonable alternative to the multi-facility surety bond to ODM upon request
for review and approval. If the NF provider, surety company, or issuer of an
ODM-approved surety bond alternative cancels the surety bond or reasonable
alternative to a surety bond, they shall notify ODM by certified mail thirty
days prior to the effective date of cancellation. (J) Limitations on charges to the PNA
account. (1) A NF provider shall
not charge a resident's PNA account for items and services that the
provider is required to furnish in order to participate in the medicare and
medicaid programs, and that are included in medicare and medicaid payments made
to the provider. (2) A NF provider shall
inform residents of the coverage and limitations of the medicare and medicaid
programs. If a resident's representative is the payee for the
resident's PNA account, the NF provider shall also explain the coverage
and limitations to the representative. (3) A NF provider shall
not use a resident's PNA account funds to pay for costs associated with
guardianship proceedings, including but not limited to the costs for
assessments, medical exams, and filing fees. (K) Items and services covered by
medicare or medicaid. (1) A NF provider shall
not charge a resident's PNA account for items and services that the
provider is required to furnish in order to participate in the medicare and
medicaid programs. (2) Items and services
that may not be purchased with PNA account funds include, but are not limited
to, the following: (a) Nursing services; and (b) Dietary services; and (c) Activities programs; and (d) Room and bed maintenance services; and (e) Routine personal hygiene items and services required to meet
the needs of the resident, including but not limited to hair hygiene supplies,
comb, brush, bath soap, disinfecting soap or specialized cleansing agents when
indicated to treat special skin problems or to fight infection, razor, shaving
cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss,
moisturizing lotion, tissues, cotton balls, deodorant, incontinence care
supplies, sanitary napkins and related supplies, towels, washcloths, hospital
gowns, over the counter drugs, hair and nail hygiene services, bathing, and
basic personal laundry; and (f) Medically related social services; and (g) Medical supplies such as irrigation trays, catheters,
drainage bags, syringes, and needles; and (h) Durable medical equipment; and (i) Air conditioners, or charges to residents for the use of
electricity; and (j) Therapy or podiatry services; and (k) Charges for telephone consultation by physicians or other
personnel. (L) Resident requests for items and
services. (1) A NF provider shall
not charge a resident's PNA account for any item or service not requested
by the resident, whether or not the item or service is requested by a
physician. (2) A NF provider shall
not require a resident or the resident's representative to request an item
or service as a condition for admission to or continued stay in the
NF. (3) When a resident
requests an item or service for which a charge to the resident's PNA
account will be made, the NF provider shall inform the resident that there will
be a charge and the amount of the charge. (M) Items and services that may be
charged to the PNA account. (1) If a resident clearly
expresses a desire for a particular brand or item not available from the NF
provider, PNA funds may be used as long as a comparable item of reasonable
quality is available to the resident from the NF provider at no charge. The NF
provider may charge the resident only the difference in cost between the
available item and the resident's preferred item. (2) Items and services
that may be charged to a resident's PNA account include, but are not
limited to, the following: (a) Telephone, including a cellular phone; and (b) Television, radio, personal computer, or other electronic
device for personal use; and (c) Personal comfort items, including smoking materials, notions,
novelties, and confections; and (d) Cosmetics and grooming items and services in excess of those
for which payment is made under the medicaid or medicare programs, including
hair cuts, permanent waves, hair coloring, and relaxing performed by barbers
and beauticians; and (e) Personal reading material; and (f) Stationary or stamps; and (g) Personal clothing; and (h) Specialty laundry services such as dry cleaning, mending, or
hand-washing; and (i) Flowers or plants; and (j) Gifts purchased on behalf of a resident; and (k) Non-covered special care services such as privately hired
nurses or nurse aides; and (l) Social events or entertainment offered outside the scope of
the NF provider's activities program; and (m) Private rooms, except when therapeutically required for
infection control or similar reasons; and (n) Specially prepared or alternative food requested instead of
food generally prepared by the NF provider; and (o) Burial plots. (N) Monitoring. The CDJFS is responsible for monitoring PNA
accounts. At least annually, a designated CDJFS employee shall determine if a
NF provider is following the provisions of this rule, and shall report any
questions concerning inappropriate use or inadequate record keeping of PNA
funds to ODM and to the Ohio department of health (ODH) for further action.
Inappropriate use of PNA account funds by a payee or a NF provider does not,
however, reduce the scope or duration of medicaid benefits for a medicaid
recipient.
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Rule 5160-3-18 | Nursing facilities (NFs): ventilator program.
Effective:
December 31, 2020
(A) Purpose. In accordance with section 5165.157 of the
Revised Code, this rule establishes an alternative purchasing model for the
provision of nursing facility (NF) services to ventilator dependent individuals
which may include ventilator weaning. (B) Definitions. For purposes of this rule the following
definitions apply: (1) "Discrete
unit" means an area in a NF that is set aside from the larger facility. A
discrete unit may be a separate building, wing, floor, hallway, one side of a
corridor, or a room or group of rooms. Beds in the unit may be utilized for
individuals who are not ventilator dependent provided that the NF can
accommodate all the ventilator dependent individuals covered under this rule
and as required by this rule. (2) "ODM NF
ventilator program" means the ventilator services, which may include
ventilator weaning services, provided to ventilator dependent individuals by a
NF in accordance with this rule, where the NF is eligible to receive an
enhanced payment rate for providing those services. (3) "Respiratory
care professional" (RCP) means the same as in division (B) of section
4761.01 of the Revised Code. (4) "Ventilator-associated pneumonia
(VAP)" means pneumonia in an individual intubated and ventilated at the
time of, or within forty-eight hours before, the onset of the
pneumonia. (5) "VAP baseline rate" means
the average of a NF's VAP rate for a fiscal year calculated by ODM using
the data from the submission of quarterly reports for the most recent full
calendar year beginning January first and ending December
thirty-first. (6) "VAP threshold rate" means
a maximum number of VAP episodes determined by ODM based on the VAP baseline
rates for all NFs statewide. (7) "VAP rate" means the number
of VAP episodes occurring in the NF per one-thousand ventilator days.
(8) "Ventilator dependent"
means the use of any type of mechanical ventilation to sustain daily
respiration for any part of the day. (9) "Ventilator
weaning" means the gradual withdrawal of ventilator support. (10) "Ventilator weaning
services" means the services provided to support the individual
resident's ventilator weaning and includes a post ventilator weaning
evaluation period of up to fourteen days. (C) Provider eligibility. In order to qualify as an ODM NF ventilator
program provider and receive an enhanced payment rate for providing ventilator
services or ventilator weaning services, a NF shall meet all of the following
criteria: (1) Be a licensed and
medicaid certified NF and meet the requirements for NFs in accordance with 42
U.S.C. 1396r (10/19/2018). (2) Provide services to
individuals who are ventilator dependent and have medicaid as their primary
payer. (3) Comply with the provisions in
Chapters 5164. and 5165. of the Revised Code regarding provider agreements, and
with the provisions in rules 5160-3-02 to 5160-3-02.2 of the Administrative
Code regarding execution and maintenance of provider agreements between ODM and
the operator of a NF. (4) Cooperate with ODM or its designee
during all provider oversight and monitoring activities including but not
limited to: (a) Being available to answer questions pertaining to the ODM NF
ventilator program. (b) Providing necessary requested documentation. (c) Providing required quarterly reports and as applicable, a
requested plan of action. (5) Designate a discrete unit within the
NF for the use of individuals in the ODM NF ventilator program. If there is a
change in the size or location of the designated discrete unit or number of
beds in the discrete unit, the NF shall notify ODM of the change via email to
nfpolicy@medicaid.ohio.gov within five business days of the
change. (6) Have ventilators connected to
emergency outlets, which are connected to an on site backup generator in an
amount sufficient to meet the needs of the ventilator dependent individuals.
(7) Have not been in the centers for
medicare and medicaid services (CMS) special focus facility (SFF) program for
the previous six months. (a) A NF participating in the ODM NF ventilator program that
becomes a SFF must notify ODM of the SFF status within one business day of
receipt of the CMS SFF letter via email to nfpolicy@medicaid.ohio.gov and
attach a copy of the letter. (b) Any individuals participating in the ODM NF ventilator
program at the time a NF becomes an SFF shall remain as participants in the ODM
NF ventilator program. The NF shall not admit new individuals to the ODM NF
ventilator program until the NF has been graduated from the SFF program for a
period of six consecutive months. At that time, the NF must submit a new
request to participate in the ODM NF ventilator program in accordance with
paragraph (D) of this rule. The NF may begin admitting new individuals to the
ODM NF ventilator program after the NF receives notice of approval by
ODM. (8) Provide all of the following
services: (a) For at least five hours per week, the services of an RCP or
the services of a registered nurse (RN) who has worked for a minimum of one
year with ventilator dependent individuals. The RCP or the RN as applicable,
shall provide direct care to the ventilator dependent individuals. (b) If ordered by a physician, initial assessments for physical
therapy, occupational therapy, and speech therapy within forty-eight hours of
receiving the order for a ventilator dependent individual. (c) If ordered by a physician, up to two hours of therapies per
day, six days per week for each ventilator dependent individual. (d) In emergency situations as determined by a physician, access
to laboratory services that are available twenty-four hours per day, seven days
per week with a turnaround time of four hours. (e) For new admissions, administer pain medications to a
ventilator dependent individual within two hours from the receipt of the
physician order. (9) Have an approved ODM 10198,
"Addendum To ODM Provider Agreement: Nursing Facility Ventilator
Program" ()(12/2018). (D) Request to participate in the ODM NF ventilator
program. (1) A NF who wishes to
participate in the ODM NF ventilator program shall email a completed ODM 10227
"Request to Participate in the ODM Nursing Facility Ventilator
Program" (12/2018) to nfpolicy@medicaid.ohio.gov. The request shall
demonstrate that the NF is capable of fulfilling all of the requirements
specified in this rule, including ventilator weaning services if requested. ODM
may request additional information regarding a NF's qualifications to
participate. (2) ODM will respond to a
request via return email within ten business days of receipt of the request. If
the request is approved, ODM will provide the ODM 10198 for the NF to complete
and submit to ODM. (3) If the request to participate in the
ODM NF ventilator program is not approved, the NF may request a reconsideration
by the medicaid director or designee within thirty calendar days of receipt of
the non-approval via email to nfpolicy@medicaid.ohio.gov. The decision of the
director or designee regarding the reconsideration shall be final. (4) The ODM 10227 shall
be re-submitted to, and re-approved by ODM, as part of each subsequent provider
agreement revalidation unless the provider chooses to withdraw from the ODM NF
ventilator program or is determined by ODM to no longer meet the eligibility
requirements as set forth in paragraph (C) of this rule and, if applicable,
paragraph (E) of this rule. ODM will respond to a request via return email
within ten business days of receipt of the request. If the request is approved,
ODM will provide the ODM 10198 for the NF to complete and submit to ODM. If the
request to participate is not approved, the NF shall follow the information in
paragraph (D)(3) of this rule. (5) In the case of a
change of operator (CHOP), if the exiting provider participated in the ODM NF
ventilator program and the entering provider wishes to continue to participate
in the program, the entering provider should submit the ODM 10227 to
nfpolicy@medicaid.ohio.gov. Notwithstanding rule 5160-3-65.1 of the
Administrative Code, if the ODM 10227 is submitted within sixty days of the
effective date of the CHOP and ODM approves the ODM 10198, the entering
provider is eligible to receive the enhanced rate or rates retroactive to the
effective date of the CHOP or the date the requirements to participate in the
NF ventilator program are met, whichever occurs later. If the ODM 10227 is not
submitted within sixty days of the effective date of the CHOP but ODM approves
the ODM 10198, the entering provider is eligible to receive the enhanced rate
or rates effective on the date of ODM approval. If there is no approved ODM
10198, the entering provider's participation in the ODM NF ventilator
program shall cease effective on the effective date of the CHOP. (E) Ventilator weaning
services. NFs that are approved to participate in the NF
ventilator program may provide ventilator weaning services if they meet the
following criteria: (1) Have an approved ODM
10198 with approval to provide ventilator weaning services. (2) Have a ventilator
weaning protocol in place established by a physician trained in pulmonary
medicine who is available by phone twenty-four hours per day seven days per
week while ventilator weaning services are provided. (3) Have an RCP with
training in basic life support on-site eight hours per day seven days per week
and available by phone during the remaining hours of the day while ventilator
weaning services are provided. (4) Have a registered
nurse or RCP with training in basic life support on-site twenty-four hours per
day seven days per week while ventilator weaning services are provided.
(F) ODM NF ventilator program payment rate. (1) The total per
medicaid day payment rate determined under section 5165.15 of the Revised Code
shall not be paid for NF services provided under the ODM NF ventilator program.
Instead, the total per medicaid day payment rate for services provided by a NF
under the NF ventilator program for each state fiscal year shall be as
follows: (a) For ventilator weaning services, sixty per cent of the
statewide average of the total per medicaid day payment rate for those
individuals receiving ventilator services in a long-term acute care hospital
for the prior calendar year. Payment at the enhanced ventilator weaning rate is
limited to ninety days per calendar year per individual, and includes a post
ventilator weaning evaluation period of up to fourteen days. (b) For ventilator only services, fifty per cent of the statewide
average of the total per medicaid day payment rate for those individuals
receiving ventilator services in a long-term acute care hospital for the prior
calendar year. (2) Prior to the
establishment of the VAP threshold rate, NFs participating in the ODM NF
ventilator program will receive the rate described in paragraph (F)(1)(a) of
this rule for ventilator weaning services and paragraph (F)(1)(b) of this rule
for ventilator only services, of this rule. (3) ODM shall notify NFs via the Ohio
department of medicaid website no later than July first of each year of each
NF's specific VAP baseline rate, the VAP threshold rate, and the ODM NF
ventilator program payment rates that shall be effective for the state fiscal
year. (4) Once ODM has calculated a NF's
VAP baseline rate and the VAP threshold rate, for any quarter thereafter in
which a NF's VAP rate exceeds the VAP threshold rate, ODM shall notify the
NF via email that a plan of action is required and a deadline for its
submission to ODM. (a) If the NF elects not to timely submit a plan of action, ODM
shall follow the termination process in paragraph (I)(2) of this
rule. (b) If the NF elects to submit a plan of action, the NF shall
submit the plan to ODM via email to nfpolicy@medicaid.ohio.gov within fifteen
calendar days of the date on the ODM notification email regarding the required
plan of action and shall include: (i) A description of the
NF's investigation of both avoidable and unavoidable factors contributing
to their quarterly VAP rate being higher than the VAP threshold
rate. (ii) Specific
interventions to reduce the NF's VAP rate. (iii) A completion date
for the plan of action which shall be within sixty days of sending the plan of
action via email to ODM. (c) Within ten business days of receipt of a plan of action, ODM
will review the plan and make one of the following decisions: (i) Approve the plan and
notify the NF via return email of the approval. The NF shall submit to ODM a
statement of completion of their plan of action within fifteen calendar days of
their completion date via email to nfpolicy@medicaid.ohio.gov. (ii) Disapprove the plan
and notify the NF via return email of the disapproval and the deficiencies
identified in their plan of action. If the NF elects not to submit a revised
plan of action, ODM shall follow the termination process in paragraph (I)(2) of
this rule. (iii) If the NF elects
to submit a revised plan of action, the NF shall submit the revised plan to ODM
via email to nfpolicy@medicaid.ohio.gov within fifteen calendar days of the
date on the ODM notification email regarding the disapproval. (a) Within ten business
days of receipt of a revised plan of action, ODM will review the revised plan
and make one of the following decisions: (i) Approve the revised
plan and notify the NF via return email of the approval. The NF shall submit to
ODM a statement of completion of their revised plan of action within fifteen
calendar days of their completion date via email to
nfpolicy@medicaid.ohio.gov. (ii) Disapprove the
revised plan and notify the NF via return email of the disapproval. ODM may
decide a NF is no longer eligible to participate in the ODM NF ventilator
program. In such cases ODM shall follow the termination process in paragraph
(I)(2) of this rule. (d) If the VAP rate exceeds the VAP threshold rate for two
consecutive quarters, ODM may reduce the ODM NF ventilator program payment
rates for both ventilator only services and ventilator weaning services by a
maximum of five per cent. The reduced ODM NF ventilator program payment rate or
rates if ventilator weaning services are provided, will become effective during
the next full quarter following report submission, and shall remain in effect
for that entire quarter. (i) ODM shall notify the
NF via certified mail return receipt requested of the reduced payment rate and
the applicable quarter. (ii) Within thirty days
of receiving receipt of the reduced payment rate or rates if ventilator weaning
services are provided, the NF may request a reconsideration by the medicaid
director or designee via email to nfpolicy@medicaid.ohio.gov. The decision of
the director or designee regarding the reconsideration shall be
final. (5) If an individual is no longer
ventilator dependent, the per medicaid day payment rate for that individual
shall be the rate determined under section 5165.15 of the Revised Code
beginning the first day the individual is no longer ventilator dependent or at
the conclusion of the post ventilator weaning evaluation period, whichever is
later. (6) Except in the case of a CHOP as
described in paragraph (D)(5) of this rule, NFs without a current approved ODM
10198 shall be paid the total per medicaid day payment rate determined under
section 5165.15 of the Revised Code. (G) Bed-hold days. Bed-hold days for individuals receiving services
under the ODM NF ventilator program shall be paid at the NF's per medicaid
day payment rate for reserving beds determined under section 5165.34 of the
Revised Code. (H) Quarterly reports. (1) ODM NF ventilator
program providers shall submit ODM 10228 "Nursing Facility Quarterly
Ventilator Program Report" (12/2018) to ODM on a calendar quarter basis.
