This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and
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| Rule |
Rule 5123-7-01 | Intermediate care facilities for individuals with intellectual disabilities - definitions.
For the purposes of rules in Chapters 5123-7 and
5123:2-7 of the Administrative Code, the following definitions shall apply
unless otherwise provided: (A) "Allowable costs" are those
costs incurred for certified beds in an ICFIID as determined by the department
to be reasonable, as defined in paragraph (K) of this rule, and do not include
recoupments, fines, penalties, or interest paid in accordance with sections
5124.39, 5124.41, 5124.42, 5124.523, and 5124.99 of the Revised Code. Unless
otherwise enumerated in Chapter 5123-7 or 5123:2-7 of the Administrative Code,
allowable costs are also determined in accordance with the following reference
material, in the following priority: (1) 42 C.F.R. Chapter IV,
as in effect on the effective date of this rule; (2) The centers for
medicare and medicaid services provider reimbursement manual (publications 15-1
and 15-2, available at
https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals.html);
and (3) Generally accepted
accounting principles in accordance with standards prescribed by the
"American Institute of Certified Public Accountants" (available at
https://www.aicpa.org). (B) "Date of licensure," for an ICFIID originally
licensed as a nursing home under Chapter 3721. of the Revised Code, means the
date specific beds were originally licensed as nursing home beds under that
chapter, regardless of whether they were subsequently licensed as residential
facility beds. For a facility originally licensed as a residential facility,
"date of licensure" means the date specific beds were originally
licensed as residential facility beds under that section. (1) If nursing home beds
licensed under Chapter 3721. of the Revised Code or residential facility beds
licensed under section 5123.19 of the Revised Code were not required by law to
be licensed when they were originally used to provide nursing home or
residential facility services, "date of licensure" means the date the
beds first were used to provide nursing home or residential facility services,
regardless of the date the present provider obtained licensure. (2) If a facility adds
nursing home or residential facility beds or in the case of an ICFIID with more
than eight beds or a nursing facility, it extensively renovates the facility
after its original date of licensure, it will have a different date of
licensure for the additional beds or for the extensively renovated facility,
unless, in the case of the addition of beds, the beds are added in a space that
was constructed at the same time as the previously licensed beds but was not
licensed under Chapter 3721. or section 5123.19 of the Revised Code at that
time. The licensure date for additional beds or facilities which extensively
renovate shall be the date the beds are placed into service. (C) "Department" means the Ohio
department of developmental disabilities. (D) "Fiscal year" means the fiscal year of this
state, as specified in section 9.34 of the Revised Code. (E) "Inpatient days" means all days during which
a resident, regardless of payment source, occupies a bed in an ICFIID that is
included in the ICFIID's certified capacity under Title XIX of the Social
Security Act, 49 stat. 620 , 42 U.S.C.A. 301, as in effect on the effective
date of this rule. Bed-hold days determined in accordance with rule 5123:2-7-08
of the Administrative Code are considered inpatient days proportionate to the
percentage of the ICFIID's per resident per day rate paid for those
days. (F) "Intermediate care facility for
individuals with intellectual disabilities" (or "ICFIID") has
the same meaning as in section 5124.01 of the Revised Code. (G) "Owner" means any person or government entity
that has at least five per cent ownership or interest, either directly,
indirectly, or in any combination, in an ICFIID. (H) "Provider" means a person or government
entity that operates an ICFIID under a provider agreement. (I) "Provider agreement" means a contract between
the Ohio department of medicaid and an operator of an ICFIID for the provision
of ICFIID services under the medicaid program. The signature of the operator or
the operator's authorized agent binds the operator to the terms of the
agreement. (J) "Qualified intellectual
disability professional" has the same meaning as in 42 C.F.R. 483.430, as
in effect on the effective date of this rule. (K) "Reasonable" means that a cost is an actual
cost that is appropriate and helpful to develop and maintain the operation of
an ICFIID and resident activities, including normal standby costs, and that
does not exceed what a prudent buyer pays for a given item or service.
Reasonable costs may vary from provider to provider and from time to time for
the same provider. (L) "Related party" means an individual or
organization that, to a significant extent, has common ownership with, is
associated or affiliated with, has control of, or is controlled by, the
provider. (1) An individual who is
a relative of an owner is a related party. (2) Common ownership
exists when an individual or individuals possess significant ownership or
equity in both the provider and the other organization. Significant ownership
or equity exists when an individual or individuals possess five per cent
ownership or equity in both the provider and a supplier. Significant ownership
or equity is presumed to exist when an individual or individuals possess ten
per cent ownership or equity in both the provider and another organization from
which the provider purchases or leases real property. (3) Control exists when
an individual or organization has the power, directly or indirectly, to
significantly influence or direct the actions or policies of an
organization. (4) An individual or
organization that supplies goods or services to a provider shall not be
considered a related party if all of the following conditions are
met: (a) The supplier is a separate bona fide
organization; (b) A substantial part of the supplier's business
activity of the type carried on with the provider is transacted with others
than the provider and there is an open, competitive market for the types of
goods or services the supplier furnishes; (c) The types of goods or services are commonly obtained by
other ICFIID from outside organizations and are not a basic element of resident
care ordinarily furnished directly to residents by the ICFIID; and (d) The charge to the provider is in line with the charge
for the goods or services in the open market and no more than the charge made
under comparable circumstances to others by the supplier. (M) "Relative of an owner" means a person who is
related to an owner of an ICFIID by one of the following
relationships: (1) Spouse; (2) Natural parent,
child, or sibling; (3) Adopted parent,
child, or sibling; (4) Stepparent,
stepchild, stepbrother, or stepsister; (5) Father-in-law,
mother-in-law, son-in-law, daughter-in-law, brother-in-law, or
sister-in-law; (6) Grandparent or
grandchild; or (7) Foster parent, foster
child, foster brother, or foster sister. (N) "Representative" means a person acting on
behalf of an individual who is applying for or receiving medicaid. A
representative may be a family member, guardian, attorney, hospital social
worker, ICFIID social worker, or any other person chosen to act on the
individual's behalf. (O) "State survey agency" means the agency that
inspects long-term care facilities for the purposes of survey and
certification. The state survey agency in Ohio is the Ohio department of
health.
