5101:3-3-16.3 Private rooms in nursing facilities (NFs).

(A) Medical necessity.

(1) A nursing facility (NF) operator shall provide private room accommodations for a medicaid eligible resident if the resident requires a private room due to medical necessity.

(2) Medicaid payment shall be considered payment in full, and no supplemental payment may be requested or accepted from a resident or a resident's representative.

(B) Semiprivate or ward accommodations unavailable.

(1) Medicaid shall not pay more for a private room than the current medicaid per diem rate the facility is receiving if semiprivate or ward accommodations are not available.

(2) Medicaid payment shall be considered payment in full, and no supplemental payment may be requested or accepted from a resident or a resident's representative.

(C) Supplemental payment.

If semiprivate or ward accommodations are available and are offered to a resident but the resident or the resident's representative makes a written request for a private room, the private room shall be considered a non-covered service for which the facility may seek supplemental payment from the resident or the resident's representative. Such supplemental payment shall conform to all of the following:

(1) The supplemental payment amount shall represent no more than the difference between the charge to private pay residents for a semiprivate room and the charge to private pay residents for a private room; and

(2) The charge for the private room shall not include charges for services covered by medicaid, whether or not medicaid payment meets a NF operator's cost for the per diem service; and

(3) A NF operator shall 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 the resident's family; and

(4) The written request for a private room shall be kept in the resident's file; and

(5) The amount of any supplemental payment shall not be considered an offset in determining patient liability for cost of care. All income that would otherwise be considered available to apply to the cost of care at the medicaid rate shall continue to be considered available.

Replaces: 5101:3-3-23

Effective: 04/01/2008
R.C. 119.032 review dates: 04/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 3721.16
Prior Effective Dates: 9/2/82, 1/1/95, 7/1/00, 7/1/03