The reporting period end date is the last day of each calendar quarter. The
quarterly report is due to ODM by day twenty-five of the month after the
reporting period end date. A provider does not have to submit quarterly reports
if the provider had no ventilator dependent residents during the reporting
period. (2) Quarterly reports shall be submitted
to ODM via secure email to nfpolicy@medicaid.ohio.gov. (I) Ensuring providers meet ODM NF ventilator program eligibility
requirements. (1) ODM shall biannually
select a random sample of the total of all ODM NF ventilator program providers,
and shall review their compliance with all of the eligibility requirements of
this rule as specified in paragraph (C) and paragraph (E) of this rule if the
NF provides ventilator weaning services. (2) ODM shall terminate a
NF from the ODM NF ventilator program if ODM determines that the NF has failed
to meet the requirements of this rule. (a) If a NF fails to continue to meet the requirements in
paragraph (E) of this rule but meets the requirements in paragraph (C) of this
rule, ODM will terminate the NF's ability to provide ventilator weaning
services and to receive the enhanced rate for ventilator weaning in accordance
with paragraph (F)(1)(a) of this rule. The NF may continue to provide
ventilator only services and to receive the enhanced rate for ventilator only
services in accordance with paragraph (F)(1)(b) of this rule, as long as the
eligibility requirements in paragraph (C) of this rule are met. (b) ODM shall notify the provider of the termination via
certified mail return receipt requested. (c) Within thirty calendar days of receipt of termination, the NF
may request a reconsideration by the medicaid director or designee. The
decision of the director or designee regarding the reconsideration shall be
final. (3) If, at the time of
revalidation of the medicaid provider agreement, a request to sign a new
provider agreement addendum is not approved, ODM shall terminate the NF from
the program. (a) ODM shall notify the NF via certified mail return receipt
requested. (b) Within thirty calendar days of receipt of the termination,
the NF may request a reconsideration by the medicaid director or designee. The
decision of the director or designee regarding the reconsideration shall be
final. (J) Change in services. A NF that chooses to no longer provide ventilator
weaning services or to no longer participate in the ODM NF ventilator program
under this rule shall do one of the following: (1) If the NF is not
providing services to any individual under the NF ventilator program and
chooses to no longer participate in the NF ventilator program: (a) The NF shall send notice to ODM via email to
nfpolicy@medicaid.ohio.gov. (b) The notice shall include a statement that the facility no
longer chooses to participate in the NF ventilator program and the desired date
of withdrawal. (c) The written notice will serve as a modification to the
NF's approved ODM 10198. (2) If the NF no longer
chooses to provide ventilator weaning services under the NF ventilator program
but chooses to continue to participate in the NF ventilator
program: (a) The NF shall send notice to ODM via email to
nfpolicy@medicaid.ohio.gov. (b) The notice shall include a statement that the facility no
longer chooses to provide ventilator weaning services but chooses to continue
to participate in the NF ventilator program. (c) The notice shall include the last date the NF will provide
ventilator weaning services. (d) The written notice will serve as a modification to the
NF's approved ODM 10198. (3) If the NF is providing services,
which may include ventilator weaning services, and chooses to withdraw from the
NF ventilator program: (a) At least sixty days before the last day of participation in
the ODM NF ventilator program, the NF shall send notice of the withdrawal to
ODM via email to nfpolicy@medicaid.ohio.gov. (b) The notice shall include a statement that the NF chooses to
withdraw from the ODM NF ventilator program and the last date the NF will
participate in the program. (c) If the NF decides to discharge current ventilator dependent
individuals, the NF shall discharge in accordance with rule 3701-61-03 of the
Administrative Code. If the NF decides to retain current ventilator dependent
individuals, the per medicaid day payment rate shall be the rate determined
under section 5165.15 of the Revised Code beginning the day after the last date
of participation in the ODM NF ventilator program. (d) The written notice will serve as official termination of the
NF's approved ODM 10198.
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Rule 5160-3-19 | Nursing facilities (NFs): relationship of NF services to other covered medicaid services.
Effective:
December 31, 2020
This rule identifies covered services generally
available to medicaid recipients and describes the relationship of such
services to those provided by a NF. Whenever reference is made to payment for
services through the NF per diem, the rules governing such payment are set
forth in Chapter 5160-3 of the Administrative Code. (A) Acupuncture services. All covered acupuncture services provided by an
eligible acupuncture provider are paid directly to the provider of acupuncture
services in accordance with rule 5160-8-51 of the Administrative Code. (B) Behavioral health services. Costs for behavioral health services are paid
directly to the provider of services, not through the NF per diem. (C) Dental services. All covered dental services provided by licensed
dentists are paid directly to the provider of the dental services in accordance
with Chapter 5160-5 of the Administrative Code. Personal hygiene services
related to dental services provided by facility staff or contracted personnel
are paid through the NF per diem. (D) Laboratory and x-ray services. Costs incurred for the purchase and
administration of tuberculin tests, and for drawing specimens and forwarding
specimens to a laboratory, are paid through the NF per diem. All costs of
laboratory and x-ray procedures covered under the medicaid program are paid
directly to the laboratory or x-ray provider in accordance with Chapter 5160-11
of the Administrative Code. (E) Medical supplier services. In accordance with rule 5160-10-02 of the
Administrative Code, costs of certain medical supplies are paid through the NF
per diem, and others are paid directly to the medical supply provider as
follows: (1) Items that must be
paid for through the NF per diem include: (a) "Medical supplies," defined as those items that
have a very limited life expectancy, such as atomizers, nebulizers, bed pans,
catheters, hypodermic needles, syringes, incontinence pads, splints, and
disposable ventilator circuits. (b) "Needed medical equipment" (and repair of such
equipment), defined as items that can stand repeated use, are primarily and
customarily used to serve a medical purpose, are not useful to an individual in
the absence of illness or injury, and are appropriate for use in the facility.
Such medical equipment items include hospital beds, wheelchairs other than
custom wheelchairs, and intermittent positive-pressure breathing machines,
except as noted in paragraph (E)(2) of this rule. (c) Emergency stand-by oxygen. (2) Items for which
payment is made directly to the provider include: (a) Ventilators. (b) "Prostheses," defined as devices that replace all
or part of a body organ to prevent or correct physical deformity or
malfunction, such as artificial arms or legs, electro-larynxes, and breast
prostheses. (c) "Orthoses," defined as devices that assist in
correcting or strengthening a distorted part, such as arm braces, hearing aids
and batteries, abdominal binders, and corsets. (d) Contents of oxygen cylinders or tanks, including liquid
oxygen; oxygen producing machines (concentrators) for specific use by an
individual recipient; and costs of equipment associated with oxygen
administration, such as carts, regulators/humidifiers, cannulas, masks, and
demurrage. (F) Pharmaceuticals. (1) Costs for
over-the-counter drugs, including selected over-the-counter drugs set forth in
paragraph (I) of rule 5160-9-03 of the Administrative Code, and nutritional
supplements are paid through the NF per diem. (2) Pharmaceuticals for
which payment is made directly to the pharmacy provider are subject to the
limitations found in Chapter 5160-9 of the Administrative Code, the limitations
established by the Ohio state board of pharmacy, and the following
conditions: (a) When new prescriptions are necessary following expiration of
the last refill, the new prescription may be ordered only after the physician
examines the patient. (b) A copy of all records regarding prescribed drugs for all
patients must be retained by the dispensing pharmacy for at least six years. A
receipt for drugs delivered to a NF must be signed by the facility
representative at the time of delivery and a copy retained by the
pharmacy. (G) Physical therapy, occupational therapy, speech therapy, and
audiology services. Costs incurred for physical therapy, occupational
therapy, speech therapy and audiology services provided by licensed therapists
or therapy assistants are paid through the NF per diem. (H) Physician services. (1) Physician services
are not paid through the NF per diem rate. Except as provided in paragraph
(H)(2) of this rule, payment is made directly to a physician for covered
services he or she provides to a resident of a NF. (2) In accordance with
rule 5160-4-06 of the Administrative Code, services provided in the capacity of
overall medical direction are payable only to a NF provider. Payment for such
services may not be made directly to a physician. (3) Physician visits must be provided to
a resident of a NF and must conform to the following schedule: (a) The resident must be seen by a physician at least once every
thirty days for the first ninety days after admission, and at least once every
sixty days, thereafter. (b) A physician visit is considered timely if it occurs not later
than ten days after the date the visit was required. (c) For payment of required physician visits, the physician
must: (i) Review the resident's total program of care including
medications and treatments, at each required visit; (ii) Write, sign, and date progress notes at each visit;
and (iii) Sign and date all orders except influenza and pneumococcal
vaccines, which may be administered per physician-approved facility policy
after an assessment for contraindications; and (d) Physician delegation of tasks. (i) A physician may delegate tasks to a physician assistant or an
advanced practice registered nurse (APRN), as defined in Chapter 4723-8 of the
Administrative Code and Chapter 4723. of the Revised Code for APRNs, and in
Chapter 4730. of the Administrative Code for physician assistants, who are in
compliance with the following criteria: (a) Are acting within the scope of practice as defined by state
law. (b) APRNs are practicing with a standard care arrangement entered
into with each physician with whom the APRN collaborates in accordance with
section 4723.431 of the Revised Code. A copy of the standard care arrangement
shall be retained on file at each NF where the nurse practices. (c) Physician assistants
are practicing with a supervision agreement with a physician in accordance with
section 4730.19 of the Revised Code. A copy of the supervision agreement shall
be retained on file at each NF where the physician assistant
practices. (ii) At the option of the
physician, required physician visits may be delegated in accordance with 42
C.F.R. 483.30. (iii) A physician may not delegate a task when regulations specify
that the physician must perform it personally, or when delegation is prohibited
by state law or the facility's own policies. (4) In accordance with
rule 5160-1-18 of the Administrative Code, physician visits may be provided via
telehealth. (5) Services payable directly to the
physician, physician assistant, or APRN must: (a) Be requested by the NF resident, with the exception of
required physician visits; and (b) Be documented by entries in the resident's medical
records along with any symptoms and findings. Every entry must be signed and
dated by the applicable physician, physician assistant, or APRN. (I) Podiatry services. Costs of covered services provided by licensed
podiatrists are paid directly to the authorized podiatric provider in
accordance with Chapter 5160-7 of the Administrative Code. (J) Respiratory therapy services. Costs incurred for physician-ordered
administration of aerosol therapy that is rendered by a licensed respiratory
care professional are paid through the NF per diem. No payment for respiratory
therapy services shall be made to a provider other than the NF through the NF
per diem. (K) Transportation services. Payment for transporting residents by ambulance
or wheelchair van to receive medical services is made directly to the
transportation supplier in accordance with Chapter 5160-15 of the
Administrative Code. Transportation of residents to receive medical services
when the resident does not require an ambulance or wheelchair van is paid
through the NF per diem. (L) Vision care services. All costs for covered vision care services,
including examinations, dispensing, and the fitting of eyeglasses, are paid
directly to authorized vision care providers in accordance with Chapter 5160-6
of the Administrative Code.
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Rule 5160-3-20 | Nursing facilities (NFs) : medicaid cost report filing, disclosure requirements, and records retention.
Effective:
March 23, 2020
In addition to the provisions contained in sections
5165.10 to 5165.109 of the Revised Code, the following provisions apply. (A) For reporting purposes NFs shall use
the chart of accounts for NFs as set forth in rule 5160-3-42 of the
Administrative Code, or relate its chart of accounts directly to the cost
report. (B) Unless an extension is granted by the
Ohio department of medicaid (ODM), NF cost reports should be filed
electronically within ninety days after the end of the reporting period via the
medicaid information technology system (MITS) web portal or other electronic
means designated by ODM. (1) For good cause shown,
cost reports may be submitted within fourteen days after the original due date
if written approval is received from ODM prior to the original due date of the
cost report. Requests for extensions should be in writing and explain the
circumstances resulting in the need for an extension. (2) In the case of a NF
that has a change of operator during a calendar year, the cost report by the
new provider should cover the portion of the calendar year following the change
of operator encompassed by the first day of participation up to and including
December thirty-first. (3) In the case of a NF that begins
participation after January first and ceases participation before December
thirty-first of the same calendar year, the reporting period should be the
first day of participation to the last day of participation. (4) Unless waived by ODM, the reporting
period ends as follows: (a) On the last day of the calendar year for a
facility's year end cost report; or (b) On the last day of medicaid participation or when the
facility closes in accordance with paragraph (A)(1) of rule 5160-3-02 of the
Administrative Code; or (c) On the last day before a change of operator for an
exiting provider. (5) If a cost report is not received by
the original due date, or by an approved extension due date if applicable, the
provider may be assessed a late file penalty for each day a complete and
adequate cost report is not received. The late file penalty may be assessed
even if ODM has provided written notice of termination to a facility.
(a) The late file penalty is determined using the prorated
medicaid days paid in the late file period multiplied by the penalty. The
penalty is two dollars per patient day. (b) The late file penalty period begins on the day after
the original due date or on the day after the extension due date, whichever is
applicable, and continues until the complete and adequate cost report is
received by ODM or the facility is terminated from the medicaid
program. (c) The late file penalty is a reduction to the medicaid
payment. No penalty is imposed during a fourteen-day extension granted by
ODM. (C) The desk review is a process of reviewing information
pertaining to the cost report without detailed verification and is designed to
identify problems warranting additional review. (1) A facility may revise
the cost report within sixty days after the original due date without the
revised information being considered an amended cost report. (2) The cost report is
considered accepted after the cost report has passed the desk review
process. (3) After final rates
have been issued, a provider that disagrees with a desk review decision may
request a rate reconsideration. (D) ODM shall not charge interest under division (B) of
section 5165.41 of the Revised Code based on any error or additional
information that is not required to be reported. (E) Cost reports shall be completed using accrual basis
accounting and generally accepted accounting principles unless otherwise
specified in Chapter 5160-3 of the Administrative Code. (F) Providers should identify all known related parties as
set forth under paragraph (F) of rule 5160-3-01 of the Administrative
Code. (G) Providers should identify all of the
following: (1) Each known
individual, group of individuals, or organization not otherwise publicly
disclosed who owns or has common ownership as set forth under paragraph (F) of
rule 5160-3-01 of the Administrative Code, in whole or in part, any mortgage,
deed of trust, property or asset of the facility; and (2) Each corporate
officer or director, if the provider is a corporation; and (3) Each partner, if the
provider is a partnership; and (4) Each provider,
whether participating in the medicare or medicaid program or not, which is part
of an organization which is owned, or through any other device controlled, by
the organization of which the provider is a part; and (5) Any director,
officer, manager, employee, individual, or organization having five per cent or
more direct or indirect ownership or control of the provider, or who has been
convicted of or pleaded guilty to a civil or criminal offense related to his
involvement in programs established by Title XVIII (December 9, 2019), Title
XIX (December 9, 2019), or Title XX (December 9, 2019) of the Social Security
Act; and (6) Any individual
currently employed by or under contract with the provider, or related party
organization, as defined under paragraph (F) of rule 5160-3-01 of the
Administrative Code, in a managerial, accounting, auditing, legal, or similar
capacity who was employed by ODM, the Ohio department of health, the office of
attorney general, the office of the auditor of state, the Ohio department of
aging, the Ohio department of developmental disabilities, the Ohio department
of commerce, or the industrial commission of Ohio within the previous twelve
months. (H) Providers are required to provide upon request all
contracts in effect during the cost report period for which the cost of the
service from any individual or organization is ten thousand dollars or more in
a twelve-month period; or for the services of a sole proprietor or partnership
where there is no cost incurred and the imputed value of the service is ten
thousand dollars or more in a twelve-month period. (1) For purposes of this
rule, "contract for service" is defined as the component of a
contract that details services provided exclusive of supplies and equipment. It
includes any contract that details services, supplies, and equipment to the
extent the value of the service component is ten thousand dollars or more
within a twelve-month period. (2) For purposes of this
rule, "subcontractor" is defined as any entity, including an
individual or individuals, that contracts with a provider to supply a service,
either to the provider or directly to the beneficiary, where medicaid
reimburses the provider the cost of the service. This includes organizations
related to the subcontractor that have a contract with the subcontractor for
which the cost or value is ten thousand dollars or more in a twelve-month
period. (I) Financial, statistical and medical records (which shall
be available to ODM or its authorized agent and to the U.S. department of
health and human services and other federal agencies) supporting the cost
reports or claims for services rendered to residents shall be retained for the
greater of seven years after the cost report is filed if ODM issues an audit
report, or six years after all appeal rights relating to the audit report are
exhausted. (1) Failure to retain the
required financial, statistical, or medical records, renders the provider
liable for monetary damages that are the greater of the following: (a) One thousand dollars per audit; or (b) Twenty-five per cent of the amount by which the
undocumented cost increased the medicaid payments to the provider during the
fiscal year. (2) Failure to retain the
required financial, statistical, or medical records to the extent that filed
cost reports are unauditable will result in the penalty as specified in
paragraph (I)(1) of this rule. Providers whose records have been found to be
unauditable will be allowed sixty days to provide the necessary documentation.