Last updated April 12, 2024 at 11:52 AM
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Rule 5123-7-02 | Intermediate care facilities for individuals with intellectual disabilities - provider agreement and other essential requirements.
Effective:
December 16, 2019
(A) Purpose This rule sets forth requirements for an
intermediate care facility for individuals with intellectual disabilities
(ICFIID) to be eligible for initial and continued participation in the Ohio
medicaid program and to receive payment for ICFIID services to eligible
residents. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Certification" means the process by which
the Ohio department of health certifies its findings to the federal centers for
medicare and medicaid services or the Ohio department of medicaid with respect
to a facility's compliance with health and safety requirements of
divisions (a), (b), (c), and (d) of section 1919 of the Social Security Act, 42
U.S.C. 1396r (1999). (2) "Certified
beds" means beds that are counted in a facility that meets medicaid
standards. A count of facility beds may differ depending on whether the count
is used for certification, licensure, eligibility for medicaid payment
formulas, eligibility for waivers, or other purposes. (3) "Change of
operator" has the same meaning as in section 5124.01 of the Revised
Code. (4) "Facility
closure" has the same meaning as in section 5124.01 of the Revised
Code. (5) "Operator"
means the individual, partnership, association, trust, corporation, or other
legal entity that operates an ICFIID. (6) "Residential
respite" has the same meaning as in rule 5123-9-34 of the Administrative
Code. (7) "Voluntary termination" has
the same meaning as in section 5124.01 of the Revised Code. (C) Eligibility for
participation (1) To participate in
the Ohio medicaid program an operator shall: (a) Operate a residential facility licensed by the
department in accordance with section 5123.19 of the Revised Code and rules
adopted to implement that section. (b) Operate a facility certified by the Ohio department of
health as being in compliance with applicable federal regulations for medicaid
participation as an ICFIID with a minimum of four certified beds. A
facility's certification as an ICFIID by the Ohio department of health
governs the types of services the facility may provide. (c) Hold a medicaid provider agreement with the Ohio
department of medicaid to operate the ICFIID. (2) An operator shall: (a) Execute the provider agreement in the format provided
by the Ohio department of medicaid. (b) Apply for and maintain a valid license issued by the
department. (c) Comply with the provider agreement and all applicable
federal, state, and local laws and rules. (d) Open all records relating to the costs of its services
for inspection and audit by the department and the Ohio department of
medicaid. (e) Supply to the department and the Ohio department of
medicaid such information as the department or the Ohio department of medicaid
requires concerning services to individuals who have applied for or been
determined to be eligible for medicaid. (f) Permit access to the ICFIID and its records for
inspection by the department, the Ohio department of medicaid, the Ohio
department of health, the county department of job and family services, and any
other state or local government entity having authority to inspect, to the
extent of that entity's authority. (g) In the case of a change of operator, adhere to the
following procedures: (i) The exiting operator
or owner and entering operator must provide a written notice to the department
and the Ohio department of medicaid, as provided in section 5124.51 of the
Revised Code, at least forty-five calendar days prior to the effective date of
any actions that constitute a change of operator, but at least ninety calendar
days prior to the effective date if residents are to be relocated. An exiting
operator that does not give proper notice is subject to the penalties specified
in section 5124.42 of the Revised Code. (ii) The entering
operator must submit documentation of any transaction (e.g., sales agreement,
contract, or lease) as requested by the department or the Ohio department of
medicaid to determine whether a change of operator has occurred. (iii) The entering
operator shall submit an application for participation in the medicaid program
and a written statement of intent to abide by rules of the department and the
Ohio department of medicaid, the provisions of the assigned provider agreement,
and any centers for medicare and medicaid services "Statement of
Deficiencies and Plan of Correction" forms (CMS-2567, February 1999)
submitted by the exiting operator. (iv) 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 the
Ohio department of health. There may be gaps in medicaid coverage at the
facility. (h) Comply with Title VI of the Civil Rights Act, 42 U.S.C.
2000d (1964), Title VII of the Civil Rights Act, 42 U.S.C. 2000e (1991), and
the Americans with Disabilities Act of 1990, 42 U.S.C. 12101 (2008), and shall
not discriminate against any resident on the basis of race, color, age, sex,
gender, sexual orientation, creed, national origin, ancestry, religion, or
disability. (i) Provide notice to the department within five calendar
days of any bankruptcy or receivership pertaining to the provider. All requests
shall be in writing and shall be mailed to "Ohio Department of
Developmental Disabilities, Division of Medicaid Development and
Administration, 30 East Broad Street, 13th Floor, Columbus, Ohio
43215-3414." (j) Provide the department, the Ohio department of
medicaid, the resident or guardian (as applicable), and anyone designated by
the resident or guardian written notice at least ninety calendar days prior to
a facility closure or voluntary termination from the medicaid program in
accordance with section 5124.50 of the Revised Code. An operator that does not
issue the proper notice is subject to the penalties specified in section
5124.42 of the Revised Code. (3) An operator shall not: (a) Charge, to an individual or applicant who is eligible
for medicaid: (i) A fee for the
application process; (ii) An admission fee;
or (iii) An advance
deposit. (b) Directly bill its residents for or directly pass
through to its residents the franchise permit fee. (c) Require a third party to accept personal responsibility
for paying the ICFIID charges out of his or her own funds. An operator,
however, may require a representative who has legal access to an
individual's income or resources available to pay for ICFIID services to
sign a contract, without incurring personal financial liability, to provide
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 operator from obtaining information about
medicare and medicaid eligibility or the availability of private insurance. The
prohibition against third-party guarantees applies to all residents and
prospective residents of an ICFIID regardless of payment source. This provision
does not prohibit a third party from voluntarily making payment on behalf of an
individual. (D) Effective dates of provider agreements (1) Effective dates of
initial provider agreements generally are assigned by the Ohio department of
health on the basis of findings of compliance or substantial compliance with
standards of certification. (2) If a provider
agreement is involuntarily terminated by the centers for medicare and medicaid
services as the result of a look behind survey, re-entry into the medicaid
