LAW
Writer®
Ohio Laws and Rules
(A) In establishing the direct care component of the intermediate care facility for the mentally retarded rate, the following definitions are used:
(1) “Annual facility average case mix score” is the score used to calculate the facility’s cost per case mix unit, and is calculated using the methodology described in paragraph (H) of this rule.
(2) “Case mix reimbursement” is a system that adjusts payment for direct services by identifying resident characteristics associated with actual measured resource use. It takes into account the fact that some residents are more costly to care for than others due to their different care needs.
(3) “Correction submission due date” is the deadline, as set forth in paragraph (F)(3) of this rule, for the ICF-MR to return to the Ohio department of job and family services (ODJFS) the completed “IAF correction document” sent as part of the “IAF Case Mix Initial Quarterly Report”. The correction submission due date applies to corrections submitted in electronic format for facility level and resident record changes.
(4) “Critical elements” are data items from a resident’s JFS 02221 “Ohio ICF-MR Individual Assessment Form Answer Sheet” (rev. 6/03) that ODJFS verifies prior to determining a resident’s class in the resident assessment classification system (RACS).
(5) “Cost per case mix unit” is calculated by dividing the facility’s desk reviewed, actual, allowable, per diem direct care costs for the calendar year preceding the fiscal year in which the rate will be paid by the annual facility average case mix score for the calendar year preceding the fiscal year in which the rate will be paid. The lesser of the facility’s cost per case mix unit or the maximum allowable cost per case mix unit for the facility’s peer group for the fiscal year shall be used to determine the facility’s rate for direct care costs, in accordance with rule 5101:3-3-79 of the Administrative Code.
(6) “Direct care peer group” is a group of Ohio medicaid certified ICFs-MR determined by ODJFS to have significant per diem direct care cost differences from the other direct care peer groups due to reasons other than the differences in care needs among the residents. Direct care peer groups are described in rule 5101:3-3-79 of the Administrative Code.
(7) “Facility level errors” are errors described in paragraphs (A)(7)(a) to (A)(7)(c) of this rule and must be corrected before a facility average case mix score can be calculated.
(a) Failure to submit the signed JFS 02222 “ICF-MR Certification of IAF Data” (rev. 6/03) form by the correction submission due date.
(b) Incomplete or inaccurate data are submitted to ODJFS on the JFS 02222 form, or, for facilities submitting in electronic format, in the IAF header record.
(c) The number of IAF records processed is more than the reported number of residents in medicaid certified beds on the reporting period end date.
(8) “Filing date” is the deadline for initial quarterly submission of the ICF-MR’s IAF data and the JFS 02222, which is the fifteenth calendar day following the reporting period end date. IAF data submission requirements are outlined in rule 5101:3-3- 73.1 of the Administrative Code.
(9) “IAF Case Mix Initial Quarterly Report” consists of a report generated by ODJFS and distributed to the ICF-MR on the status of the IAF assessment data which the ICF-MR submitted to ODJFS for the initial quarterly filing. The report contains four components:
(a) “Submission Tracking Summary”, which shows the status of the IAF data after initial processing by ODJFS; and
(b) “Detailed Listing of Successfully Grouped Assessments”, which is a list of IAF records that were grouped into RACS groups one through four; and
(c) “Correction Document” which is to be used by the ICF-MR to correct errors in the IAF data and is submitted in paper format. The ICF-MR must submit its corrections using a format approved by ODJFS; and
(d) “Deleted/Discharged Assessments” which is a list of resident records being deleted, and/or a list of residents being discharged from the facility.
(10) The JFS 02220 “Ohio ICF-MR Individual Assessment Form” (rev. 11/92) [instructions] is the resident assessment instrument used in the RACS.
(11) The JFS 02221 “Ohio ICF-MR Individual Assessment Form Answer Sheet” provides the resident assessment data which is used to classify the resident into a resident class in the RACS.