If, at the end of the sixty days, the required records have been provided and
are determined auditable, the proposed penalty will be withdrawn. If ODM, after
review of the documentation submitted during the sixty-day period, determines
that the records are still unauditable, ODM will impose the penalty as
specified in paragraph (I)(1) of this rule. (3) Refusing legal access
to financial, statistical, or medical records will result in a penalty as
specified in paragraph (I)(1) of this rule for outstanding medical services
until such time as the requested information is made available to
ODM. (4) All requested
financial, statistical, and medical records supporting the cost reports or
claims for services rendered to residents shall be available at a location in
the state of Ohio for facilities certified for participation in the medicaid
program by this state within at least sixty days after request by the state or
its subcontractors. The preferred Ohio location is the facility itself, but may
be a corporate office, an accountant's office, or an attorney's
office elsewhere in Ohio. The state or its subcontractors may conduct the audit
or a review at the site of such records if outside of Ohio. (J) When completing cost reports, the following guidelines
shall be used to properly classify costs: (1) All depreciable
equipment valued at five thousand dollars or more per item and a useful life of
at least two years or more is to be reported in the capital cost component set
forth under the Administrative Code. The costs of any equipment leases executed
before December 1, 1992 and reported as capital costs, shall continue to be
reported under the capital cost component. The costs of any new leases for
equipment executed on or after December 1, 1992, shall be reported under the
capital costs component. Operating lease costs for equipment that result from
extended leases under the provision of a lease option negotiated on or after
December 1, 1992 shall be reported under the capital cost
component. (2) Except for
employers' share of payroll taxes, workers compensation, employee fringe
benefits, and home office costs, allocation of commonly shared expenses across
cost centers is not allowed. Wages and benefits for staff, including related
parties, who perform duties directly related to functions performed in more
than one cost center that would be expended under separate cost centers if
performed by separate staff may be expended to separate cost centers based upon
documented hours worked, provided the facility maintains adequate documentation
of hours worked in each cost center. For example, the salary of an aide who is
assigned to bathing and dressing chores in the early hours but works in the
kitchen as a dietary aide for the remainder of the shift may be expended to
separate cost centers provided the facility maintains adequate documentation of
hours worked in each cost center. (3) The costs of resident
transport vehicles are reported under the capital cost component. Maintenance
and repairs of these vehicles is reported under the ancillary/support cost
component.
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Rule 5160-3-24 | Nursing facilities (NFs): prospective rate reconsideration for possible calculation errors.
Effective:
November 24, 2019
(A) A nursing facility provider, or a
group or association of nursing facility providers, may request a
reconsideration of a prospective NF rate on the basis of a possible error in
the calculation of the rate as follows: (1) A request for
reconsideration shall be filed with the Ohio department of medicaid (ODM) no
more than thirty days after the later of the date on the rate setting package
notification or the effective date of the rate. (2) The request for a
reconsideration shall be filed in accordance with the following
procedures: (a) The request for rate reconsideration shall be in writing;
and (b) The request shall be addressed to "Ohio Department of
Medicaid, Fiscal Operations - LTC Rate Methodology Unit, P.O. Box 182709,
Columbus, Ohio 43215-3414"; and (c) The request shall indicate that it is a request for rate
reconsideration due to a possible error in the calculation of the rate;
and (d) The request shall include a detailed explanation of the
possible error and the proposed corrected calculation; and (e) The request shall include references to the relevant sections
of the Revised Code or paragraphs of the Administrative Code as
appropriate. (3) ODM shall respond in
writing within sixty days of receiving each written request for
reconsideration. If ODM requests additional information to determine whether a
rate adjustment is warranted, the NF shall respond in writing and shall provide
additional supporting documentation no more than thirty days after the receipt
of the request for additional information. ODM shall respond in writing within
sixty days of receiving the additional information to the request for
reconsideration. (4) If a rate adjustment
is warranted as the result of a reconsideration of a prospective rate, the
adjustment shall be implemented retroactively to the initial service date for
which the rate is effective. (B) ODM's decision at the conclusion
of the rate reconsideration process is final and shall not be subject to any
administrative proceedings under Chapter 119. or any other provision of the
Revised Code or Administrative Code.
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Rule 5160-3-30.1 | Nursing facilities (NFs) and hospital long term care units: appeal of the franchise permit fee (FPF) determination or re-determination.
Effective:
August 31, 2017
(A) When submitting an appeal of a FPF determination or re-determination for a nursing home or hospital long term care unit in accordance with section 5168.53 of the Revised Code, a facility operator shall follow these procedures: (1) The appeal shall be in writing and must be received by the Ohio department of medicaid (ODM) not later than fifteen days after the date on which the FPF assessment notice was mailed. (2) The appeal shall be submitted to ODM and addressed to the organization listed in the instructions that are sent with the assessment notice. If this address is invalid, the facility shall contact the ODM bureau of long term services and supports (BLTSS). (3) The appeal shall indicate it is an appeal of the FPF due to a possible material error in determining the amount of the fee. (4) The appeal shall include a detailed explanation of the possible material error and the proposed correction of the amount of the fee. (5) The appeal shall include references to the relevant sections of the Revised Code or rules of the Administrative Code that support the position of the appeal. (B) If a representative of a facility is unable to attend the hearing, the representative shall request a teleconference hearing at least five days prior to the scheduled hearing.
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Rule 5160-3-30.4 | Nursing facilities (NFs), nursing homes (NHs), and long term care hospital beds: procedure for terminating the franchise permit fee (FPF).
(A) Definitions. "Effective FPF termination date" (EFTD)
means the date on which the centers for medicare and medicaid services (CMS)
determines that the FPF does not qualify for federal financial
participation. (B) Determination of the FPF as an
impermissible health care related tax. If CMS determines that the FPF is an
impermissible health care related tax, the Ohio department of medicaid (ODM)
shall take all necessary actions to cease implementation of the FPF program,
pursuant to section 5168.42 of the Revised Code. (C) Notification. ODM shall notify each facility previously
assessed the FPF of the effective date of the termination of the FPF program,
and what impact this change will have on the facility. (D) Reconciliation
procedure. ODM shall conduct an accounting of the funds paid
to or collected from each facility as a result of the FPF program and shall do
all of the following: (1) Reconcile FPFs paid
by NFs, NHs, and hospitals. (a) The annual assessment of the FPF shall be prorated on a daily
basis. (b) FPF assessments for the days preceding the EFTD shall remain
due and payable. (c) Collection shall be pursued in accordance with sections
5168.51 and 5168.55 of the Revised Code. (d) FPF assessments issued for days on and after the EFTD shall
be rescinded. (i) ODM shall issue
refunds to NHs and hospitals for any FPF remittances representing payment for
daily fees on or beyond the EFTD, unless a NF or skilled nursing
facility/nursing facility (SNF/NF) has already received medicaid payment for
service dates described in paragraph (D)(3) of this rule. (ii) The source of the
refunds shall be the funds established by the FPF assessments as set forth in
section 5168.54 of the Revised Code, if necessary, to each NH and hospital
assessed the FPF. (2) Adjust NF rates set
by ODM that include reimbursement for FPF assessment payments by medicaid
certified NFs and SNF/NFs. ODM shall adjust the per diem rate of a NF to remove
any FPF reimbursement-related amount retroactively and/or prospectively from
the rate for dates of service on and after EFTD. (3) Reconcile paid claims
for service dates on and following the EFTD with rates adjusted according to
paragraph (D)(2) of this rule. (a) Active providers. (i) If claims have
already been submitted to ODM and processed for dates of service on or after
the EFTD, ODM shall offset the amount of overpayment received with the amount
of refund due from paragraph (D)(1) of this rule. (ii) If the offset
results in amounts owed to the facility, refunds shall be issued. (iii) If the offset
results in amounts owed to ODM, the amount payable may be collected via offsets
of future payments. (b) Inactive providers. (i) If claims have
already been submitted to ODM and processed for dates of service on or after
the EFTD by a NF or SNF/NF provider that no longer participates in the medicaid
program, ODM shall offset the amount of overpayment received with the amount of
refund due from paragraph (D)(1) of this rule. (ii) If the offset
results in amounts owed to the facility, refunds shall be issued if the
provider has furnished an adequate forwarding address. (iii) If the offset
results in amounts owed to ODM, the amount payable may be collected via direct
payment from the provider. (iv) Failure to provide
payment may result in certification to the attorney general for collection as
set forth in section 5168.55 of the Revised Code.
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Rule 5160-3-32 | Nursing facilities (NFs): debt estimation methodology.
Effective:
March 11, 2024
(A) The Ohio department of medicaid (ODM)
uses the debt estimation methodology set forth in this rule to estimate the
exiting operator's actual and potential debts to ODM and the United States
centers for medicare and medicaid services (CMS) under the medicaid program in
cases of a change of operator, facility closure, voluntary termination,
involuntary termination, or voluntary withdrawal. (B) ODM totals the value of all of the
following that are determined applicable in calculating the debt
estimate: (1) Overpayments
determined due to ODM pursuant to section 5165.108 of the Revised Code,
including the following: (a) Overpayments owed to ODM for adjudicated final fiscal audit
periods. (b) Overpayments identified in proposed adjudication orders that
have been issued but not adjudicated. (c) Overpayment amounts for any outstanding periods where a final
fiscal audit has not yet been issued. Such amounts are estimated by generating
preliminary reports of amounts owed by the exiting operator for the applicable
periods. (2) Overpayments
determined by ODM pursuant to section 5165.49 of the Revised Code, including
the following: (a) Overpayments identified in the post-payment review summary
that have been issued but not collected. (b) Overpayment amounts for any outstanding periods where a
post-payment review summary has not yet been issued. Such amounts are estimated
by generating preliminary reports of amounts owed by the exiting operator for
the applicable periods. (3) Monies owed to ODM and CMS resulting
from penalties authorized by federal and state law, including but not limited
to the following: (a) Civil monetary penalties (CMPs) imposed by CMS that CMS has
requested ODM to collect. (b) Penalties assessed pursuant to section 5165.42 of the Revised
Code for lack of proper notice of a change of operator, facility closure, or
voluntary withdrawal from the medicaid program, or when a provider fails to
furnish invoices or other documentation that ODM requests during an
audit. (c) Late cost report filing penalties assessed pursuant to rule
5160-3-20 of the Administrative Code. (4) Interest monies owed to ODM pursuant
to section 5165.41 of the Revised Code, and to CMS pursuant to 42 C.F.R.
488.442 (October 1, 2020) that CMS has requested ODM to collect. (5) Monies owed to ODM and CMS pursuant
to sections 5165.52 and 5165.525 of the Revised Code, including a final fiscal
audit for the last fiscal year or portion thereof that the exiting operator
participated in the medicaid program. (6) Franchise permit fee (FPF) owed to
ODM pursuant to section 5168.47 of the Revised Code. FPF owed to ODM includes
unpaid FPF for the following: (a) Amounts due for periods assessed or to be assessed but for
which payment is not yet required pursuant to section 5168.47 of the Revised
Code. (b) Amounts due that are certified to the Ohio attorney
general's office for collection, including penalties assessed pursuant to
section 5168.51 of the Revised Code for failure to pay the full amount when
due. (7) Monies owed due to a credit
balance. (8) Monies owed pursuant to successor
liability or assumption of liability agreements the exiting operator entered
into. (9) Other amounts ODM determines are
applicable. (C) The sum of the amounts determined
owed, or estimated to be owed, to ODM and CMS pursuant to paragraphs (B)(1) to
(B)(9) of this rule is the total estimated debt. (D) ODM may release a portion of funds
withheld pursuant to division (A) of section 5165.521 of the Revised Code if
the funds withheld are materially greater than the debt calculated by the
department in the initial debt summary report issued pursuant to section
5165.525 of the Revised Code.
Last updated March 11, 2024 at 12:12 AM
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Rule 5160-3-32.1 | Nursing facilities (NFs): debt summary report procedure.
Effective:
March 11, 2024
(A) Debt summary reports issued in
accordance with section 5165.525 of the Revised Code are served in the same
manner as notices issued under rule 5160-70-03 of the Administrative
Code. (B) Notice to the Ohio department of
medicaid (ODM) of facility closure, voluntary withdrawal of participation, and
notice of change of operator. Notice to ODM should be made in writing and
emailed to LTCEnrollment@medicaid.ohio.gov, or mailed or personally delivered
to ODM's office address. (C) Request for review and submission of information by
nursing facilities to ODM. (1) Any request for
review or submission of additional information made as the result of notice of
an initial or revised debt summary report issued pursuant to section 5165.525
of the Revised Code should be made in writing and emailed to
"MCD_DebtSummary@medicaid.ohio.gov" or mailed or personally delivered
to the ODM office and address identified in the debt summary report within
thirty calendar days of the date ODM issues the debt summary
report. (2) If a request for
review or submission of additional information is mailed to the ODM office and
address identified in the debt summary report, the request or submission is
deemed to have been made as follows: (a) If the request or submission is mailed by certified
mail, as of the date stamped by the U.S. postal service on its receipt form (PS
form 3800 or any future equivalent postal service form). (b) If the request or submission is mailed by regular U.S.
mail, as of the date of the postmark appearing upon the envelope containing the
request. (c) If the request or submission is mailed by regular U.S.
mail and the postmark is illegible or fails to appear on the envelope, as of
the date of its receipt by ODM office identified in the debt summary report as
evidenced by that office's time stamp. (3) If a request for
review or submission of additional information is made by electronic mail to
the office identified in the debt summary report, the request or submission is
deemed to have been made as of the date of its receipt as evidenced by the date
of receipt shown in the source code of the electronic mail received by the
office identified in the debt summary report. (4) If a request for
review or submission of additional information is mailed, personally delivered,
or made by electronic mail to a party or address other than the proper office
identified in the debt summary report, the request or submission is deemed to
have been made as of the date of its receipt by the office identified in the
debt summary report as evidenced by that office's time stamp. (5) If a request for
review or submission of additional information is personally delivered to the
office identified in the debt summary report, the request or submission is
deemed to have been made as of the date of its receipt as evidenced by that
office's time stamp. (6) All requests and
submissions should clearly identify both the affected party involved and the
debt summary report that is being contested. (D) Computation of time deadlines. Section 1.14 of the Revised Code controls the
computing of time deadlines imposed by section 5165.525 of the Revised Code.
Last updated March 11, 2024 at 12:12 AM
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Rule 5160-3-32.2 | Nursing facilities (NFs): successor liability agreements for operators.
(A) Successor liability agreements entered into pursuant to
section 5165.521 of the Revised Code are subject to approval by the Ohio
department of medicaid (ODM). (B) Successor liability agreements must be signed by the exiting
operator, ODM, and the entity assuming liability pursuant to section 5165.521
of the Revised Code. (1) Only the ODM successor liability agreement
forms (rev. November, 2014, available at
http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTerm
CareFacilities/SuccessorLiabilityAgreements.aspx) may be used for successor
liability agreements entered into pursuant to section 5165.521 of the Revised
Code. The ODM language on the successor liability agreement forms shall not be
changed, modified, or altered in any way. (2) Nursing facility operators shall furnish the
original signed successor liability agreement form to ODM. Forms shall be
submitted to "Ohio Department of Medicaid, Bureau of Network Management,
P.O. Box 182709, Columbus, OH. 43218-2709." In cases of a facility closure
the form shall be submitted to the attention of "LTC Enrollment
Coordinator." In cases of a change of operator the form shall be submitted
to the attention of "LTC CHOP Coordinator."
Last updated March 1, 2024 at 12:04 PM
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Rule 5160-3-33 | Nursing facilities (NFs): reimbursement of NF relief payments upon sale of business or bed license.