program requires satisfaction of the reasonable assurance period as set forth
in the "Medicaid State Operations Manual," chapter 2, section 2016F
(October 17, 2018). (E) Conditional provider agreements and cancellation
clauses (1) If the Ohio
department of health determines that an ICFIID is in substantial compliance
with medicaid standards but has deficiencies that must be corrected, the Ohio
department of medicaid may execute a conditional provider agreement for a term
of up to twelve full calendar months, subject to an automatic cancellation
clause. (2) The ICFIID must
correct deficiencies within sixty calendar days following the scheduled date of
correction as established by the Ohio department of health. (3) If deficiencies are
corrected before the cancellation date, the Ohio department of health may
rescind the cancellation notice, and shall notify the department and the Ohio
department of medicaid in writing of its decision. (4) If deficiencies are
not corrected before the cancellation date, the Ohio department of health may
propose termination of the provider agreement. (5) If deficiencies are
not corrected, the Ohio department of medicaid may cancel the provider
agreement in accordance with section 5164.38 of the Revised Code, unless the
Ohio department of health: (a) Finds that all required corrections have been made and
notifies the department and the Ohio department of medicaid; or (b) Determines that substantial progress has been made in
carrying out a plan of correction that has been submitted to and accepted by
the Ohio department of health. (F) Termination, suspension, denial, or
non-renewal of provider agreement (1) At the request of the department or
upon its own initiative, the Ohio department of medicaid may terminate,
suspend, or not enter into the provider agreement upon thirty calendar days
written notice to the provider for a violation of Chapter 5123., 5124., or
5160. of the Revised Code or rules adopted pursuant to those chapters and if
applicable, subject to Chapter 119. of the Revised Code. (2) In accordance with
section 5164.33 of the Revised Code, a provider agreement may be terminated,
suspended, denied, or not revalidated if the Ohio department of medicaid
determines such an agreement is not in the best interests of the state or
medicaid recipients. (3) The Ohio department
of medicaid shall terminate, deny, or not revalidate a provider agreement when
any of the situations set forth in division (E) of section 5164.38 of the
Revised Code occur. (G) Waiver of licensed
capacity (1) To accommodate
persons in emergency need of ICFIID services, the department may issue an
operator a waiver of licensed capacity. A waiver of licensed capacity is
time-limited and temporarily permits the operator to exceed the maximum number
of licensed beds. (2) A waiver of licensed
capacity may be made specifically in order to provide residential respite as a
prior-authorized service to a person enrolled in a home and community-based
services waiver. Beds designated for residential respite for persons enrolled
in home and community-based services waivers shall not be included in the
provider agreement. (H) Beds subject to certification
survey (1) All beds in a
medicaid-participating ICFIID that are not designated for residential respite
for persons enrolled in home and community-based services waivers shall be
surveyed to determine compliance with the applicable certification
standards. (2) If the beds are
certifiable, they shall be included in the provider agreement. (3) Beds authorized
through a waiver of licensed capacity in accordance with paragraph (G)(1) of
this rule that are used to provide ICFIID services shall be included in the
provider agreement. (4) The only other basis
for allowing non-participation of a portion of an Ohio ICFIID is certification
of noncompliance by the Ohio department of health. (I) Requirements for out-of-state
providers of ICFIID services To participate in the Ohio medicaid program and
receive payment for ICFIID services to eligible Ohio residents, an operator of
a facility located outside Ohio shall: (1) Hold a valid
state-required license, registration, or equivalent from the respective state
that specifies the level of care the facility is qualified to
provide; (2) Hold a medicaid
provider agreement from the respective state as an ICFIID provider
type; (3) Hold a medicaid
provider agreement with the Ohio department of medicaid; and (4) Obtain
resident-specific and date-specific prior authorization in accordance with
rules 5160-1-11 and 5160-1-31 of the Administrative Code.
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Rule 5123-7-04 | Intermediate care facilities for individuals with intellectual disabilities - payment during the Ohio department of medicaid administrative appeals process for termination of a provider agreement.
Effective:
December 16, 2019
(A) Purpose This rule clarifies conditions under which
payment may be made to an intermediate care facility for individuals with
intellectual disabilities (ICFIID) during proposed termination and upon
termination of the ICFIID's provider agreement by the Ohio department of
medicaid. (B) Payment during the appeals
process When the Ohio department of medicaid 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 of an ICFIID's
provider agreement. Payment shall not be made under this provision for services
rendered on or after the effective date of the issuance of a final order of
adjudication pursuant to Chapter 119. of the Revised Code, except as provided
in paragraph (C)(1) of this rule. (C) Payment following termination of
provider agreement (1) Payment may be
provided up to thirty calendar days following the effective date of termination
of an ICFIID's provider agreement or after an administrative hearing
decision that upholds the termination action. Payment will be available if both
of the following conditions are met: (a) Payment is for residents admitted to the ICFIID before
the effective date of termination; and (b) The ICFIID cooperates with federal, state, and local
entities in the effort to transfer residents to other facilities or community
programs that can meet the residents' needs. (2) When the Ohio
department of medicaid 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 5123-7-05 | Intermediate care facilities for individuals with intellectual disabilities - payment during the Ohio department of health administrative appeals process for termination or non-renewal of medicaid certification.
Effective:
December 16, 2019
(A) Purpose This rule clarifies conditions under which
payment may be made to an intermediate care facility for individuals with
intellectual disabilities (ICFIID) during proposed termination or non-renewal
and upon termination or non-renewal of the ICFIID's medicaid certification
by the Ohio department of health. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Effective date
of termination" means the date set by the Ohio department of health or the
United States department of health and human services for the termination of
medicaid certification. (2) "Informal
reconsideration" is the process by which an ICFIID may refute in writing,
prior to the termination or non-renewal of medicaid certification, the Ohio
department of health's findings on which the termination or non-renewal is
based. The ICFIID must receive a written response to the informal
reconsideration request which either affirms or reverses the survey decisions.
