5101:3-3-65.1 Nursing facilities (NFs): rates for providers that change provider agreements.

(A) For an entering NF operator, as defined under section 5111.65 of the Revised Code, that begins participation in the medicaid program with an initial date of July 1, 2006 through October 31, 2006, the Ohio department of job and family services (ODJFS) shall determine the initial rate as the lesser of the following:

(1) The rate the exiting operator would have received on the date the entering operator begins participation in the medicaid program; or

(2) The sum of the following:

(a) The rate for direct care costs shall be the product of the cost per case mix unit determined under division (D) of section 5111.231 of the Revised Code for the facility’s peer group and the case mix score that would have been used for the exiting operator on the day that the entering operator begins participation in the medicaid program.

(b) The rate for ancillary and support costs shall be the median rate for the facility’s peer group determined under division (D) of section 5111.24 of the Revised Code.

(c) The rate for capital costs shall be the median rate for the facility’s peer group determined under division (D) of section 5111.25 of the Revised Code.

(d) The rate for tax costs as defined in section 5111.242 of the Revised Code shall be the median rate for tax costs for the facility’s peer group in which the facility is placed under division (C) of section 5111.24 of the Revised Code.

(e) The quality incentive payment shall be the mean payment specified under rule 5101:3-3-58 of the Administrative Code.

(f) The rate for franchise permit fees determined for the NF under section 5111.243 of the Revised Code.

(B) On November 1, 2006, a NF operator that began participation in the medicaid program through a change of provider agreement July 1, 2006 through October 31, 2006, shall receive the rate the exiting operator would have received had the exiting operator continued to participate in the medicaid program.

(C) For an entering NF operator that begins participation in the medicaid program on and after November 1, 2006, the NF 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.

(D) The rate determined in paragraphs (A), (B) and (C) of this rule shall not be subject to adjustment until the following fiscal year.

(E) 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 sections 5111.20 to 5111.33 of the Revised Code. The rate for direct care costs shall be redetermined to reflect the entering operator’s actual semiannual case mix score determined under section 5111.232 of the Revised Code after the NF submits its first two quarterly assessment data that qualify for use under paragraph (E) of rule 5101:3-3- 43.3 of the Administrative Code.

Effective: 11/01/2006

R.C. 119.032 review dates: 07/01/2011

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.676

Rule Amplifies: 5111.222, 5111.254, 5111.676

Prior Effective Dates: 7/1/2006