Effective:
March 23, 2023
(A) For purposes of Section 220.60 of
Amended Substitute House Bill 169 of the 134th General Assembly and this rule,
a "sale" occurs when a purchase agreement or similar document that
outlines the terms of the purchase and results in the payment of money for the
business or bed license, is signed or, if the signature is not dated, the
effective date specified in the purchase agreement or similar
document. (B) Any nursing facility that sells any
of its business or bed licenses in accordance with paragraph (A) of this rule
from March 29, 2022 through June 30, 2023 will reimburse the state in the
following manner: (1) If the proceeds from
the sale are less than the relief payment received by the nursing facility
pursuant to Section 220.60 of Amended Substitute House Bill 169 of the 134th
General Assembly, the nursing facility will reimburse the state the full amount
of the sale proceeds; (2) If the proceeds from
the sale are greater than the relief payment received by the nursing facility
pursuant to Section 220.60 of Amended Substitute House Bill 169 of the 134th
General Assembly, the nursing facility will reimburse the state the full amount
of the relief payment and retain any amount remaining from the sale after the
relief payment is reimbursed in full. (C) The department of medicaid will
notify each nursing facility that is obligated to reimburse relief payments to
the state. The notification will be by certified mail and include the manner of
reimbursement and the deadline. If the reimbursement is not received by the
department by the deadline, the department may, without further notice, offset
from medicaid payments the amount of the reimbursement until it is paid in
full. (D) A nursing facility notified that it
is obligated to reimburse the state pursuant to this rule may request a
reconsideration pursuant to rule 5160-70-02 of the Administrative Code within
thirty days of the date appearing on the notification.
Last updated March 23, 2023 at 8:30 AM
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Rule 5160-3-39 | Payment and adjustment process for nursing facilities (NFs) and intermediate care facilities for the mentally retarded (ICFs-MR).
Effective:
January 10, 2013
(A) Forms. For dates of services preceding July 1, 2005, NFs shall submit the form "Nursing Facility Payment and Adjustment Authorization" (JFS 09400, rev. 10/2012) directly to the Ohio department of job and family services (ODJFS) for the reimbursement of services. The county department of job and family services (CDJFS) and NFs shall use the "Facility/CDJFS Transmittal" (JFS 09401, rev. 4/2011) form to exchange information necessary to complete the billing process for payment. (B) Notification of admission. The facility shall notify the CDJFS using the JFS 09401 form within five business days of admission of a new resident who is medicaid eligible or who has an application for medicaid that is pending even if care may initially be covered under a medicare benefit. (C) Notification of death. The NF shall notify the CDJFS of the death of a medicaid resident by completing the JFS 09401 and forwarding it to the CDJFS within five business days following the death of the resident. The CDJFS shall terminate medicaid eligibility within ten days after the receipt of the JFS 09401. For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401. (1) The CDJFS shall complete and return the JFS 09401, when appropriate, to the NF within ten days of the receipt of the JFS 09401 for any required payment adjustment. (2) The NF shall complete the JFS 09400, when appropriate (e.g., final payment adjustment), within thirty days of the receipt of the JFS 09401 and submit it to the address listed on the bottom of form JFS 09400. (D) Notification of discharge. Discharge has the same meaning as defined in rule 5101:3-3-16.4 of the Administrative Code. The NF shall notify the CDJFS within five business days of the discharge of a medicaid eligible resident by completing the JFS 09401 identifying the type of discharge, and forwarding the JFS 09401 to the CDJFS. The CDJFS shall adjust medicaid eligibility within ten days after the receipt of the JFS 09401. For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401. (1) The CDJFS shall complete and return the JFS 09401, when appropriate, to the NF within ten days after the receipt of the JFS 09401 for any required payment adjustment. (2) The NF shall complete the JFS 09400, when appropriate (e.g., final payment adjustment), within thirty days of the receipt of the JFS 09401 and submit to the address listed on the bottom of form JFS 09400. (E) Notification of hospice enrollment. If a NF resident on medicaid vendor payment elects to receive medicaid hospice services in accordance with rule 5101:3-56-03 of the Administrative Code, the NF shall notify the CDJFS by completing the JFS 09401 and forwarding it to the CDJFS within five business days of receiving notice from the hospice agency that a resident elected hospice services. The CDJFS shall adjust medicaid eligibility within ten days after receipt of the JFS 09401 for the resident enrolled in hospice. For dates of service preceding July 1, 2005, the CDJFS shall stop vendor payment within ten days after the receipt of the JFS 09401. (1) The CDJFS shall complete and return the JFS 09401, when appropriate (e.g., final payment adjustment), to the NF within ten days of the receipt of the JFS 09401 for any required payment adjustment. (2) The NF shall complete the JFS 09400, when appropriate, within thirty days of the receipt of the JFS 09401 and submit it to the address on the bottom of form JFS 09400.
Supplemental Information
Authorized By:
–
Amplifies:
–
Five Year Review Date:
Prior Effective Dates:
12/1/1994, 5/1/1996, 7/1/1997, 7/1/1998, 9/1/2002, 7/1/2005
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Rule 5160-3-39.1 | Nursing facilities (NFs): claim submission.
Effective:
February 1, 2023
(A) Nursing facilities shall submit
claims in accordance with rule 5160-1-19 of the Administrative Code. Additional
requirements specific to the submission of long-term care per diem claims are
in paragraphs (B) to (E) of this rule. (B) Additional requirements to be met
prior to submitting claims for services included in the per diem. (1) Individual is a
medicaid recipient for the dates of service. (2) Individual is not in
a restricted medicaid coverage period (RMCP). (3) Preadmission
screening and resident review (PASRR) is completed in accordance with rules
5160-3-15, 5160-3-15.1 and 5160-3-15.2 of the Administrative Code. (4) NF-based level of
care is completed in accordance with rules 5160-3-05, 5160-3-06, 5160-3-08, and
5160-3-14 of the Administrative Code. (C) Per diem claims must be submitted as
one claim per calendar month which includes all dates for which a medicaid
individual is considered a resident. All dates within the monthly claim are to
be identified as those eligible for medicaid reimbursement, per rule
5160-3-16.4 of the Administrative Code, or billed as non-covered days. Any
claim for less than the full month is limited to admission, discharge, death,
changes in payer, and hospice enrollment that occurs during the
month. (D) If a medicaid recipient in the NF has
a patient liability (PL) obligation as determined by the Ohio department of
medicaid or its designee, the amount of PL in accordance with rule 5160:1-6-07
of the Administrative Code, is to be reported by the NF on the
recipient's monthly claim. The PL will be applied as an offset against
the amount medicaid would otherwise reimburse for the claim. If the PL exceeds
the amount medicaid would reimburse, the claim will be processed with a payment
of zero dollars. (E) If an individual receives a lump-sum
and the county department of job and family services (CDJFS) and recipient
determine that the lump-sum is to be applied to past medicaid payments, the NF
provider must submit adjustment claims for as many prior months as are
necessary to fully offset the amount of the lump-sum.
Last updated February 1, 2023 at 8:53 AM
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Rule 5160-3-41 | Nursing facilities (NFs): placement into peer groups.
Effective:
September 22, 2018
(A) NF peer groups shall be assigned
according to sections 5165.16, 5165.17, and 5165.19 of the Revised Code based
on the provider's geographical location and the number of licensed beds
reported on the provider's annual cost report for the calendar year
preceding the fiscal year for which the rate is established. (1) For a provider new
to the medicaid program, the Ohio department of medicaid (ODM) shall initially
determine the number of beds in the facility from the number of licensed beds
documented in the provider's licensure application as verified by the Ohio
department of health (ODH). ODM shall subsequently determine the number of beds
in the facility from the number of licensed beds reported on the
provider's annual cost report. (2) In the case of a
change of operator, the entering operator shall be assigned to the peer group
that had previously been assigned to the exiting operator on the day
immediately preceding the date on which the change of operator occurred. ODM
shall subsequently determine the number of beds in the facility from the number
of licensed beds reported on the entering provider's annual cost
report. (B) No adjustment will be made to the
provider's placement in a peer group due to a change in bed size until the
first day of the fiscal year following the filing of an annual cost report that
reflects the change.
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Rule 5160-3-42 | Nursing facilities (NFs): chart of
accounts.
(A) The Ohio department of medicaid
(ODM) requires that all facilities file cost reports annually to comply with
section 5165.10 of the Revised Code. (1) The chart of
accounts in table 1 to table 8 of appendix A to this rule is to establish the
minimum level of detail to allow for cost report preparation. (2) If the chart of
accounts in appendix A to this rule is not used by the provider, it is the
responsibility of the provider to relate its chart of accounts directly to the
cost report. (3) Where a chart of
accounts number has sub-accounts that relate directly to a cost report line
item, the provider shall capture the information requested so that the
information will be broken out for cost reporting purposes. (4) For example, when
revenue accounts appear by payer type, it is required that those charges be
reported by payer type where applicable; when salary accounts are
differentiated between "supervisory" and "other," it is
required that this level of detail be reported on the cost report where
applicable. (B) While the chart of accounts
facilitates the level of detail necessary for medicaid cost reporting purposes,
providers may find it desirable or necessary to maintain their records in a
manner that allows for greater detail than is contained in the chart of
accounts in appendix A to this rule. (1) The chart of
accounts in appendix A to this rule allows for a range of account numbers for a
specified account. (2) For example, account
1001 is listed for petty cash, with the next account, cash, beginning at
account 1010. Therefore, a provider could delineate sub-accounts 1010-1,
1010-2, 1010-3, 1010-4, to 1010-9 as separate cash accounts. Providers need
only use the sub-accounts applicable for their facility. (C) Within the expense section (tables 5,
6, and 7), accounts identified as "salary" accounts are only to be
used to report wages for facility employees. (1) Wages are to include
wages for sick pay, vacation pay and other paid time off, as well as any other
compensation to be paid to the employee. (2) Expense accounts
identified as "contract" accounts are only to be used for reporting
the costs incurred for services performed by contracted personnel employed by
the facility to do a service that would otherwise be performed by personnel on
the facility's payroll. (3) Expense accounts
identified as "purchased nursing services" are only to be used for
reporting the costs incurred for personnel acquired through a nursing pool
agency. (4) Expense accounts
designated as "other" can be used for reporting any appropriate
nonwage expenses, including contract services and supplies. (D) Completion of the cost report as
required by section 5165.10 of the Revised Code will require that the number of
hours paid be reported (depending on facility type of control, on an accrual or
cash basis) for all salary expense accounts. Providers' record keeping
should include accumulating hours paid consistent with the salary accounts
included within the chart of accounts in appendix A to this rule.
View Appendix
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Rule 5160-3-42.3 | Nursing facilities (NFs): capital asset and depreciation guidelines.
Effective:
November 24, 2019
(A) Depreciation on buildings,
components, and equipment used in the provision of patient care that are not
reimbursable by medicaid directly to the medical equipment supplier may be paid
for through the NF per diem rate. (B) For purposes of determining if an
expenditure should be capitalized, NF providers are to refer to the centers for
medicare and medicaid services (CMS) publication 15-1, Chapter 1 entitled
"Depreciation," (December 15, 2011), available on the internet at
http://www.cms.gov/, and shall use the following guidelines: (1) Any expenditure for
an item that costs five thousand dollars or more and has a useful life of two
or more years per item must be capitalized and depreciated over the
asset's useful life. (2) A provider may use a
capitalization policy less than five thousand dollars per item, but is required
to obtain prior approval from the Ohio department of medicaid (ODM) if the
provider wishes to change its capitalization policy from its initial
capitalization policy. (C) All capital assets shall be
depreciated using the straight-line method of depreciation and salvage value
shall be used to adjust capital asset values when calculating
depreciation. (D) For purposes of determining the
useful life of a capital asset, NF providers shall use the guidelines in the
revised 2018 edition of the american hospital association (AHA) publication
entitled "Estimated Useful Lives of Depreciable Hospital Assets,"
which is available on the internet at http://www.aha.org/, or different useful
life guidelines if approved by ODM. If a capital asset is not reflected in
"Estimated Useful Lives of Depreciable Hospital Assets," internal
revenue service (IRS) publication 946 "How to Depreciate Property"
(rev. February 15, 2019), available on the internet at http://www.irs.gov/,
shall be used for purposes of determining the useful life of that capital
asset. (E) For newly acquired assets in the
month that a capital asset is placed into service, no depreciation expense is
recognized as an allowable expense. A full month's depreciation expense is
recognized in the month following the month the asset is placed into
service. (F) The disposal of assets shall be
accounted for as follows: (1) For assets not
acquired through a change in ownership, in the month that the capital asset is
disposed, if the capital asset is not fully depreciated, the allowable
depreciation expense is the historical cost of the asset less the accumulated
depreciation of the asset. At no time shall an asset be depreciated more than
its adjusted basis; or (2) For assets acquired
through a change in ownership, there shall be no recognition of the disposal of
individual assets. At the time of a subsequent change of ownership the disposal
of all assets acquired through a change of ownership shall be
recognized. (G) Providers shall maintain the
following property records: (1) For assets not
acquired through a change in ownership, detailed depreciation schedules listing
each asset acquired; or (2) For assets acquired
through a change in ownership: (a) Depreciation schedules on a lump sum basis for land,
building, and equipment; and (b) A list of all assets disposed after the change in ownership
with the applicable dates of disposal.
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Rule 5160-3-42.4 | Nursing facilities (NFs): non-reimbursable costs.
Effective:
August 31, 2017
The following costs are not reimbursable to NFs through the NF per diem, except as specified under Chapter 5160-3 of the Administrative Code. Non-reimbursable costs include but are not limited to: (A) Fines or penalties paid under sections 5165.1010, 5165.72 to 5165.77, 5165.83, and 5165.99 of the Revised Code. (B) Disallowances made during the audit of NF cost reports that are sanctioned through adjudication in accordance with Chapter 119. of the Revised Code. (C) Costs that exceed prudent buyer tests of reasonableness that may be applied pursuant to the provisions of the centers for medicare and medicaid services (CMS) publication 15-1 "Provider Reimbursement Manual" (rev. 9/28/15) during the audit of NF cost reports. (D) Costs of ancillary services rendered to NF residents by providers who bill medicaid directly. Ancillary services include but are not limited to physicians, legend drugs, radiology, and laboratory. (E) Costs per case-mix units in excess of the applicable peer group ceiling for direct care costs. (F) Expenses in excess of the capital costs limitations. (G) Expenses associated with lawsuits filed against the Ohio department of medicaid (ODM) that are not upheld by the courts. (H) Costs of meals sold to visitors or the public (e.g., meals on wheels). (I) Costs of supplies or services sold to nonfacility residents or the public. (J) Costs of operating a gift shop.
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Rule 5160-3-43.1 | Nursing facilities (NFs): case mix assessment instrument - minimum data set version 3.0 (MDS 3.0).
(A) As used in this rule: (1) "Annual facility
average case mix score" is the score used to calculate the facility's
cost per case-mix unit. (2) "Assessment
reference date (ARD)" is the last day of the observation (or "look
back") period that the MDS 3.0 assessment covers for the
resident. (3) "Case mix report" is a
report generated by the Ohio department of medicaid (ODM) and distributed to
the provider on the status of all MDS 3.0 assessment data that pertains to the
calculation of a quarterly, semiannual, or annual facility average case mix
score. (4) "Comprehensive assessment"
means an assessment that includes completion of the appropriate MDS 3.0
assessment type listed in paragraph (B)(2) of this rule. (5) "Critical elements" are
data items from a resident's MDS 3.0 that ODM verifies prior to
determining a resident's resource utilization group (RUG)
classification. (6) "Critical errors" are
errors in the MDS 3.0 critical elements that prevent ODM from determining the
resident's RUG classification. (7) "Default group" is the case
mix group assigned to residents with MDS 3.0 records with inconsistent date
fields, missing, incomplete, out of range, or inaccurate data, including
inaccurate resident identifiers, any of which precludes grouping the record
into non-default RUG groups. (8) "Encoded," when used with
reference to a record, means that the record has been recorded in electronic
format. The record must be encoded in accordance with MDS 3.0 data submission
specifications version 1.15.0. (9) "Filing date" is the
deadline for submission of the NF's MDS 3.0 assessment data that will be
used to calculate the preliminary facility quarterly average case mix score.