Informal reconsideration is a process independent of the formal appeal. An
ICFIID may or may not choose to utilize informal reconsideration. (C) Informal reconsideration In addition to or in conjunction with the appeals
process, an ICFIID may request informal reconsideration. If informal
reconsideration results in an affirmation of the original survey findings, the
appeals process moves forward to the administrative hearing if one was
requested. If informal reconsideration results in a reversal of the original
survey findings, the Ohio department of health's termination or
non-renewal action, based on those original findings, is dismissed. (D) Payment during the appeals
process (1) During the appeals
process provided by the Ohio department of health in accordance with rule
3701-63-01 of the Administrative Code for the proposed termination or
non-renewal of medicaid certification, payment under regulations for covered
services provided to eligible residents shall continue through the earlier
of: (a) The date of issuance of a final order of adjudication
that upholds the Ohio department of health's termination or non-renewal
action; or (b) The one hundred twentieth calendar day after the
effective date of termination of the ICFIID's provider
agreement. (2) Payment may be
provided up to an additional thirty calendar days following either the
cessation of payment on the one hundred twentieth calendar day post termination
or non-renewal; or after the issuance of an adjudication order that upholds the
termination or non-renewal action. Payment will be available if both of the
following conditions are met: (a) Payment is for residents admitted to the ICFIID before
the effective date of termination or non-renewal; and (b) The ICFIID cooperates with federal, state, and local
entities in the effort to transfer residents to other facilities or community
programs that can meet the residents' needs. (E) Payment following termination of
medicaid certification (1) When the Ohio
department of medicaid acts under instructions from the United States
department of health and human services, payment ends on the termination date
specified by that agency. (2) When the Ohio
department of health 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. (F) Termination of provider
agreement When an ICFIID's medicaid certification is
terminated or not renewed, the Ohio department of medicaid shall terminate the
ICFIID's provider agreement.
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Rule 5123-7-08 | Intermediate care facilities for individuals with intellectual disabilities - bed-hold days.
Effective:
October 15, 2021
(A) Purpose This rule establishes requirements and procedures
for an intermediate care facility for individuals with intellectual
disabilities (ICFIID) to be reimbursed for reserving a bed for a resident who
is temporarily absent. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Admission"
occurs when an individual who was not being counted in the census of any Ohio
medicaid-certified ICFIID becomes a resident of an ICFIID. An admission may be
a new admission or a return admission after a discharge. (2) "Advanced
practice registered nurse" has the same meaning as in section 4723.01 of
the Revised Code. (3) "Bed-hold day" means a day
for which a bed is reserved for a resident of an ICFIID through medicaid
reimbursement while the resident is temporarily absent from the ICFIID for
hospitalization, therapeutic leave, or a visit with friends or relatives.
Reimbursement for bed-hold days may be made only if the resident has the intent
and ability or may have cause to return to the same ICFIID. A resident on
bed-hold day status is not considered discharged because the ICFIID is
reimbursed to hold the bed while the resident is on temporary
leave. (4) "Business day" means a day
of the week, excluding Saturday, Sunday, or a legal holiday as defined in
section 1.14 of the Revised Code. (5) "Discharge" means the full
release of a resident from an ICFIID so that he or she is no longer counted in
the ICFIID's census. Reasons for discharge include, but are not limited
to, the resident's move to another ICFIID, decision to reside in a
community-based setting, or death. The day of discharge is not counted as a
bed-hold day or an occupied day except when discharge and admission occur on
the same day, in which case the day is considered a day of admission and counts
as one occupied day. (6) "Home and community-based
services" has the same meaning as in section 5123.01 of the Revised
Code. (7) "Hospital" has the same
meaning as in rule 3701-59-01 of the Administrative Code. (8) "Hospitalization" means a
resident is temporarily absent from an ICFIID for the purpose of receiving
services or being treated in a hospital. (9) "Institution for mental
disease" has the same meaning as in rule 5160-3-16.4 of the Administrative
Code. (10) "Occupied day" means
either: (a) A day of admission; or (b) A day during which a medicaid-eligible resident's
stay in an ICFIID is eight or more hours. A day begins at twelve a.m. and ends
at eleven fifty-nine p.m. (11) "Readmission" occurs when a
resident returns to the same ICFIID following use of bed-hold
days. (12) "Skilled nursing facility"
means a nursing facility certified to participate in the medicare
program. (13) "Therapeutic leave" means a
resident is temporarily absent from an ICFIID, 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 of therapeutic services or visiting a potential new
residential setting. (C) Prohibition of preadmission bed-hold
payment (1) The department shall
not make payment to an ICFIID to reserve a bed for a medicaid-eligible
prospective resident. (2) An ICFIID shall not
accept preadmission payment to reserve a bed from a medicaid-eligible
prospective resident or from any other source on the prospective
resident's behalf as a precondition for admission. (D) Limits and reimbursement for bed-hold
days (1) For a
medicaid-eligible resident of an ICFIID, except those excluded in accordance
with paragraph (H) of this rule, the department may reimburse the ICFIID to
reserve a bed only for as long as the resident has a developmental disabilities
level of care determination and intends or may have cause to return to the same
ICFIID, but not for more than thirty days in any calendar year unless
additional days have been authorized by the department in accordance with
paragraph (E) of this rule. (2) Reimbursement for
bed-hold days shall be paid at one hundred per cent of the ICFIID's per
diem rate. (3) Reimbursement for
bed-hold days may be made for the following reasons: (a) Hospitalization Bed-hold days used for hospitalization may be
reimbursed only until: (i) The day the
resident's anticipated level of care at time of discharge from the
hospital changes to a level of care that the ICFIID is not certified to
provide; (ii) The day the resident
is discharged from the hospital, including discharge resulting in transfer to
the ICFIID, a nursing facility, or a skilled nursing facility; (iii) The day the
resident decides to go to another ICFIID upon discharge from the hospital and
notifies the first ICFIID; or (iv) The day the
hospitalized resident dies. (b) Therapeutic leave (i) A plan to use
bed-hold days for therapeutic leave for the purpose of receiving a regimen of
therapeutic services must be approved in advance by a physician or an advanced
practice registered nurse and documented in the resident's medical record.
The documentation shall be available for viewing by the
department. (ii) A plan to use
bed-hold days for therapeutic leave for the purpose of visiting a potential new
residential setting must be approved in advance by a physician, an advanced
practice registered nurse, or a qualified intellectual disability professional
and documented in the resident's medical record or individual plan. The
documentation shall be available for viewing by the department. (iii) An ICFIID shall make arrangements for the resident to
receive required care and services while on approved therapeutic leave.