(12) “Payment quarter” is two quarters following the reporting quarter and is the quarter following the processing quarter, in which the direct care rate is paid based on the quarterly facility average case mix score from the reporting quarter’s IAF data.
(13) “Postmark” means any of the following:
(a) The official postmark applied to the package or envelope by the United States postal service; or
(b) The date the material is received by a commercial delivery service, if marked legibly on the package; or
(c) If the package or letter is delivered but no date is legible on the package, ODJFS shall consider the postmark to be four calendar days prior to receipt by ODJFS.
(14) “Processing quarter” is the quarter that follows the reporting quarter and is the quarter in which ODJFS receives the resident assessment data for the reporting quarter and calculates the direct care rate for the payment quarter.
(15) “Quarterly facility average case mix score” is the facility average case mix score based on data submitted for one reporting quarter and is calculated using the methodology described in paragraph (G) of this rule.
(16) “Record” means a resident’s “Ohio ICF-MR Individual Assessment Form Answer Sheet” (JFS 02221) processed by ODJFS.
(17) “Relative resource weight” is the measure of the relative costliness of caring for residents in one case mix class versus another, indicating the relative amount and cost of staff time required on average for defined job types to care for residents in a single case mix class. The methodology for calculating relative resource weights is described in rule 5101:3-3- 73.2 of the Administrative Code.
(18) “Reporting period end date” is the last day of each calendar quarter.
(19) “Reporting quarter” is the quarter which precedes the processing quarter and from which the ICF-MR’s resident assessment data are used to establish the direct care rate for the payment quarter.
(20) “Resident assessment classification system” is the system known as RACS for classifying ICF-MR residents into case mix classes, as outlined in rule 5101:3-3- 73.2 of the Administrative Code, and used by ODJFS to gather data for the direct care payment system. The case mix classes are clusters of ICF-MR residents, defined by resident characteristics, that explain resource use.
(21) “Resident case mix score” is the relative resource weight for the RACS class to which the resident is assigned based on data elements from the resident’s IAF assessment.
(B) ODJFS shall process resident assessment data submitted by ICFs-MR in accordance with rule 5101:3-3-73.1 of the Administrative Code and classify residents using the RACS to determine resident case mix scores in accordance with rule 5101:3-3-73.2 of the Administrative Code. These resident case mix scores, based on relative resource weights as set forth in appendix C to rule 5101:3-3- 73.2 of the Administrative Code, are used to establish the quarterly facility average case mix score. The methodology for determining the quarterly facility average case mix score is described in paragraph (G) of this rule.
(C) The quarterly facility average case mix score from the reporting quarter is used in conjunction with the lesser of the facility’s cost per case mix unit or the maximum allowable cost per case mix unit, adjusted by the inflation rate, to establish the quarterly direct care rate for the payment quarter, as outlined in rule 5101:3-3-79 of the Administrative Code. The facility’s cost per case mix unit is calculated using the annual facility average case mix score. The methodology for determining the annual facility average case mix score is described in paragraph (H) of this rule.
(D) ODJFS shall establish each ICF-MR’s rate for direct care costs quarterly in accordance with rule 5101:3-3-79 of the Administrative Code. ODJFS shall assign a quarterly facility average case mix score or cost per case mix unit used to establish a facility’s rate for direct care costs if the facility fails to submit its resident assessment data in accordance with rule 5101:3-3- 73.1 of the Administrative Code or fails to correct facility level errors. Before taking such action ODJFS shall permit the provider a reasonable period of time to correct the information, as described in paragraph (F)(3) of this rule. ODJFS’ assignment of the quarterly facility average case mix score or cost per case mix unit will occur as follows:
(1) ODJFS may assign a quarterly facility average case mix score that is five per cent less than the facility’s quarterly average case mix score for the preceding calendar quarter instead of using the quarterly average case mix score calculated based on the facility’s submitted information as described in paragraph (G) of this rule.