The filing date is the fifteenth calendar day following the reporting period
end date (RPED). (10) "MDS 3.0"
is the uniform resident assessment instrument specified for use in Ohio
pursuant to 42 C.F.R. 483.20 (October 1, 2014) for implementing standardized
resident assessments and for facilitating care management in nursing
facilities. The MDS 3.0 provides the core data elements used to group residents
into case mix categories. It also includes Ohio-specific data elements,
designated as section S. A copy of the section S requirements is available at
http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTerm
CareFacilities.aspx. (11) "Medicare
required assessment" means the MDS 3.0 that is required only for
facilities participating in the medicare prospective payment
system. (12) "Other medicare required
assessment (OMRA)" is an unscheduled MDS 3.0 prospective payment system
(PPS) assessment required to be completed during a resident's medicare
"Part A" SNF covered stay based on the start or cessation of
rehabilitation services. (13) "PPS assessment" is the MDS
3.0 that skilled nursing facilities (SNFs) use to assess the clinical condition
for each medicare resident receiving "Part A" SNF level care for
reimbursement under the SNF PPS. (14) "Quarterly facility average
total case mix score" is the facility average case mix score based on both
medicaid and non-medicaid resident data submitted for one reporting quarter and
calculated pursuant to paragraph (B)(1) of rule 5160-3-43.3 of the
Administrative Code. (15) "Quarterly facility average
medicaid case mix score" is the facility average case mix score based on
only medicaid resident data submitted for one reporting quarter and calculated
pursuant to paragraph (B)(2) of rule 5160-3-43.3 of the Administrative
Code. (16) "Quarterly review
assessment" means an assessment that is normally conducted no less than
once every three months using the MDS 3.0. (17) "Record" means a
resident's encoded MDS 3.0 assessment as described in paragraphs (B)(1) to
(B)(4) of this rule. (18) "Relative resource weight"
is the measure of the relative costliness of caring for residents in one case
mix group versus another, indicating the relative amount and cost of staff time
required on average for defined worker classifications to care for residents in
a single case mix group. The methodology for calculating relative resource
weights is described in paragraph (E) of rule 5160-3-43.2 of the Administrative
Code. (19) "Reporting period end date"
(RPED) is the last day of each calendar quarter. (20) "Reporting quarter" is the
calendar quarter in which the MDS 3.0 is completed, as indicated by the
assessment reference date in MDS 3.0 section A, item A2300, except as specified
in paragraphs (C)(7) and (C)(8) of this rule. (21) "Resident Assessment Instrument
(RAI)" is the MDS 3.0 used by NFs in Ohio to comply with regulations in 42
C.F.R. 483.20. (22) "Resident case mix score"
is the relative resource weight for the RUG group to which the resident is
assigned based on data elements from the resident's MDS 3.0
assessment. (23) "Resident identifier code"
is an alternative resident identifier if the resident does not have a social
security number. The resident identifier code shall be reported in MDS 3.0
section S, item S0150. The following method must be used to construct the
identifier code: (a) In the first three boxes, enter the first three letters
of the resident's last name. (b) In the next six boxes, enter the six digits of the
resident's date of birth. (c) Omit the century in the birth date. (24) "RUG" is the resource
utilization groups system of classifying NF residents described in paragraph
(B) of rule 5160-3-43.2 of the Administrative Code. Resource utilization groups
are clusters of NF residents defined by resident characteristics that correlate
with resource use. (a) For rates paid for services provided before July 1,
2016, the RUG version used in Ohio is version III (RUG III). (b) For rates paid for services provided July 1, 2016 and
thereafter, the RUG version used in Ohio shall be version IV (RUG
IV). (25) "Semiannual facility average
medicaid case mix score" is the average of a facility's two quarterly
facility average medicaid case mix scores. It is used to establish the direct
care rate and is calculated pursuant to paragraph (E) of rule 5160-3-43.3 of
the Administrative Code. (B) For the purpose of assigning a RUG
classification for determining medicaid payment rates for NFs, ODM shall
utilize the data from the MDS 3.0. Each NF shall assess all residents of
medicaid-certified beds using the appropriate MDS 3.0. When the assessment
coincides with medicare assessment time frames, one assessment shall be used to
satisfy both assessments. Admission assessments must be combined with either
the medicare five day or medicare fourteen day assessment. For a resident who
is not a new admission to the facility, the quarterly, annual, and significant
change in status assessments must be combined with any medicare assessment if
the assessment reference date (ARD) is within the assigned medicare observation
period. When combining the assessments, the most stringent requirement for MDS
completion must be met. ODM may not utilize the data in the other medicare
required assessments (OMRAs) for calculating case mix scores or determining
medicaid payment rates. (1) Comprehensive
assessments, medicare-required assessments, quarterly review assessments, and
significant corrections of quarterly assessments must be conducted in
accordance with the requirements and frequency schedule found at 42 C.F.R.
483.20. (2) For a comprehensive
assessment, NFs must use the MDS 3.0, including section S. The comprehensive
assessment is completed as specified in the MDS 3.0 RAI manual. NFs must use
the quarterly MDS 3.0, including section S, for the quarterly review assessment
or a significant correction to a prior quarterly assessment. The nursing home
PPS assessment must be used for all medicare required assessments. (3) NFs must use the MDS
3.0 discharge item set for any residents who transfer or are discharged, and
the MDS 3.0 tracking record for any residents entering or reentering or who
died in the facility in accordance with 42 C.F.R. 483.20. (4) NFs must use the MDS
correction request in section X of the MDS 3.0 for modification or inactivation
of MDS records that have been accepted into the CMS database. (C) All NFs must submit to the CMS
database encoded, accurate, and complete MDS 3.0 data for all residents of
medicaid certified NF beds, regardless of pay source or anticipated length of
stay. (1) MDS 3.0 data
completed in accordance with paragraphs (B)(1) to (B)(4) of this rule must be
encoded in accordance with MDS 3.0 data submission specifications version
1.15.0. (2) MDS 3.0 data must be
encoded. The data may be submitted at any time during the reporting quarter
that is permitted by instructions in the MDS 3.0 RAI manual. Except as provided
in paragraph (D) of this rule, all records used in determining the quarterly
facility average total case mix score and quarterly facility average medicaid
case mix score must be submitted by the filing date. (3) If a NF submits MDS
3.0 data needed for determining the quarterly facility average total case mix
score and quarterly facility average medicaid case mix score after the
forty-fifth day after the RPED, ODM may assign a quarterly facility average
total case mix score as set forth in paragraph (C)(3) of rule 5160-3-43.3 of
the Administrative Code and a quarterly facility average medicaid case mix
score as set forth in paragraph (D)(4) of rule 5160-3-43.3 of the
Administrative Code. (4) MDS 3.0 data
submitted by a provider that can not be timely extracted by ODM from the CMS
data server may result in assignment of a quarterly facility average total case
mix score as set forth in paragraph (C)(3) of rule 5160-3-43.3 of the
Administrative Code and a quarterly facility average medicaid case mix score as
set forth in paragraph (D)(4) of rule 5160-3-43.3 of the Administrative
Code. (5) The annual facility
average case mix score, quarterly facility average total case mix score, and
quarterly and semiannual facility average medicaid case mix scores will be
calculated using the MDS 3.0 record in effect on the RPED for: (a) Residents who were admitted to the medicaid certified NF
prior to the RPED and continue to be physically present in the NF on the RPED;
and (b) Residents who were admitted to the medicaid certified NF on
the RPED; and (c) Residents who were temporarily absent on the RPED but are
considered residents and for whom a return is anticipated from hospital stays,
visits with friends or relatives, or participation in therapeutic programs
outside the facility. (6) Records for residents
who were permanently discharged from the NF, transferred to another NF, or
expired prior to or on the RPED will not be used for determining the quarterly
facility average total case mix score and quarterly facility average medicaid
case mix score. (7) For a resident
admitted within fourteen days prior to the RPED, and whose initial assessment
is not due until after the RPED, both of the following shall
apply: (a) The NF shall submit the appropriate initial assessment as
specified in 42 C.F.R. 483.20 and in the MDS 3.0 RAI manual. (b) The initial assessment, if completed and submitted timely in
accordance with paragraphs (C)(1) and (C)(2) of this rule, shall be used for
determining the quarterly facility average total case mix score and may be used
for determining the quarterly facility average medicaid case mix score in the
quarter the resident entered the facility even if the assessment reference date
is after the RPED provided the record is identified as a medicaid record
pursuant to the calculation methodology in rule 5160-3-43.3 of the
Administrative Code. (8) For a resident who
had at least one MDS 3.0 assessment completed before being transferred to a
hospital, then reenters the NF within fourteen days prior to the RPED, and has
experienced a significant change in status that requires a comprehensive
assessment upon reentry, the following shall apply: (a) The NF shall submit a significant change assessment within
fourteen days of reentry, as indicated by the MDS 3.0 assessment reference date
(MDS 3.0, item A2300). (b) The significant change assessment shall be used for
determining the quarterly facility average total case mix score and may be used
for determining the quarterly facility average medicaid case mix score for the
quarter in which the resident reentered the facility even if the assessment
reference date is after the RPED provided the record is identified as a
medicaid record pursuant to the calculation methodology in rule 5160-3-43.3 of
the Administrative Code. (D) Corrections to MDS 3.0 data must be
made in accordance with the requirements in the MDS 3.0 RAI
manual. (1) For use in
determining the quarterly facility average total case mix score and quarterly
facility average medicaid case mix score, the facility must transmit the
corrections to the CMS database no later than forty-five days after the
RPED. (2) For use in
determining the quarterly facility average total case mix score and quarterly
facility average medicaid case mix score, all significant correction
assessments must contain an assessment reference date within the reporting
quarter. (3) The provider shall
submit an accurate, encoded MDS 3.0 record for each resident in a medicaid
certified bed on the RPED. (a) The provider shall transmit MDS assessments that were
completed timely but omitted from the previous transmissions and ODM shall use
the resident case mix scores from the assessments for determining the quarterly
facility average total case mix score, and may use them for determining the
quarterly facility average medicaid case mix score if the assessments are
transmitted no later than forty-five days after the RPED provided the record is
identified as a medicaid record pursuant to the calculation methodology in rule
5160-3-43.3 of the Administrative Code. If the assessments are not transmitted
within forty-five days after the RPED, ODM may assign a default group for those
records. (b) The provider shall notify ODM within forty-five days of the
RPED of any records for residents in medicaid certified beds on the RPED that
were not completed timely and were not transmitted to the CMS database. ODM may
assign default scores to those records. (c) The provider has forty-five days after the RPED to transmit
the appropriate discharge assessment to the CMS database if more residents are
determined to be in the facility on the RPED than the number of medicaid
certified beds in the facility on that same date. If the facility does not
correct the error within forty-five days after the RPED, ODM may assign a
quarterly facility average total case mix score as specified in paragraph
(C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly facility
average medicaid case mix score as specified in paragraph (D)(4) of rule
5160-3-43.3 of the Administrative Code. (d) The provider shall notify ODM within forty-five days of the
RPED of any residents who were reported to be residents of the facility on the
RPED, but who had actually been discharged prior to the RPED. If the provider
fails to correct the error within forty-five days after the RPED, ODM may
assign a quarterly facility average total case mix score as specified in
paragraph (C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly
facility average medicaid case mix score as specified in paragraph (D)(4) of
rule 5160-3-43.3 of the Administrative Code. (e) The provider has forty-five days after the RPED to submit
appropriate modifications or discharge assessments to rectify any discrepancy
between the records selected for determining the quarterly facility average
total case mix score and the facility census on the RPED. If the facility does
not correct the error(s) within forty-five days after the RPED, ODM may assign
a quarterly facility average total case mix score as specified in paragraph
(C)(3) of rule 5160-3-43.3 of the Administrative Code and a quarterly facility
average medicaid case mix score as specified in paragraph (D)(4) of rule
5160-3-43.3 of the Administrative Code. (4) If the
provider's number of records assigned to the default group in accordance
with paragraphs (D)(3)(a) and (D)(3)(b) of this rule is greater than ten per
cent, ODM may assign a quarterly facility average total case mix score as
specified in paragraph (C)(3) of rule 5160-3-43.3 of the Administrative Code
and a quarterly facility average medicaid case mix score as specified in
paragraph (D)(4) of rule 5160-3-43.3 of the Administrative Code.
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Rule 5160-3-43.2 | Nursing facilities (NFs): case mix classification system - resource utilization groups (RUG).
The Ohio department of medicaid (ODM) shall pay
each eligible NF a per resident per day rate for direct care costs established
prospectively for each facility. The department shall establish each
facility's rate for direct care costs semiannually. Each facility's
rate for direct care costs shall be based on a case mix payment system. (A) The Ohio medicaid case mix payment system for direct care
contains the following core components: (1) As set forth in rule 5160-3-43.1 of the
Administrative Code, a uniform resident assessment instrument (minimum data set
version 3.0 (MDS 3.0)), that provides the data used to group residents into
case mix categories. The MDS 3.0 includes section S. Information regarding
section S is available on the ODM website at
http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/
LongTermCareFacilities.aspx. (2) A methodology for grouping residents into
case mix groups in a way that is clinically meaningful and uses criteria that
sufficiently differentiates one group from another, as provided in paragraphs
(B) to (E) of this rule. (3) A means of measuring the relative costliness
of caring for residents in one group versus another, known as "relative
resource weights," as described in paragraph (D) of this
rule. (B) The Ohio case mix payment system shall use the following
methodologies for grouping residents: (1) For rates paid for services provided before
July 1, 2016, resource utilization groups version III (RUG III) classification
system. The RUG III major categories listed in paragraph (C) of rule this rule
are listed in descending order of hierarchy. Based on the items in the MDS 3.0,
if a resident meets the criteria for placement in more than one group, the
resident will be placed in a group within the highest major category of
resident types according to the hierarchy unless the activities of daily living
(ADL) index score is not met for placement within the highest major category of
resident types. (2) For rates paid for services provided July 1,
2016 and thereafter, resource utilization groups version IV (RUG IV)
classification system. The RUG IV major categories listed in paragraph (C) of
this rule are listed in descending order of hierarchy. Based on the items in
the MDS 3.0, if a resident meets the criteria for placement in more than one
group, the resident will be placed in a group according to the
hierarchy. (3) ODM will use the forty-five grouper model
with the RUG III methodology. (4) ODM will use one of the following grouper models with the RUG
IV methodology: (a) Forty-eight grouper
model. (b) Fifty-seven grouper
model. (c) Sixty-six grouper
model. (C) The hierarchy of RUG major categories in descending order is
as follows: (1) RUG III using the forty-five grouper
model: (a) Extensive
services. (b) Special
rehabilitation. (c) Special
care. (d) Clinically
complex. (e) Impaired
cognition. (f) Behavior
problems. (g) Reduced physical
function. (2) RUG IV using the forty-eight, fifty-seven, or
sixty-six grouper model: (a) Rehabilitation plus
extensive services (sixty-six grouper model only). (b) Rehabilitation. (c) Extensive
services. (d) Special care
high. (e) Special care
low. (f) Clinically
complex. (g) Behavioral symptoms and
cognitive performance. (h) Reduced physical
function. (D) All MDS 3.0 data
elements related to the RUG classification system must be completed before a
resident can be classified. Residents whose MDS 3.0 forms contain missing or
out-of-range responses to data elements used to determine the RUG
classification shall be assigned to the default group. Corrections to MDS 3.0
data may be made only as described in paragraph (D) of rule 5160-3-43.1 of the
Administrative Code. (E) Each of the RUG groups
is assigned a relative resource weight. This weight indicates the relative
amount of staff time required on average for workers in the registered nurse
(RN), licensed practical nurse (LPN), and nurse aide (NA) worker
classifications to deliver care to residents in that RUG group. (1) The relative resource weights are calculated
as follows using the average minutes per worker classification per RUG group
provided by the United States department of health and human services (HHS),
and the most recent available three-year averages of RN, LPN, and NA wages in
Ohio medicaid certified NFs as reported in annual medicaid cost reports
submitted by providers to ODM pursuant to section 5165.10 of the Revised
Code. (a) By setting the NA wage
weight at one, wage weights for RNs and LPNs are calculated by dividing the NA
wage into the RN or LPN wage. (b) To calculate the total
weighted minutes for each RUG group, the wage weight for each worker
classification is multiplied by the average number of minutes that
classification of workers spends caring for a resident in the RUG group, and
then the products for each RUG group are summed. (c) Relative resource
weights are calculated by dividing the lowest group's total weighted
minutes into each group's total weighted minutes. Weight calculations are
rounded to the fourth decimal place. The RUG group with the lowest total
weighted minutes receives a relative resource weight of one. (2) The lowest weight for the RUG groups is used
as the weight for the default group. (3) Relative resource weights are set forth on the ODM website at
http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities
.aspx.
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Rule 5160-3-43.3 | Nursing facilities (NFs): calculation of case mix scores.