Medicaid funding, however, shall not be used for state plan home health
services, durable medical equipment, and/or private duty nursing on days for
which the ICFIID receives reimbursement for bed-hold days. (c) Visit with friends or relatives (i) A plan to use
bed-hold days to visit with friends or relatives must be approved in advance by
a physician, an advanced practice registered nurse, or a qualified intellectual
disability professional and documented in the resident's medical record or
individual plan. The documentation shall be available for viewing by the
department. (ii) An ICFIID shall make
arrangements for the resident to receive required care and services while on
approved visits. Medicaid funding, however, shall not be used for state plan
home health services, durable medical equipment, and/or private duty nursing on
days for which the ICFIID receives reimbursement for bed-hold
days. (iii) The number of days
per visit is flexible within the maximum bed-hold days, allowing for
differences in the resident's physical condition, the type of visit, and
travel time. (4) The number and
frequency of bed-hold days used shall be considered in evaluating the
continuing need of a resident for care in an ICFIID. (E) Requests for additional bed-hold
days (1) Additional bed-hold
days beyond the original thirty days in a calendar year require prior
authorization except in the event of an emergency situation. In the event of an
emergency situation, authorization may be requested after the fact if the
request is submitted no later than one business day following the first
additional bed-hold day. A maximum of thirty additional consecutive bed-hold
days may be authorized per request. (2) An ICFIID shall
submit a request for additional bed-hold days to the department electronically
via the department's website. The request shall be consistent with the
goals of the resident's individual plan and medical records and
include: (a) Reason for bed-hold days (i.e., hospitalization,
therapeutic leave, or visit with friends or relatives); (b) Projected dates of absence; and (c) Projected date of return. (3) The department shall review the
request for additional bed-hold days and send notice within five business days
of approval or denial to the ICFIID. (a) When a request is approved, the notice shall specify
the time period during which the bed-hold days may be used. (b) When a request is denied, the notice shall specify the
reason for denial and explain the individual's right to a state hearing in
accordance with section 5101.35 of the Revised Code. (4) The department shall review requests
for additional bed-hold days on a case-by-case basis. Conditions under which a
request may be denied include, but are not limited to, visits with friends or
relatives exceeding thirty consecutive days or forty-five total days in a
calendar year. (5) An approved request for additional
bed-hold days is for the specified period of time only. Unused bed-hold days
from an approved request shall not be used at a later time. A new request must
be submitted if additional bed-hold days are required during that same calendar
year. (6) Bed-hold days beyond the original
thirty days used without prior authorization by the department may result in an
adjustment to the ICFIID's reimbursement. (F) Readmission An ICFIID shall readmit a resident upon depletion
of approved bed-hold days or at any time prior to depletion of approved
bed-hold days upon the resident's request for readmission. (G) Residents eligible for bed-hold
days (1) Medicaid
reimbursement for bed-hold days is available under the provisions specified in
this rule if a resident: (a) Is eligible for medicaid services and has met the
patient liability and financial eligibility requirements set forth in Chapter
5160:1-6 of the Administrative Code; (b) Requires a developmental disabilities level of care;
and (c) Is not excluded in accordance with paragraph (H) of
this rule. (2) If a resident meets
all of the criteria in paragraph (G)(1) of this rule and is pending approval of
a medicaid application and requires bed-hold days, medicaid reimbursement shall
be made retroactive to the date the resident became medicaid-eligible and
approved for medicaid vendor reimbursement through the date the resident
returns from a leave or until the maximum number of bed-hold days are
exhausted. (H) Exclusions Bed-hold days are not available to a
medicaid-eligible resident of an ICFIID who is: (1) Enrolled in a
medicare or medicaid hospice program; (2) Over age twenty-one
and under age sixty-five and becomes a patient of an institution for mental
disease; (3) Enrolled in a home
and community-based services waiver; (4) In a period of
restricted medicaid coverage because of an improper transfer of resources as
set forth in rule 5160:1-6-06.5 of the Administrative Code; or (5) Relocating due to
anticipated closure of an ICFIID, an ICFIID's voluntary withdrawal from
participation in the medicaid program, or other events that result in
termination of an ICFIID's medicaid provider agreement except when the
ICFIID becomes a downsized ICFIID as defined in section 5124.01 of the Revised
Code or converts beds from ICFIID services to home and community-based services
in accordance with section 5124.60 or 5124.61 of the Revised Code. No span of
bed-hold days shall be approved that ends on an ICFIID's date of closure
or termination from participation in the medicaid program. (I) Compliance (1) Without limiting such
other remedies provided by law for noncompliance with this rule: (a) The Ohio department of medicaid may terminate the
ICFIID's provider agreement; or (b) The department may require the ICFIID to submit and
implement a corrective action plan on a schedule specified by the
department. (2) An ICFIID shall
cooperate with any investigation and shall provide copies of any records
requested by the department or the Ohio department of medicaid.
Last updated October 15, 2021 at 8:29 AM
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Rule 5123-7-09 | Intermediate care facilities for individuals with intellectual disabilities - personal needs allowance accounts.