(a) If the facility was subject to an exception review in accordance with rule 5101:3-3- 73.4 of the Administrative Code for the preceding calendar quarter, the assigned quarterly facility average 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 average case mix score for the preceding calendar quarter, the assigned quarterly facility average case mix score shall be the score that is five per cent less than that score assigned for the preceding quarter.
(2) ODJFS may assign a cost per case mix unit that is five per cent less than the provider’s calculated or assigned cost per case mix unit for the preceding calendar year if the provider has fewer than two acceptable quarterly average case mix scores.
(E) ODJFS shall calculate and use the actual quarterly facility average case mix score described in paragraph (G) of this rule for determining the quarterly direct care rate if:
(1) In accordance with rule 5101:3-3- 73.1 of the Administrative Code, the resident assessment information is submitted by the filing date; and includes resident assessments for at least ninety per cent of all residents of medicaid certified ICFs-MR as of the reporting period end date; and
(2) In accordance with the procedures outlined in paragraph (F) of this rule for correcting inaccurate information, the facility’s resident assessment information is submitted timely and corrected timely for that reporting quarter; and
(3) The facility’s submission of resident assessment data and the JFS 02222 does not contain facility level errors or such errors have been corrected timely, and the facilities submission of any additional IAF data.
(F) After ODJFS has processed the ICF-MR resident assessment data for a reporting quarter, the “Case Mix Provider Summary Report” will be mailed to the ICF-MR. The ICF-MR may correct either ODJFS identified or ICF-MR identified errors or omissions by sending in a modification submission and submitting corrections to ODJFS along with, if necessary, an amended JFS 02222.
(1) ODJFS shall notify ICFs-MR of a missing or incomplete certification form.
(2) ODJFS may notify ICFs-MR of its initial quarterly submission through four documents:
(a) The “Submission Tracking Summary” report.
(b) The “Detailed Listing of Successfully Grouped Assessments” report.
(c) The “Deleted/Discharged Assessments” report.
(d) The “Correction Document”.
(3) ODJFS shall allow eighty days after the reporting period end date to make corrections and return them to ODJFS. Timeliness of the submission to ODJFS shall be determined by the postmark.
(4) Corrections received by ODJFS will be used in computing the quarterly facility average case mix score, in accordance with the conditions outlined in paragraph (E) of this rule.
(5) ODJFS will process corrections submitted in electronic format if the file format is the same as used by ODJFS.
(6) Changes made on the “IAF Modification Submission” for IAF data element entries, except for corrections of ODJFS data entry errors, must be consistent with changes made to the original IAF form maintained at the facility.
(G) The quarterly facility average case mix score for ICFs-MR that submitted their IAF data and modifications timely, and have no facility level errors is calculated as follows:
(1) All residents’ case mix scores for the quarter are added together.
(2) The sum of resident case mix scores is divided by the total number of residents.
(H) The annual facility average case mix score is used to compute the cost per case mix unit for the ICF-MR and the direct care peer group maximum cost per case mix unit. Resident assessment data for all four quarters of the calendar year shall be used to calculate the annual facility average case mix score:
(1) ODJFS assigned facility average case mix scores will be omitted from the facility’s annual average case mix score calculation.
(2) The annual facility average case mix score shall be calculated from no fewer than two acceptable quarterly average case mix scores. Acceptable quarterly facility average case mix scores shall be summed and divided by the total number of quarters of acceptable scores. Acceptable quarterly average case mix scores for the purposes of calculating the annual facility average case mix score include, in order of hierarchy:
(a) Adjusted quarterly facility average case mix scores as a result of exception review findings, or
(b) Quarterly facility average case mix scores calculated based on the facility’s submitted information as described in paragraph (G) of this rule.
(3) If at least two acceptable quarterly facility average case mix scores are not available ODJFS shall assign the cost per case mix unit, as defined in paragraph (D)(2) of this rule.
Effective: 07/01/2007
R.C. 119.032 review dates: 07/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.23