Effective:
December 31, 2020
(A) The definitions of all terms used in
this rule are the same as set forth in rules 5160-3-01, 5160-3-43.1, and
5160-3-43.4 of the Administrative Code. (B) To determine resident case mix
scores, the Ohio department of medicaid (ODM) shall process resident assessment
data submitted by NFs in accordance with rule 5160-3-43.1 of the Administrative
Code, and shall classify residents in accordance with rule 5160-3-43.2 of the
Administrative Code. These resident case mix scores, based on relative resource
weights calculated in accordance with rule 5160-3-43.2 of the Administrative
Code, are used to establish two quarterly facility average case mix scores each
quarter. (1) The first quarterly
facility average case mix score shall be calculated using all records selected
for the quarter and shall be the quarterly facility average total case mix
score. (2) The second quarterly
facility average case mix score shall be calculated using only the records
selected for the quarter that ODM identifies as medicaid records and shall be
the quarterly facility average medicaid case mix score. (C) ODM shall calculate a quarterly
facility average total case mix score for all providers meeting the following
requirements: (1) In accordance with
rule 5160-3-43.1 of the Administrative Code, the provider submitted resident
assessment information by the filing date, and the data included resident
assessments for all residents in medicaid certified beds as of the reporting
period end date, and (a) The provider's resident assessment data submitted timely
for that reporting quarter provided sufficient information for accurately
classifying at least ninety per cent of all residents in medicaid certified
beds into RUG non-default groups, or (b) The provider's resident assessment data submitted timely
and corrected timely, in accordance with the procedures outlined in rule
5160-3-43.1 of the Administrative Code for correcting incomplete or inaccurate
information, for that reporting quarter, provided sufficient information for
accurately classifying at least ninety per cent of all residents in medicaid
certified beds into RUG non-default groups; and (c) There were no errors that prevented ODM from verifying the
records to be used in determining the quarterly facility average total case mix
score. (d) The prospective payment system (PPS) other medicare required
assessments (OMRAs) may not be selected for calculating case mix
scores. (2) The quarterly
facility average total case mix score for providers that submitted their
minimum data set version 3.0 (MDS 3.0) data in compliance with paragraph (C)(1)
of this rule shall be calculated as follows: (a) All resident case mix scores for the quarter, including
resident case mix scores in the RUG default group, are added together;
then (b) The sum of resident case mix scores is divided by the total
number of residents. (3) If a provider does
not comply with paragraph (C)(1) of this rule, ODM may assign the NF a penalty
score. If assigned, the penalty score for the quarterly facility average total
case mix score shall be a score that is five per cent less than the quarterly
facility average total case mix score for the preceding calendar
quarter. (a) If the facility was subject to an exception review for the
preceding quarter in accordance with rule 5160-3-43.4 of the Administrative
Code, the assigned quarterly facility average total case mix score shall be the
score that is five per cent less than the score determined by the exception
review. (b) If the facility was assigned a quarterly facility average
total case mix score for the preceding calendar quarter, the assigned quarterly
facility average total case mix score shall be the score that is five per cent
less than the score assigned for the preceding quarter. (D) ODM shall calculate a quarterly
facility average medicaid case mix score for all providers meeting the
following requirements: (1) The provider's
resident assessment data submitted timely for that reporting quarter provided
sufficient information for classifying at least ninety per cent of records
identified as medicaid records into RUG non-default groups, or (a) The provider's resident assessment data submitted timely
and corrected timely in accordance with the procedure outlined in rule
5160-3-43.1 of the Administrative Code for correcting incomplete or inaccurate
information for that reporting quarter, provided sufficient information for
accurately classifying at least ninety per cent of all residents into RUG
non-default groups; and (b) There were no errors that prevented ODM from verifying the
records to be used in determining the quarterly facility average medicaid case
mix score. (2) ODM shall identify a
MDS 3.0 assessment as a medicaid record if the MDS 3.0 assessment meets the
following requirements: (a) The MDS 3.0 assessment is not completed to meet the
requirements for a medicare part A stay. (b) The social security number (SSN) on the MDS 3.0 assessment
matches a SSN on the medicaid recipient master file (RMF) (c) The assessment reference date (ARD) on the MDS 3.0 assessment
falls within the recipient's medicaid eligibility span. (3) The quarterly
facility average medicaid case mix score for providers that submitted their MDS
3.0 data in compliance with paragraph (C)(1) of this rule shall be calculated
as follows: (a) Medicaid resident case mix scores for the quarter, including
resident case mix scores in the RUG default group, are added together;
then (b) The sum of medicaid resident case mix scores is divided by
the total number of medicaid residents. (4) If a provider does
not comply with paragraph (D)(1) of this rule, ODM may assign the NF a penalty
score. If assigned, the penalty score for the quarterly facility average
medicaid case mix score shall be a score that is five per cent less than the
quarterly facility average medicaid case mix score for the preceding calendar
quarter. (a) If the facility was subject to an exception review for the
preceding quarter in accordance with rule 5160-3-43.4 of the Administrative
Code, the assigned quarterly facility average medicaid case mix score shall be
the score that is five per cent less than the score determined by the exception
review. (b) If the facility was assigned a quarterly facility average
medicaid case mix score for the preceding calendar quarter, the assigned
quarterly facility average medicaid case mix score shall be the score that is
five per cent less than the score assigned for the preceding
quarter. (5) ODM may use a
facility's assigned penalty score to calculate the semiannual facility
average medicaid case mix score. (E) ODM shall calculate the semiannual
facility average medicaid case mix score as follows: (1) The semiannual
facility average medicaid case mix score for the payment period beginning the
first day of July for a given fiscal year shall be the average of the quarterly
facility average medicaid case mix score from the preceding December and March
reporting quarters. If a facility does not have a quarterly facility average
medicaid case mix score for both the December and March reporting quarters, the
median annual facility average case mix score for the NF's peer group
shall be assigned as the semiannual facility average medicaid case mix score to
determine the direct care rate. (2) The semiannual
facility average medicaid case mix score for the payment period beginning the
first day of January for a given fiscal year shall be the average of the
quarterly facility average medicaid case mix score from the preceding June and
September reporting quarters. If a facility does not have a quarterly facility
average medicaid case mix score for both the June and September reporting
quarters, the median annual facility average case mix score for the NF's
peer group shall be assigned as the semiannual facility average medicaid case
mix score to determine the direct care rate. (F) ODM shall calculate the annual
facility average case mix score as follows: (1) The annual facility
average case mix score shall be calculated only for facilities with at least
two quarterly facility average total case mix scores meeting the requirements
of paragraphs (C)(1) and (C)(2) of this rule. In addition, for any score
meeting the requirements of paragraphs (C)(1) and (C)(2) that was adjusted, the
adjusted score will be substituted according to the following
hierarchy: (a) Adjusted quarterly facility average total case mix scores
established by a rate reconsideration decision resulting from an exception
review of resident assessment information conducted before the effective date
of the rate; or (b) Adjusted quarterly facility average total case mix scores as
a result of exception review findings. (2) If ODM assigned a
facility a quarterly facility average total case mix score in accordance with
paragraph (C)(3) of this rule, the assigned score will not be used to calculate
the provider's annual facility average case mix score. (3) The qualifying case
mix scores shall be summed and divided by the total number of quarters of
qualifying scores to arrive at the annual facility average case mix
score. (G) For each provider that submits MDS
3.0 data in a given week, ODM shall send the "Case Mix Report"
containing the following four components: (1) The "Provider
Detail Listing of Successfully Grouped Records," which identifies records
that were successfully grouped by ODM. The report will include all records
received, even if the records will not be used in the quarterly score
calculation. (2) The "Critical
Error Summary," which identifies the records that will be assigned into
the default group unless they are corrected before the end of the reporting
quarter in accordance with rule 5160-3-43.1 of the Administrative
Code. (3) The "Provider
Detail Listing of Records with Critical Errors," which provides detail for
each record listed on the "Critical Error Summary" identifying the
failed edits. (4) The "Discharge
and Reentry Tracking Form Summary," which identifies all discharge
assessments and reentry tracking forms that were received by ODM. (H) ODM shall provide two preliminary
"Calculation of Facility Case Mix Scores" reports. The first report
will reflect records submitted up to the quarterly filing date. The second
report will reflect records submitted up to approximately two weeks prior to
the quarterly corrections deadline. Both reports will include a calculation of
the quarterly facility average total case mix score and the quarterly facility
average medicaid case mix score. Providers may file corrections to the extent
permitted by rule 5160-3-43.1 of the Administrative Code. (I) After the quarterly corrections
deadline specified in rule 5160-3-43.1 of the Administrative Code, ODM shall
provide a final "Calculation of Facility Case Mix Scores" report. The
report will include a calculation of the quarterly facility average total case
mix score and the quarterly facility average medicaid case mix
score. (J) Following the determination of the
two quarterly facility average medicaid case mix scores used to calculate the
semiannual facility average medicaid case mix scores effective July first and
January first of the fiscal year, ODM shall provide a "Semiannual Medicaid
Case Mix Score Calculation Report" to each provider. (K) Following the calculation of the
annual facility average case mix score, ODM shall provide an "Annual
Facility Average Case Mix Score Calculation Report" to each
provider.
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Rule 5160-3-43.4 | Nursing facilities (NFs): exception review process.
(A) The definitions of all terms not
defined in this rule are the same as set forth in rules 5160-3-01 and
5160-3-43.1 of the Administrative Code. (1) "Combination
review" is a type of exception review where the Ohio department of
medicaid (ODM) reviews records selected in one of the following
ways: (a) A combination of records selected pursuant to random and
targeted criteria. (b) Records initially selected for a targeted review, but
insufficient records were available to meet the targeted review sample size
requirements, combined with randomly selected records to complete the sample
size. (c) Records initially selected for a random review, combined with
records selected for a targeted review as a result of findings of the random
review. (2) "Effective date
of the rate" is either the first day of July or January for a given fiscal
year. (3) "Exception review" is a
review of minimum data set (MDS) assessment data. It is conducted at selected
NFs by registered nurses and other appropriate licensed or certified health
professionals as determined by ODM who are employed by or under contract with
ODM. The purpose of an exception review is to identify any patterns or trends
related to resident assessments submitted in accordance with rule 5160-3-43.1
of the Administrative Code that could result in inaccurate case mix scores used
to calculate the direct care component of the nursing facility per diem rate.
Exception reviews shall be conducted in accordance with section 5165.193 of the
Revised Code. (4) "Exception
review tolerance level" is the level of variance between the facility and
ODM in MDS assessment item responses affecting the resource utilization groups
(RUG) classification of a facility's residents. Two kinds of tolerance
levels have been established for exception reviews: initial sample tolerance
level, and expanded review tolerance level. (a) "Initial sample tolerance level" is the percentage
of unverifiable records found during the initial sample of an exception review,
below which no further review will be pursued for the same six month period.
The initial sample tolerance level shall be less than fifteen per cent of the
entire sample. (b) "Expanded review tolerance level" is an acceptable
level of variance in the calculation of a provider's quarterly facility
average medicaid case mix score or an acceptable per cent of the records
sampled at exception review that were unverifiable. (5) "Random
review" is a type of exception review that examines randomly selected
records from any of the RUG major categories listed in paragraph (C) of rule
5160-3-43.2 of the Administrative Code. (6) "Targeted review" is a type
of exception review that targets records in restorative nursing programs,
current toileting program or trial, and/or bowel toileting program, clinically
complex with depression, or one or more of the RUG major categories listed in
paragraph (C) of rule 5160-3-43,2 of the Administrative Code. (7) The "variance" is the
percentage difference between the quarterly facility average medicaid case mix
score based on exception review findings and the quarterly facility average
medicaid case mix score from the provider's submitted MDS
records. (a) The exception review tolerance level shall be either less
than a two per cent variance between the quarterly facility average medicaid
case mix score based on exception review findings and the quarterly facility
average medicaid case mix score from the provider's submitted MDS records
or less than twenty per cent of the medicaid records sampled at exception
review were unverifiable. (b) The variance calculation will not recognize modifications to
MDS assessments and new assessments following an inactivation, submitted by the
facility after notification of the exception review. (8) A "verifiable MDS record"
is a provider's completed MDS assessment form, based on facility supplied
MDS assessment data submitted to ODM for a resident for a specific reporting
quarter, which upon examination by ODM during an exception review has been
determined to accurately represent the aspects of the resident's condition
that affect the correct RUG classification of that record during the specified
assessment time frame. (9) An "unverifiable MDS
record" is a provider's completed MDS assessment form, based on
facility supplied MDS assessment data, submitted to ODM for a resident for a
specific reporting quarter which, upon examination by ODM, has been determined
to inaccurately represent the aspects of the resident's condition that
affect the RUG classification of that record during the specified assessment
time frame. MDS coding may be deemed unsupported if inconsistencies are found
in the sources of information through verification activities. (B) All exception reviews will comply
with the applicable provisions of the medicare and medicaid
programs. (C) Providers may be selected for an
exception review by ODM based on any of the following: (1) The findings of a
certification survey conducted by the Ohio department of health (ODH) that may
indicate that the facility is not accurately assessing residents, which may
result in the resident's inaccurate classification into the RUG
system. (2) A risk analysis
profile that may include, but is not limited to, one or more of the
following: (a) A change in the frequency distribution of residents who
receive nursing rehabilitation/restorative care in accordance with section O of
the minimum data set version 3.0 (MDS 3.0), or who meet the RUG criteria for
depression in accordance with section D of the MDS 3.0. (b) The frequency distribution of residents who receive nursing
rehabilitation/restorative care in accordance with section O of the MDS 3.0, or
who meet the RUG criteria for depression in accordance with section D of the
MDS 3.0 exceeds statewide averages. (c) A sudden or drastic change in the quarterly facility average
total case mix score or the quarterly facility average medicaid case mix
score. (d) A change in the frequency distribution of coded responses to
a MDS item. (3) Prior resident
assessment performance of the provider, may include, but is not limited to,
ongoing problems with assessment submission deadlines, error rates, incorrect
assessment dates, and apparent unchanged assessment practice(s) following a
previous exception review. (D) Exception reviews shall be conducted
at the facility by registered nurses and other licensed or certified health
professionals as determined by ODM who are under contract with or employed by
ODM. When a team of reviewers conducts an on-site exception review, the team
shall be led by a registered nurse. Persons conducting exception reviews on
behalf of ODM shall meet the following conditions: (1) During the period of
their professional employment or contract with ODM, whichever is applicable,
reviewers must neither have nor be committed to acquire any direct or indirect
financial interest in the ownership, financing, or operation of a NF for which
they conduct an exception review. Employment of a member of a reviewer's
family by a provider at which the reviewer does not conduct an exception review
does not constitute a direct or indirect financial interest in the ownership,
financing, or operation of the provider on the part of the
reviewer. (2) Reviewers shall not
conduct an exception review at any facility where a member of their family is a
current resident. (3) Reviewers shall not
conduct an exception review at any facility that has been a client of the
reviewer within the past twenty-four months. (4) Reviewers shall not conduct an
exception review at any facility that has been an employer of the reviewer
within the past twenty-four months. (E) Prior notice: ODM shall notify the
provider by telephone at least two working days prior to the
review. (F) Providers selected for exception
reviews must provide reviewers with reasonable access to residents,
professional and nonlicensed direct care staff, the facility assessors, and
completed resident assessment instruments and supporting documentation
regarding the residents' care needs and treatments. Providers must also
provide ODM with sufficient information to be able to contact the
resident's attending or consulting physicians, other professionals from
all disciplines who have observed, evaluated, or treated the resident, such as
contracted therapists, and the resident's family or significant others.