Effective:
April 27, 2023
(A) Purpose This rule establishes requirements and procedures
regarding personal needs allowance accounts of residents of an intermediate
care facility for individuals with intellectual disabilities (ICFIID). (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Patient
liability" means an individual's financial obligation toward the
medicaid cost of care. (2) "Personal needs allowance"
means a required deduction in the computation of patient liability for needs of
a resident of an ICFIID. (3) "Personal needs allowance
account" means an account or petty cash fund that holds the personal needs
allowance funds of a resident of an ICFIID and is managed for the resident by
the ICFIID. (C) Management of resident
funds (1) An ICFIID will allow
residents to manage their financial affairs and teach them to do so to the
extent of their capabilities in accordance with 42 C.F.R. 483.420, as in effect
on the effective date of this rule. (2) An ICFIID will hold,
safeguard, manage, account for, and convey a resident's funds in
accordance with rule 5123-2-07 of the Administrative Code. (D) Personal needs allowance
account (1) A medicaid-eligible
resident of an ICFIID may retain a personal needs allowance account in the
amount set forth in section 5163.33 of the Revised Code. (2) A personal needs
allowance account is the exclusive property of the resident, who may use the
funds as the resident chooses in any lawful manner. (3) An ICFIID shall not
require a resident to deposit personal needs allowance funds with the ICFIID; a
resident wishing to do so will submit a request to the ICFIID in
writing. (4) An ICFIID shall
explain both verbally and in writing to a resident or the resident's
representative, as applicable, that personal needs allowance funds are for the
resident to use as the resident chooses. If a resident's representative is
the payee for the resident's personal needs allowance account, the
resident's representative is responsible for ensuring that the funds are
used to meet the personal needs of the resident. (E) Notification of certain balances and
transactions that may affect medicaid eligibility (1) When the funds in a
personal needs allowance account of a medicaid-eligible resident reach two
hundred dollars less than the resource limit set forth in rule 5160:1-3-05.1 of
the Administrative Code or section 5163.092 of the Revised Code, as applicable,
the ICFIID shall: (a) Give written notice to the resident or the resident's
representative, as applicable, that the resident may lose medicaid eligibility
if the amount in the personal needs allowance account, in addition to the value
of other nonexempt resources, exceeds the resource limit and retain a copy of
the written notice in the resident's file; and (b) Work with the resident or the resident's representative,
as applicable, and the county department of job and family services to
coordinate a spenddown plan. (2) An ICFIID shall
report to the county department of job and family services any personal needs
allowance account balance in excess of the resource limit. The county
department of job and family services will apply the excess amount to the
routine cost of the resident's ICFIID services. (3) If a resident is
considering using personal needs allowance funds to purchase life insurance,
grave space, a burial account, or other item that may be considered a countable
resource, the ICFIID shall refer the resident or the resident's
representative, as applicable, to the county department of job and family
services for an explanation of the effect the purchase may have on the
resident's medicaid eligibility. (F) Limitations on charges to the personal needs allowance
account (1) An ICFIID shall not
charge a resident's personal needs allowance account for items and
services that the ICFIID is required to furnish in order to participate in the
medicaid program and that are included in medicaid payments made to the ICFIID.
An ICFIID shall provide or arrange for, at no charge to a resident, any item or
service that is ordered by a physician, determined medically necessary by the
resident's team, and does not conflict with any state or federal
regulations. (2) Items and services that may not be
purchased with personal needs allowance account funds include, but are not
limited to: (a) Nursing services; (b) Dietary services; (c) Activities programs; (d) Room and board maintenance services; (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, feminine hygiene products, towels, washcloths, hospital gowns,
over-the-counter medication, hair and nail hygiene services, and basic personal
laundry; (f) Medically related social services; (g) Medical supplies such as irrigation trays, catheters,
drainage bags, syringes, and needles; (h) Durable medical equipment; (i) Air conditioners or charges to resident for the use of
electricity; (j) Therapy or podiatry services; and (k) Charges for telephone consultation by physicians or other
personnel. (G) Resident requests for items and
services (1) A resident's
personal needs allowance account funds may be used to purchase only those items
and services requested by the resident. (2) When a resident
requests an item or service for which a charge to the resident's personal
needs allowance account will be made, the ICFIID shall inform the resident that
there will be a charge and the amount of the charge. (3) An ICFIID shall not
require a resident to request an item or service as a condition for admission
to, or continued stay in, the ICFIID. (H) Items and services that may be
charged to the personal needs allowance account (1) An ICFIID shall
accept medicaid payment as payment in full for items and services that are
covered by the medicaid program. If a resident clearly expresses a desire for a
particular brand or item not available from the ICFIID, the resident's
personal needs allowance funds may be used as long as a comparable item of
reasonable quality is available from the ICFIID at no charge. (2) Items and services
that may be charged to a resident's personal needs allowance account
include, but are not limited to: (a) Telephone, television, or radio for the resident's
exclusive use; (b) Personal comfort items, including smoking materials, notions,
novelties, and confections; (c) Cosmetics and grooming items and services in excess of those
for which payment is made under the medicaid program; (d) Personal reading material; (e) Stationary or stamps; (f) Personal clothing in excess of that required by paragraph
(H)(1) of rule 5123-3-04 of the Administrative Code; (g) Specialty laundry services such as dry cleaning, mending, or
hand-washing; (h) Flowers or plants; (i) Gifts the resident purchases for others; (j) Social events or entertainment offered outside the scope of
the ICFIID's activities program; and (k) Burial plots. (I) Monitoring The county department of job and family services
will monitor personal needs allowance accounts in accordance with section
5163.33 of the Revised Code. At least once a quarter, a designated employee of
the county department of job and family services will determine if an ICFIID is
following the provisions of this rule and report any questions concerning
inappropriate use or inadequate record keeping of personal needs allowance
funds to the department and to the Ohio department of health for further
action. Inappropriate use of personal needs allowance funds by a payee or an
ICFIID does not, however, reduce the scope or duration of medicaid benefits for
a medicaid recipient. (J) Disposition of personal needs
allowance account funds in the event of a resident's death (1) A department-operated
ICFIID that has possession of a resident's personal needs allowance
account funds at the time of the resident's death will dispose of the
funds in accordance with section 5123.28 of the Revised Code. (2) An ICFIID other than
a department-operated ICFIID that has possession of a resident's personal
needs allowance account funds at the time of the resident's death will
dispose of the funds in accordance with paragraphs (J)(2)(a) to (J)(2)(c) of
this rule, as applicable. (a) If funeral or burial expenses for a deceased resident
have not been paid and the only resource left to pay those expenses is the
resident's personal needs allowance account funds, or all other resources
of the resident are inadequate to pay the full amount, the resident's
personal needs allowance account funds will be used to pay the
expenses. (b) If, within sixty calendar days after the
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
ICFIID will transfer the resident's personal needs allowance account funds
and a final accounting of those funds to the administrator, executor,
commissioner, or person who filed the application for release from
administration. (c) If, within sixty calendar days after the
resident's death, letters testamentary or letters of administration 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 ICFIID
will transfer the resident's personal needs allowance account funds to the
Ohio department of medicaid no earlier than sixty calendar days and no later
than ninety calendar days after the resident's death, with the exception
of the amount used for funeral or burial expenses in accordance with paragraph
(J)(2)(a) of this rule. Personal needs allowance account funds transferred to
the Ohio department of medicaid will be accompanied by a completed Ohio
department of medicaid form 09405, "Personal Needs Allowance Account
Remittance Notice," in accordance with the instructions on the
form.
Last updated April 27, 2023 at 8:42 AM
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Rule 5123-7-11 | Intermediate care facilities for individuals with intellectual disabilities - relationship of other covered medicaid services.
Effective:
April 27, 2023
(A) Purpose This rule identifies covered services generally
available to individuals who are eligible for medicaid and describes the
relationship of such services to those provided to residents of an intermediate
care facility for individuals with intellectual disabilities (ICFIID) other
than a department-operated ICFIID. Reimbursement of services through the
"ICFIID cost report mechanism" referenced in this rule is governed by
rule 5123-7-12 of the Administrative Code. (B) Dental services All covered dental services provided by licensed
dentists are reimbursed directly to the provider of the dental services in
accordance with Chapter 5160-5 of the Administrative Code. Personal hygiene
services provided by staff or contracted personnel of the ICFIID are reimbursed
through the ICFIID cost report mechanism. (C) 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 reimbursed through the ICFIID cost report
mechanism. All laboratory and x-ray procedures covered under the medicaid
program are reimbursed directly to the laboratory or x-ray provider in
accordance with Chapter 5160-11 of the Administrative Code. (D) Medical supplier
services (1) Medical supplier
services that are reimbursed through the ICFIID cost report mechanism
include: (a) Costs incurred for "needed medical and program
supplies," defined as items that have a very limited life expectancy. Such
items include atomizers, nebulizers, bed pans, catheters, electric pads,
hypodermic needles, syringes, incontinence pads, splints, and disposable
ventilator circuits. (b) Costs incurred for the purchase and repair of
"needed medical equipment," defined as items that can stand repeated
use, are primarily and customarily used to serve a medical purpose, are not
useful to a person in the absence of illness or injury, and are appropriate for
use in the ICFIID. Such items include hospital beds, wheelchairs, and
intermittent positive-pressure breathing machines, except as noted in paragraph
(D)(2) of this rule. (c) Costs of equipment associated with oxygen
administration such as carts, regulators, humidifiers, cannulas, masks, and
demurrage. (2) Medical supplier
services that are reimbursed directly to the medical supplier provider in
accordance with Chapter 5160-10 of the Administrative Code
include: (a) Certain durable medical equipment items, specifically,
ventilators and custom-made wheelchairs that have parts which are actually
molded to fit the resident. (b) "Prostheses," defined as devices that replace
all or part of a body organ to prevent or correct physical deformity or
malfunction. Such devices include artificial arms or legs, electro-larynxes,
and breast prostheses. (c) "Orthoses," defined as devices that assist in
correcting or strengthening a distorted part. Such devices include arm braces,
hearing aids and batteries, abdominal binders, and corsets. (d) Contents of oxygen cylinders or tanks including liquid
oxygen, except emergency stand-by oxygen which is reimbursed through the ICFIID
cost report mechanism. (e) Oxygen-producing machines (concentrators) for specific
use by an individual resident. (E) Pharmaceuticals (1) Over-the-counter
drugs covered in accordance with rule 5160-9-03 of the Administrative Code and
nutritional supplements are reimbursed through the ICFIID cost report
mechanism. (2) Pharmaceuticals
reimbursed directly to the pharmacy provider are subject to the limitations 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 resident. (b) A copy of all records regarding prescribed drugs for a
resident of an ICFIID will be retained by the dispensing pharmacy for at least
six years. A receipt for drugs delivered to an ICFIID will be signed by a
representative of the ICFIID at the time of delivery and a copy retained by the
pharmacy. (F) Therapy services (1) Costs incurred for
physical therapy, occupational therapy, speech therapy, and audiology services
provided by licensed therapists or therapy assistants that are covered for
residents of an ICFIID by medicaid are reimbursed through the ICFIID cost
report mechanism. (2) Costs incurred for
psychology services provided by licensed psychologists or psychology assistants
that are covered for residents of an ICFIID by medicaid are reimbursed through
the ICFIID cost report mechanism. No reimbursement for psychology services will
be made to a provider other than the ICFIID or a community mental health center
certified by the Ohio department of mental health and addiction services.
Services provided by an employee of the community mental health center will be
billed directly to medicaid by the community mental health center. (3) Costs incurred for
respiratory therapy services provided by licensed respiratory care
professionals that are covered for residents of an ICFIID by medicaid are
reimbursed through the ICFIID cost report mechanism. No reimbursement for
respiratory therapy services will be made to a provider other than the
ICFIID. (4) Reasonable costs for
rehabilitative, restorative, or maintenance therapy services rendered to
residents of an ICFIID by staff or contracted personnel of the ICFIID and the
overhead costs to support the provision of such services are reimbursed through
the ICFIID cost report mechanism. (G) Physician services (1) A physician may be
directly reimbursed for providing the following services to a resident of an
ICFIID: (a) All covered diagnostic and treatment services in
accordance with Chapter 5160-4 of the Administrative Code. (b) All medically necessary physician visits in accordance
with rule 5160-4-06 of the Administrative Code. (c) All required physician visits as described in this rule
when the services are billed in accordance with rule 5160-4-06 of the
Administrative Code. (i) Physician visits
provided to a resident of an ICFIID are considered timely if they occur no
later than ten calendar days after the date the visit was
requested. (ii) For reimbursement of
the required physician visits, the physician shall: (a) Review the resident's total program of care
including medications and treatments at each visit required by this
rule; (b) Write, sign, and date progress notes at each
visit; (c) Sign all orders; and (d) Personally visit the resident except as provided in
paragraph (G)(1)(c)(iii) of this rule. (iii) At the option of
the physician, required visits after the initial visit may be delegated in
accordance with paragraph (G)(1)(c)(iv) of this rule and alternate between
physician and visits by a physician assistant or certified nurse
practitioner. (iv) A physician may delegate tasks to a physician assistant
(in accordance with Chapter 4730. of the Revised Code and Chapter 4730-1 of the
Administrative Code) or a certified nurse practitioner (in accordance with
Chapter 4723. of the Revised Code and Chapter 4723-4 of the Administrative
Code) provided the physician assistant or certified nurse practitioner is
acting within the scope of practice and is under supervision and employment of
the billing physician. A physician will not delegate a task when regulations
specify that the physician must perform it personally or when delegation is
prohibited by state law or the ICFIID's policies. (2) Services directly
reimbursed to the physician will be: (a) Based on medical necessity, as defined in rule
5160-1-01 of the Administrative Code, and requested by the resident of the
ICFIID with the exception of the required visits described in paragraph
(G)(1)(c) of this rule. (b) Documented by entries in the resident's medical
record along with any symptoms and findings that are signed and dated by the
physician. (3) Services provided in
the capacity of overall medical direction are reimbursed only to an ICFIID and
will not be directly reimbursed to a physician. (H) Podiatry services Covered services provided by licensed podiatrists
are reimbursed directly to the authorized podiatric provider in accordance with
Chapter 5160-7 of the Administrative Code. (I) Transportation services Costs incurred by the ICFIID for transporting
residents by means other than covered ambulance or ambulette services are
reimbursed through the ICFIID cost report mechanism. Payment is made directly
to authorized providers for covered ambulance and ambulette services as set
forth in Chapter 5160-15 of the Administrative Code. (J) Vision care services All covered vision care services, including
examinations, dispensing, and the fitting of eyeglasses, are reimbursed
directly to authorized vision care providers in accordance with Chapter 5160-6
of the Administrative Code.