These sources of information may help to validate information provided on the
resident assessment instrument submitted to ODM. Verification activities may
include reviewing resident assessment forms and supporting documentation,
conducting interviews with staff knowledgeable about the resident during the
observation period for the MDS, and observing residents. (G) An exception review shall be
conducted of a random, targeted, or a combination of random and targeted
samples of completed resident assessment instruments. The initial sample size
shall be greater than or equal to the minimum sample size. The expanded sample
size is based on the initial sample findings. Sample sizes are available on the
ODM website at http://medicaid.ohio. gov/PROVIDERS/ProviderTypes/LongTermCare
Facilities.aspx. (H) Results from review of the initial
sample shall be used to decide if further action by ODM is warranted. If the
initial sample is to be expanded for further review, ODM reviewers shall hold a
conference with facility representatives advising them of the next steps of the
review and discussing the initial sample findings. If the sample of reviewed
records exceeds the initial sample tolerance level described in paragraph
(A)(4)(a) of this rule, ODM may subsequently expand the exception review
process as follows: (1) If the initial sample
was a targeted review, the expanded sample size shall be the lesser of the
remaining records in the targeted category or the applicable minimum expanded
sample size. (2) If the initial sample
was a random review that became a targeted review, the expanded sample shall be
the lesser of the remaining records in the targeted category or the applicable
minimum expanded sample size. (3) If the initial sample
was a random review, the expanded sample size shall be at least the applicable
minimum sample size. (4) If the initial sample
was a combination review, the expanded sample size shall be at least the
applicable minimum sample size. The expanded sample may consist of the
remaining records in the targeted and random categories. (5) If the expanded
review tolerance level is exceeded, ODM may subsequently expand the sample size
for the same reporting quarter up to and including one hundred per cent of the
records and continue the review process. (I) At the conclusion of the on-site
portion of the exception review process, reviewers shall hold an exit
conference with facility representatives. Reviewers will share preliminary
findings and/or concerns about verification or failure to verify RUG
classification for reviewed records. Reviewers will give provider
representatives one written preliminary copy of the exception review findings
indicating whether the facility was under or over the established tolerance
levels. (J) All exception reviews shall include a
final written summary of the exception review findings, including the final
facility tolerance level calculations as well as the revised quarterly facility
average total case mix score and the revised quarterly facility average
medicaid case mix score. ODM shall mail a copy of the final written summary to
the provider. (K) All exception review reports shall be
retained by ODM for at least six years. (L) If the expanded review tolerance
level is exceeded, ODM shall use the exception review findings to calculate or
recalculate resident case mix scores, quarterly facility average total case mix
scores, quarterly and semiannual facility average medicaid case mix scores, and
annual facility average case mix scores. Calculations or recalculations shall
apply only to records actually reviewed by ODM and shall not be based on
extrapolations to unreviewed records of findings from reviewed records. For
example, ODM shall recalculate the quarterly facility average total case mix
score and quarterly facility average medicaid case mix score by replacing
resident case mix scores of reviewed records and not changing the resident case
mix scores of unreviewed records. (M) ODM shall use the quarterly facility
average total case mix score, quarterly and semiannual facility average
medicaid case mix scores, and annual facility average case mix score based on
exception review findings that exceed the exception review tolerance level to
calculate or recalculate the facility's rate for direct care costs for the
appropriate six month period(s). However, scores recalculated based on
exception review findings shall not be used to override any assignment of a
quarterly facility average total case mix score, quarterly facility average
medicaid case mix score, or a peer group cost per case mix unit made in
accordance with rule 5160-3-43.3 of the Administrative Code as a result of the
facility's failure to submit, or submission of incomplete or inaccurate
resident assessment information, unless the recalculation results in a lower
quarterly facility average total case mix score, or lower quarterly or
semiannual facility average medicaid case mix score, or lower peer group cost
per case mix unit than the one to be assigned. (1) If the exception
review of a specific reporting quarter is conducted before the effective date
of the rate for the corresponding six month period, and the review results in
findings that exceed the tolerance level, ODM shall use the recalculated
quarterly facility average total case mix score and quarterly facility average
medicaid case mix score to calculate the facility's semiannual facility
average medicaid case mix score for the facility's direct care rate for
that six month period. Calculated rates based on exception review findings may
result in a rate increase or rate decrease compared to the rate based on the
facility's submission of assessment information. (2) If the exception
review of a specific reporting quarter is conducted after the effective date of
the rate for a corresponding six month period, and the review results in
findings that exceed the exception review tolerance level and indicate the
facility received a lower rate than it was entitled to receive, ODM shall
increase the direct care rate prospectively for the remainder of the six month
period, beginning one month after the first day of the month after the
exception review is completed. (3) If the exception
review of a specific reporting quarter is conducted after the effective date of
the rate for a corresponding six month period, and the review results in
findings that exceed the exception review tolerance level and indicate the
facility received a higher rate than it was entitled to receive, ODM shall
reduce the direct care rate and apply it to the six month periods when the
provider received the incorrect rate to determine the amount of the
overpayment. Overpayments are payable in accordance with rule 5160-3-22 of the
Administrative Code. (N) Except for additional information
submitted to ODM as part of the processes set forth in paragraphs (O) and (P)
of this rule, the ODM exception review determination for any resident case mix
score shall be considered final. A provider may submit corrections for
individual records in accordance with rule 5160-3-43.1 of the Administrative
Code; however, the exception review determination for any resident assessment
case mix score will be used to establish the quarterly facility average total
case mix score, quarterly and semiannual facility average medicaid case mix
scores, and annual facility average case mix score. (O) A provider may seek reconsideration
of any prospective direct care rate that was established by recalculating the
direct care rate as a result of an exception review of resident assessment
information conducted before the effective date of the rate. (1) A reconsideration of
a prospective direct care rate on the basis of a dispute with ODM exception
review findings shall be submitted by the provider to ODM in accordance with
the following: (a) The request shall be submitted no later than thirty
days after receipt of the exception review finding. (b) The request shall be in writing, and shall be addressed
to "Ohio Department of Medicaid, Bureau of Long Term Care Services and
Supports, P.O. Box 182709, 5th Floor, Columbus, Ohio, 43218". (c) The request shall indicate that it is a request for
rate reconsideration due to a dispute with exception review
findings. (d) The request shall include a detailed explanation of the
items on the resident assessment records under dispute as well as copies of
relevant supporting documentation from specific individual records. The request
shall also include the provider's proposed resolution. (2) ODM shall respond in writing within
sixty days of receiving each written request for a rate reconsideration related
to disputed exception review findings. If ODM requests additional information
to determine if the rate adjustment is warranted, the provider shall respond in
writing and shall provide additional supporting documentation no more than
thirty days after the receipt of the request for additional information. ODM
shall respond in writing within sixty days of receiving the additional
information. (3) If the rate is increased pursuant to
a rate reconsideration due to disputed exception review findings, the rate
adjustment shall be implemented retroactively to the initial service date for
which the rate is effective. (4) When calculating the annual facility
average and semiannual facility average medicaid case mix scores in accordance
with rule 5160-3-43.3 of the Administrative Code, ODM shall use any resident
case mix scores adjusted as a result of a rate reconsideration determination in
lieu of the resident case mix scores from the exception review
findings. (P) The findings of an exception review
conducted after the effective date of the rate may be appealed under Chapter
119. of the Revised Code. ODM shall not withhold from the facility's
current payments any amounts ODM claims to be due from the facility as a result
of the exception review findings while the provider is pursuing administrative
or judicial remedies in good faith.
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Rule 5160-3-50 | Nursing facilities (NFs): use of additional dollars as a result of rebasing of rates.
(A) Definitions. For purposes of this rule: (1) "Ancillary and support costs," "cost center," "direct care costs," "rebasing" and "tax costs" have the same meaning as in section 5165.01 of the Revised Code. (2) "Cost center report" means a report submitted to the Ohio department of medicaid (ODM) by a nursing facility provider that identifies the amount spent on each cost center included in rebasing. (B) Direct care spending. (1) In accordance with section 5165.36 of the Revised Code, nursing facilities should increase direct care spending by at least seventy percent of any additional dollars received as a result of rebasing. (2) For purposes of determining compliance with section 5165.36 of the Revised Code, the increased spending in direct care will be evaluated using calendar year 2019 medicaid nursing facility cost report data for direct care. (C) Submission of cost center reports. (1) In accordance with Section 333.240 of Amended Substitute House Bill 110 of the 134th General Assembly, for state fiscal years 2022 and 2023, cost center reports are to be submitted as follows: (a) The first cost center report is to be submitted not later than ninety days after the end of calendar year 2021 and should cover the period of July 1, 2021 through December 31, 2021. (b) Subsequent cost center reports should cover one calendar year each and should be submitted not later than ninety days after the end of the applicable calendar year. (2) Reports should include only direct care, ancillary and support, and tax costs as well as inpatient days. (3) Reports should be submitted on an electronic form prescribed by ODM. (D) Extensions. For good cause shown, cost center reports may be submitted within fourteen days after the original due date if written approval is received from ODM prior to the original due date of the report. Requests for extensions should be sent via email to LTCAudits@medicaid.ohio.gov and explain the circumstances resulting in the need for an extension. (E) Late reporting penalties. (1) If a report is not received by the original due date, or by an approved extension due date if applicable, the provider may be assessed a late reporting penalty for each day a complete and adequate report is not received (2) The late reporting penalty period begins on the day after the original due date or on the day after the extension due date, whichever is applicable, and continues until the complete and adequate report is received by ODM. (3) The late reporting penalty will be one hundred dollars per calendar day for each day after the original due date or the extension due date, whichever is applicable, that a nursing facility does not submit a cost center report. (4) The late reporting penalty is assessed annually and will be a reduction in payments to providers that submit claims directly to ODM or by payment submitted to ODM outside the claims process for providers that do not submit claims directly to ODM. No penalty is imposed during a fourteen-day extension granted by ODM. (F) Change of operator (CHOP). In cases of a change of operator, the exiting operator's 2019 cost reports and the additional dollars received as a result of rebasing will be used for the purposes of determining the entering operator's compliance with section 5165.36 of the Revised Code and Section 333.240 of Amended Substitute House Bill 110 of the 134th General Assembly. (G) New providers. For state fiscal years 2022 and 2023, nursing facilities with an initial medicaid certification date on or after January 1, 2020 are excluded from the requirements set forth in paragraphs (B) and (C) of this rule. (H) Reviews. For purposes of determining compliance with this rule, Section 333.240 of Amended Substitute House Bill 110 of the 134th General Assembly, and section 5165.36 of the Revised Code, ODM may conduct reviews of cost center report data beginning with calendar year 2022 data. (I) Reimbursement of funds to ODM. (1) Any amounts spent on cost centers other than as permitted by this rule, Section 333.240 of Amended Substitute House Bill 110 of the 134th General Assembly, and section 5165.36 of the Revised Code will be reimbursed to ODM with interest. (a) The interest will be no greater than two times the current average bank prime rate determined at the mid-point of the reporting quarter. (b) Interest will accrue from the mid-point of the reporting quarter until the date funds are recouped from medicaid payments or until payment is submitted to ODM outside the claims process for providers who do not submit claims directly to ODM. (2) Reimbursement of funds pursuant to a review as set forth in paragraphs (H) and (I) of this rule is not subject to appeal under Chapter 119. of the Revised Code.
Last updated July 11, 2022 at 1:35 PM
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Rule 5160-3-57 | Nursing facilities (NFs): tax costs payment rate.
Effective:
September 22, 2018
(A) The Ohio department of medicaid (ODM)
shall pay a provider a per medicaid day payment rate for tax costs determined
under section 5165.21 of the Revised Code except for the initial rate for new
providers. ODM shall determine each new nursing facility's initial per
medicaid day payment rate for tax costs in accordance with section 5165.151 of
the Revised Code. (B) For purposes of calculating the
initial rate for tax costs pursuant to division (A)(4)(a) of section 5165.151
of the Revised Code, a new nursing facility shall provide ODM with the
facility's projected tax costs for the calendar year in which the new
nursing facility obtains an initial provider agreement. The projected tax costs
may include any of the type of tax costs reportable on schedule "B-1"
of the medicaid nursing facility cost report, which is available at
http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTermCareFacilities/AutomatedCostReporting.aspx.
The projected tax costs must be accompanied by the state and county tax records
and assessments supporting the projection. The tax records and assessments
provided must be for amounts payable by the new provider. If such state and
county tax records and assessments are not available, the new facility may
provide any other documentation satisfactory to ODM that verifies the amount
and type of tax costs reportable on schedule "B-1" of the medicaid
nursing facility cost report, (1) If any documentation
required under this rule is not received within thirty days of approval of the
initial provider agreement or is determined to be unsatisfactory, the initial
tax rate shall be the statewide median tax rate for tax costs for the new
facility's peer group in which the facility is placed under division (B)
of section 5165.16 of the Revised Code. (2) The effective date of
the initial tax cost rate for a new nursing facility shall be the same as the
effective date of the new facility's medicaid provider agreement.
(3) All documentation required under this
rule shall be submitted to "Ohio Department of Medicaid, Fiscal Operations
- Rate Setting Section, P.O. Box 182709, Columbus, Ohio
43215-3414." (C) If a nursing facility does not have a
cost report filed with ODM for the applicable calendar year used to determine
the rate for tax costs under section 5165.21 of the Revised Code, the tax rate
shall be the statewide median tax rate for tax costs for the peer group in
which the facility is placed under division (B) of section 5165.16 of the
Revised Code.
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Rule 5160-3-64 | Nursing facilities (NFs): payment for medicare part A cost sharing.
Effective:
August 31, 2017
(A) For nursing facility services the nursing facility provides on or after January 1, 2012, "medicaid maximum allowable amount" means one hundred per cent of the nursing facility's medicaid rate on the date that the service was provided. (B) For qualified medicare beneficiaries (QMB) as defined in rule 5160:1-3-02.1 of the Administrative Code and medicaid consumers admitted to a nursing facility as a medicare part A benefit, the Ohio department of medicaid (ODM) will pay as cost sharing for nursing facility services the lesser of: (1) The coinsurance amount as provided by the medicare part A plan; or (2) The medicaid maximum allowable amount for the identified service or services minus the medicare part A plan's payment to a nursing facility for the same service or services. If the medicare part A plan's payment to a nursing facility for a service or services identified is greater than the medicaid maximum allowable amount, ODM will pay nothing for the same identified service or services. (C) The medicaid provider is ultimately responsible for accurate and valid reporting of medicaid claims submitted for payment. Providers submitting medicare part A crossover claims to the medicaid program must be able to provide upon request documentation supporting that the information provided on the claim matches the information on the part A plan's remittance advice.
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Rule 5160-3-64.1 | Nursing facilities (NFs): payment for cost-sharing other than medicare part A.
Effective:
February 14, 2019
(A) For medicaid eligible NF residents,
the NF per diem rate includes medicaid payments for medicare or other
third-party insurance cost-sharing, including coinsurance or deductible
payments, associated with services that are included in the NF per diem
rate. (B) Neither the medicaid eligible NF
resident nor the Ohio department of medicaid (ODM) is responsible for any
medicare or other third-party insurance cost-sharing, including coinsurance or
deductibles, associated with services that are included in the NF per diem
rate.
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Rule 5160-3-65 | Nursing facilities (NFs): rates for providers with an initial date of certification on or after July 1, 2006.
Effective:
September 22, 2018
(A) In accordance with section 5165.151
of the Revised Code, the Ohio department of medicaid (ODM) shall determine the
initial rate for the fiscal year in which the NF begins participation in the
medicaid program for a NF with a first date of licensure and subsequent
certification on or after July 1, 2006, including a NF that replaces one or
more existing facilities, or a NF with a first date of licensure before July 1,
2006 that was initially certified for the medicaid program on or after July 1,
2006 under section 5165.151 of the Revised Code. (1) If the number of beds
in the replacement facility is greater than the number of beds in the replaced
facility, the case mix score shall be equal to the weighted average of the
semiannual case mix score used for the replaced beds on the last day of service
at the replaced facility and the median annual average case mix score for the
NF's peer group for the additional beds. (2) If a rate for direct
care costs is determined under section 5165.151 of the Revised Code for a NF
using the median annual average case mix score for the NF's peer group,
the rate shall be redetermined to reflect the NF's actual semiannual case
mix score determined under section 5165.192 of the Revised Code after the NF
submits its first two quarterly assessment data that qualify for use under
paragraph (E) of rule 5160-3-43.3 of the Administrative Code. If the NF's
quarterly submissions do not qualify for use in calculating a case mix score,
ODM shall continue to use the median annual average case mix score for the
NF's peer group in lieu of the NF's semiannual case mix score until
the NF submits two consecutive quarterly assessment data that qualify for use
in calculating a case mix score. (B) After the end of the fiscal year in
which the NF began participation in the medicaid program, the rates for the
second fiscal year and subsequent fiscal years shall be set in accordance with
section 5165.15 of the Revised Code.
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Rule 5160-3-65.1 | Nursing facilities (NFs): rates for providers that change provider agreements.
Effective:
February 14, 2019
(A) An entering operator's initial
rate shall be the rate the exiting operator would have received had the exiting
operator continued to participate in the medicaid program. (B) The rate determined in paragraph (A) of this rule shall
not be subject to adjustment until the following state fiscal
year. (C) After the end of the state fiscal year in which the
entering operator began participation in the medicaid program, the rates for
subsequent state fiscal years for other than direct care costs shall be set in
accordance with sections 5165.01 to 5165.49 of the Revised Code. (D) After the end of the state fiscal
year in which the entering operator began participation in the medicaid
program, the rate for direct care costs for the second state fiscal year shall
be redetermined to reflect the entering operator's actual semiannual case
mix score determined under section 5165.192 of the Revised Code after the NF
submits its first two quarterly assessment data that qualify for use under
paragraph (E) of rule 5160-3-43.3 of the Administrative Code. If the entering
operator's quarterly submissions do not qualify for use in calculating a
case-mix score, the median annual average case-mix score for the entering
operator's peer group shall be used to calculate a case-mix score in lieu
of the entering operator's actual semiannual case-mix score until the
entering operator submits two consecutive quarterly assessment data that
qualify for use under paragraph (E) of rule 5160-3-43.3 of the Administrative
Code. The rate for direct care costs for subsequent state fiscal years shall be
set in accordance with sections 5165.01 to 5165.49 of the Revised
Code.
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Rule 5160-3-70 | Nursing facilities (NFs): appeals for special focus facilities (SFFs) proposed for termination from the medicaid program.
(A) Appeal. (1) A nursing facility may appeal under Chapter 119. of the Revised Code an order pursuant to section 5165.771 of the Revised Code terminating a nursing facility's participation in the medicaid program as provided in this rule. (2) A nursing facility may only appeal the length of time the facility has been listed in a table as described in division (B) of section 5165.771 of the Revised Code. (3) The appeal is to be submitted by the nursing facility to the Ohio department of medicaid (ODM) within forty-eight hours of the nursing facility's receipt of the termination order. (B) Hearing. (1) ODM will conduct a hearing within seven business days of the filing of the appeal by the nursing facility. (2) For good cause shown, the hearing date may be extended.
Last updated July 11, 2022 at 1:35 PM
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Rule 5160-3-90 | Authorization for the Ohio department of developmental disabilities (DODD) to administer the medicaid program for services provided by intermediate care facilities for individuals with intellectual disabilities (ICFs-IID).
(A) The Ohio department of developmental
disabilities (DODD), through an interagency agreement with the Ohio department
of medicaid (ODM), and with oversight by ODM, administers the medicaid program
for services provided by intermediate care facilities for individuals with
intellectual disabilities (ICFs-IID) in accordance with section 5162.35 of the
Revised Code. Pursuant to section 5162.021 of the Revised Code, DODD may
develop rules and policies governing the administration of the ICF-IID program,
which are filed in Chapter 5123-7 of the Administrative Code upon review and
approval by ODM. (B) In collaboration with DODD, ODM will
create and implement oversight measures related to the ICF-IID program in
accordance with Chapter 5124. of the Revised Code. Reviews may consist of, but
are not limited to, physical inspections of records and sites where services
are provided, and interviews of providers and recipients of ICF-IID services.
ICF-IID providers will provide any records related to the administration or
provision of ICF-IID services to ODM, the centers for medicare and medicaid
services (CMS), the medicaid fraud control unit, and any of their designees in
accordance with the medicaid provider agreement. (C) ODM will monitor payment made under
authority of this rule as necessary to ensure that funding is used for
authorized purposes in compliance with federal and state laws, regulations, and
policies governing the medicaid program. ODM and DODD may recover any
overpayment identified by requesting voluntary repayment, or through provider
payment offsets, or formal adjudicatory or non-adjudicatory recovery
proceedings. (D) Whenever an applicant for or
recipient of ICF-IID services is affected by any action proposed or taken by
DODD or ODM, the entity recommending or taking the action will provide medicaid
due process in accordance with section 5101.35 of the Revised Code and as
specified in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code. Such
actions may include, but are not limited to, the approval, denial, or
termination of enrollment or a denial of ICF-IID services. If an applicant or
enrollee requests a hearing related to an action taken by DODD, the
participation of DODD is necessary during the hearing proceedings to justify
the decision under appeal.
Last updated July 10, 2023 at 8:37 AM
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Rule 5160-3-99 | Payment methodology for state-operated intermediate care facilities for individuals with intellectual disabilities (ICFs/IID).
Effective:
January 1, 2019
This rule describes the methodology for calculating
payment rates for state-operated intermediate care facilities for individuals
with intellectual disabilities (ICFs/IID) operated by the Ohio department of
developmental disabilities (DODD) and is effective for periods on or after July
1, 2019. (A) Definitions. (1) "Ancillary care
costs" are costs for services other than direct care, incurred by the
ICF/IID that are reasonable and provided to ICF/IID residents through an
ICF/IID employee or through a contractual arrangement with the ICF/IID. For the
purpose of the ICF/IID cost reporting and rate calculation, ancillary care
costs include pharmacy, radiology, and laboratory, clinic care, and physician
service costs. (2) "Base rate
year" means the period used to establish the interim payment rate for each
ICF/IID. (3) "Base year cost report"
means the cost report used to establish the interim payment rate. (4) "Capital costs" are
reasonable costs for the depreciation, amortization and interest on any capital
assets that cost one thousand dollars or more per item, including buildings and
improvements, equipment, transportation equipment, land improvements, leasehold
improvements, and financing costs. (5) "Clinic care costs" for the
purpose of the ICF/IID cost reporting and rate calculation, are a component of
ancillary care costs and include audiology, dental and vision services and
exclude direct care costs. (6) "Cost report" means an ODM
approved, electronically filed, cost report format, including its supplements
and attachments, used to report cost and statistical data for the operation of
an ICF/IID. (7) "Covered services" are
medicaid reimbursable services provided to a resident of an ICF/IID by an
ICF/IID employee or through a contractual arrangement with an ICF/IID. Covered
services include ancillary care and direct care services. (8) "Direct care costs" are
costs which can be directly assigned to one program or cost center for services
delivered to a resident of an ICF/IID through an ICF/IID employee or
contractual arrangement with an ICF/IID. Direct care costs include wages,
taxes, staff development, contracting and consulting services. Direct care
costs exclude ancillary care costs. (9) "Federal financial participation
(FFP)" means the federal government's share of a state's
expenditures under the medicaid program. (10) "Final payment rate" means
the rate of payment calculated using the audited rate year cost report
data. (11) "Final settlement" is the
process where allowable and reasonable costs included in the audited rate year
cost report are used to establish a final payment rate that is reconciled to
the interim payment rate. (12) "Indirect cost" are costs
which cannot be directly assigned to one program or cost center, and benefit
multiple programs or cost centers. (13) "Interim payment rate"
means the rate of payment calculated using the desk reviewed base year cost
report data until the final payment rate is determined. (14) "Medicaid days" are days an
individual is eligible to receive medicaid covered services. (15) "Medicaid paid days" are
days that an ICF/IID is paid by the Ohio department of medicaid (ODM) for a
medicaid eligible resident residing in an ICF/IID. (16) "Non-medicaid days" are
days an individual is not covered by medicaid and are, therefore, not
billable. (17) "Per diem" means the
payment made to an ICF/IID covering all costs (direct care, ancillary care, and
capital) related to the services furnished to medicaid recipients. (18) "Rate
year" means the period where calculated interim rates are paid to the ICF/
IID using the base year cost report data. (19) "Rate year cost
report" means the cost report used to establish the final payment
rate. (20) "Reasonable and
allowable costs" means costs established in accordance with the centers
for medicare and medicaid services (CMS) publications 15-1 ("The Provider
Reimbursement Manual - Part 1") and 15-2 ("The Provider Reimbursement
Manual - Part 2") as in effect October 16, 2018, available at
https://www.cms.gov/ and 45 C.F.R. part 92 in effect as of October 16,
2018. (21) "State-operated
intermediate care facility for individuals with intellectual disabilities"
means an institution as defined in section 1905(d) of the Social Security Act
42 U.S.C. 1396d(d) (October 16, 2018) and operated by DODD under a medicaid
provider agreement with ODM. (22) "Total
inpatient days" means the sum of all days during which a resident,
regardless of payment source, occupies a bed in an ICF/IID that is included in
the ICF/IID certified capacity under Title XIX of the Social Security Act, 49
stat. 620, 42 U.S.C.A. 301 in effect as of October 16, 2018. Therapeutic and
hospital leave days for which payment is made under section 5124.34 of the
Revised Code are considered inpatient days. (B) Source data for
calculations. (1) The cost report
covers the period of July first to June thirtieth. All cost reports shall be
submitted to ODM in an electronic format provided by ODM. DODD shall maintain,
on the DODD website (http://dodd.ohio.gov/Pages/default.aspx), an electronic
version of the cost report for each cost report period. (2) The calculations
described in this rule will be based on the most recent desk reviewed base year
cost report data submitted to ODM. The ICF/IID cost report must: (a) Be prepared in accordance with medicare principles
governing reasonable and allowable cost reimbursement. The method used to
allocate supporting cost centers shall be the step-down method described in CMS
publication 15-1, section 2306. The statistics on the approved cost reporting
form, must be used for cost allocation purposes; and (b) Include all information necessary for the proper
determination of costs payable under medicaid including financial records and
statistical data; and (c) Include a cost report certification executed by DODD
attesting to the accuracy of the cost report, and compliance with applicable
federal and state rules and regulations. In addition, all subsequent revisions
to the cost report must include an executed certification; and (d) Include costs for all covered services, provided
directly by ICF/IID employees or through a contractual arrangement with the
ICF/IID, that are generally available to medicaid recipients and provided to a
resident of an ICF/IID by the ICF/IID, and shall be reimbursed only to ICF/IID.
These costs are subject to all otherwise applicable audit guidelines and tests
of reasonableness; and (e) Not include the cost of pharmacy and legend drugs when
these are reimbursed directly to a pharmacy provider; and (f) Not include the cost of any goods or services that are
otherwise reimbursed to a provider other than the ICF/IID regardless of the
type of service. (3) A desk review will be
performed by ODM on all base year cost reports for the purpose of determining
interim payment rates, all of which are subject to final settlement under
paragraph (E) of this rule. Desk review procedures will take into consideration
the relationship between the prior year's audited costs and the current
year's reported costs. Adjustments may be made to the cost report by ODM
as necessary to determine reasonable and accurate interim payment rates.
Adjustments made by ODM do not preclude findings of additional cost exceptions
issued as the result of an audit. (4) An ICF/IID certified
cost report shall be filed with ODM within one hundred eighty days of the end
of the fiscal year. If the cost report is not received within one hundred
eighty days of the end of the fiscal year the rate paid will be the lower of
ninety per cent of the state wide average rate or the interim payment rate.
(5) DODD may request an
extension in writing and ODM may grant one extension of up to thirty calendar
days for filing a cost report. ODM shall designate the individual to receive
the request within ODMs financial management, planning and rate setting
section. The extension request shall be submitted to ODM no later than one
hundred fifty days after the end of the fiscal year. ODM shall respond to DODD
within fifteen calendar days of receipt of the extension request. (C) Calculation of interim payment
rates. (1) Interim payment rates
for each ICF/IID shall be based upon the source data described in paragraph (B)
of this rule. (2) The interim payment
rate shall be calculated as follows: (a) Calculation of direct care cost per diem
rate. (i) Calculate the direct
care cost per diem for each ICF/IID by dividing direct care costs by total
inpatient days. (ii) For each ICF/IID
multiply the ICF/IID's direct care cost per diem by the ICF/IID's
total inpatient days. Sum results for all ICFs/IID and divide by the sum of the
ICF/IID total inpatient days for all ICFs/IID. (iii) Calculate the
direct care cost per diem ceiling by taking the amount calculated in paragraph
(C)(2)(a)(ii) of this rule and multiplying it by one hundred twelve per
cent. (iv) The interim ICF/IID
direct care cost per diem will be the lower of the amount calculated in
paragraph (C)(2)(a)(i) of this rule or the direct care cost per diem ceiling as
calculated in paragraph (C)(2)(a)(iii) of this rule. (b) Calculate the ancillary care cost per diem rate for
each ICF/IID by dividing ancillary care costs by total inpatient
days. (c) Calculate the capital cost per diem for each
state-operated ICF/IID by dividing capital costs by total inpatient
days. (d) The interim payment rate for each state-operated
ICF/IID shall be the sum of the amounts calculated in paragraphs (C)(2)(a)(iv),
(C)(2)(b) and (C)(2)(c) of this rule, inflated from the mid-point of the base
year to the midpoint of the rate year using the skilled nursing facility (SNF)
market basket as calculated by "Global Insight" available at
www.globalinsight.net or a successor firm, and submitted to ODM by March
thirty-first, before the beginning of the new rate year. (D) Audit. (1) ODM will perform
field audits either directly or through arrangement of the most current cost
report for each ICF/IID at least once every three years or more often as
determined by ODM. Cost reports for other periods may also be audited within
three years from the fiscal year end, unless justified from previous audit
findings. ODM will use a full or limited scope audit. The audits will be
performed in accordance with auditing standards adopted by ODM. ODM will
develop a risk-based methodology to determine which ICFs/IID are subject to
audit. (2) The audit scope will
be determined by ODM and will be sufficient to determine if costs reflected in
the cost report are accurate, made in compliance with pertinent regulations,
and based on actual cost. (3) DODD must maintain
documentation to support all transactions, to permit the reconstruction of all
transactions and the proper completion of all reports required by state and
federal laws and regulations, and to substantiate compliance with all
applicable federal laws and regulations, state laws and administrative rules.
This documentation must be maintained for the greater of seven years after the
cost report is filed or, if ODM issues an audit report, six years after all
appeal rights relating to the audit report are exhausted. Documentation must
include sufficient detail to disclose: (a) Services provided; and (b) Administrative costs of services provided;
and (c) Costs of operating the organizations, agencies,
program, activities, and functions; and (d) Total inpatient days, medicaid days, and non-medicaid
days; and (e) Services claimed are covered under the medicaid program
and made in accordance with applicable rules of the Administrative Code;
and (f) Amounts of third-party payments reported are indicative
of actual amounts received; and (g) Costs reported to ODM represent actual incurred,
reasonable, and allowable costs in accordance with provisions of the CMS
provider manual 15-1, Chapter 5160-3 of the Administrative Code as applicable,
and 45 C.F.R. 92. (4) Each ICF/IID shall
collect, report, and maintain separately all data and records sufficient to
support the rate calculation including but not limited to statistical and
financial data: (a) Related to costs that are included in or listed in the
cost report as reimbursable costs; and (b) Related to non-reimbursable costs. (5) DODD must maintain
adequate systems of internal control (e.g. preventive, detective, and
compensating controls) as related to federal funding to ensure: (a) Accurate and reliable financial and administrative
records; and (b) Efficient and effective use of resources;
and (c) Compliance with pertinent laws and
regulations. (E) Final settlement. (1) Final settlement
shall include adjustments to the base rate year cost report included in
paragraphs (B) (2) and (D) (1) to (D) (5) of this rule. (2) The final payment
rate shall be calculated as follows: (a) Calculation of direct care cost per diem
rate. (i) Calculate the direct
care cost per diem rate for each ICF/IID by dividing direct care costs by total
inpatient days. (ii) For each ICF/IID,
multiply the ICF/IID's direct care cost per diem rate as calculated in
paragraph (E)(2)(a)(ii) of this rule by the ICF/IID's total inpatient
days. Sum results for all ICFs/IID and divide by the sum of total inpatient
days for all ICFs/IID. (iii) Calculate the
direct care cost per diem ceiling by taking the amount calculated in paragraph
(E)(2)(a)(ii) of this rule and multiplying it by one hundred twelve per
cent. (iv) The final ICF/IID
direct care cost per diem rate will be the lower of the amount calculated in
paragraph (E)(2)(a)(i) of this rule or the direct care per diem ceiling as
calculated in paragraph (E)(2)(a)(iii) of this rule. (b) Calculate the ancillary care cost per diem rate for
each ICF/IID by dividing ancillary care costs by total inpatient
days. (c) Calculate the capital cost per diem rate for each
ICF/IID by dividing capital costs by total inpatient days. The final rate for
each ICF/IID shall be the sum of the amounts calculated in paragraphs
(E)(2)(a)(iv), (E)(2)(b) and (E)(2)(c) of this rule. (3) The final payment
rate calculated in paragraph (E)(2) of this rule is subtracted from the interim
payment rate calculated in paragraph (C)(2) of this rule. The result is
multiplied by the medicaid paid days and applicable federal financial
participation (FFP) rate. The result of this calculation is the final
settlement amount. Where the interim payment rate exceeds the final payment
rate, the excess payment shall be remitted to ODM. If the final payment rate
exceeds the interim payment rate, ODM shall remit the amount to
DODD. (4) The audit and final
settlement shall be issued within thirty-six months of receipt of the rate year
cost report. If an audit is not issued for final settlement within thirty-six
months, the rates calculated using the desk reviewed base year cost report
shall be used for final settlement. (5) No further
adjustments to payments or rates can occur after the implementation of the
final cost settlement. (F) Upper payment limit
assurance. Payments made to ICFs/IID in accordance with this
rule under medicaid are, in the aggregate on a statewide basis, equal to or
less than amounts which would have been recognized under Title XVIII of the
Social Security Act, 42 U.S.C. 1395 for comparable services in accordance with
42 C.F.R 447.272, in effect as of October 16, 2018. (G) Dispute resolution. All disputes regarding the application of this
rule, including but not limited to desk reviews, payment, rate setting, and
audits shall be resolved between ODM and DODD in accordance with terms set
forth in the interagency agreement. Disputes that arise from the application of
this rule shall not be subject to hearings conducted under Chapter 119. of the
Revised Code. (H) Rule exclusion. Excluding those rules referring to reasonableness
ceilings, cost limitations, cost reimbursement, occupancy levels, disallowance
of costs, payment calculations, payment methodology, and appeals, all other
rules which govern the operation of medicaid-certified ICFs/IID under Chapters
5160-1, 5160-3, 5123-7, and 5123:2-7 of the Administrative Code shall apply to
ICFs/IID. The payment methodology specified in this rule shall govern the
reimbursement of medicaid costs for ICFs/IID. (I) Claim submission, payment and
adjustment process. All ICFs/IID shall comply with claim submission,
payment, and adjustment requirements in accordance with rule 5123:2-7-15 of the
Administrative Code.
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