Last updated April 27, 2023 at 8:43 AM
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Rule 5123-7-12 | Intermediate care facilities for individuals with intellectual disabilities - cost report and chart of accounts.
Effective:
April 27, 2023
(A) Purpose This rule sets forth standards and requirements
for an intermediate care facility for individuals with intellectual
disabilities (ICFIID), other than a department-operated ICFIID, to submit cost
reports to the department and maintain supporting documents and records. (B) Submission of cost reports (1) An ICFIID shall
utilize the medicaid information technology system maintained by the Ohio
department of medicaid to submit a cost report to the department in accordance
with sections 5124.10, 5124.101, and 5124.522 of the Revised Code. (2) For good cause, an ICFIID may request
and the department may grant an extension of fourteen calendar days for
submitting a cost report. An ICFIID requesting an extension must do so in
writing via email to cr-icf@dodd.ohio.gov, explain the circumstances resulting
in the need for an extension, and submit the request no later than ninety
calendar days after the end of the reporting period. (C) Classifying costs (1) For purposes of the
cost report, an ICFIID shall use the chart of accounts in the appendix to this
rule and classify costs in accordance with applicable guidance and directives
issued by the centers for medicare and medicaid services. (a) When an account has sub-accounts, the sub-accounts will be
used to capture the information for cost reporting purposes. For
example: (i) When revenue accounts
appear by payor type, charges will be reported by payor type as applicable;
and (ii) When salary accounts
differentiate between "supervisory" and "other," this level
of detail will be reported as applicable. (b) While the chart of accounts facilitates the level of detail
necessary for cost reporting purposes, an ICFIID may maintain records in a
manner that allows for greater detail. (c) The chart of accounts allows for a range of account numbers
for a specified account. For example, account 1001 is for petty cash, with the
next account, cash in bank, beginning at account 1010. An ICFIID may delineate
sub-accounts 1010.1 to 1010.7 as separate cash accounts. An ICFIID need only
use the applicable sub-accounts. (d) Within the expense section (i.e., tables 5, 6, and 7),
accounts identified as "salary" accounts are only to be used to
report wages for employees of the ICFIID. 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 an employee. (e) Expense accounts identified as "contract" accounts
are only to be used to report costs incurred for services performed by
contracted personnel engaged by the ICFIID to perform a service that would
otherwise be performed by personnel on the ICFIID's payroll. (f) Expense accounts identified as "purchased nursing
services" are only to be used to report costs incurred for personnel
acquired through a nursing pool agency. (g) Expense accounts designated as "other" may be used
to report any appropriate non-wage expenses, including contract services and
supplies. (h) Completion of the cost report requires that the number of
hours paid be reported (depending on ICFIID type of control, on an accrual or
cash basis) for all salary expense accounts. An ICFIID's record keeping
will include accumulating hours paid consistent with the salary accounts
included within the chart of accounts. (i) Expenses related to a technology solution, acquired or
implemented as a result of the person-centered assessment and planning process
described in rule 5123-2-01 of the Administrative Code are to be reported in
the appropriate account or sub-account unless they are directly covered by the
medicaid state plan. (2) Cost reports
submitted by a county-operated ICFIID may be completed on accrual basis
accounting and generally accepted accounting principles unless otherwise
specified in Chapter 5123-7 or 5160-3 of the Administrative Code. (3) All depreciable
equipment valued at five hundred dollars or more per item with a useful life of
at least two years, is to be reported in the capital cost component set forth
in rule 5123-7-18 of the Administrative Code. The costs of equipment (including
vehicles) acquired by an operating lease executed before December 1, 1992, may
be reported in the indirect care cost component if the costs were reported as
administrative and general costs on the ICFIID's cost report for the
reporting period ending December 31, 1992, until the current lease term
expires. The costs of any equipment leases executed before December 1, 1992 and
reported as capital costs, will continue to be reported under the capital cost
component. The costs of any new leases for equipment executed on or after
December 1, 1992, will be reported under the capital cost component. Operating
lease costs for equipment, which result from extended leases under the
provision of a lease option negotiated on or after December 1, 1992, will be
reported under the capital cost component. (4) Costs of
ownership (a) The desk-reviewed, actual, allowable, per diem costs of
ownership are based upon certified beds for property costs and equipment for
the calendar year preceding the fiscal year in which the rate will be paid and
include: (i) The costs of
ownership directly related to purchasing or acquiring capital assets
including: (a) Except as otherwise required by paragraph (C)(4)(e) of this
rule, depreciation expense for the cost of buildings equal to the actual cost
depreciated in accordance with rule 5123-7-18 of the Administrative Code. The
provider is not to change the accumulated depreciation that has been previously
reported. This accumulated depreciation will be carried forward as previously
reported and audited. The current depreciation will then be added to
accumulated depreciation as recognized. (b) Except as otherwise required by paragraph (C)(4)(e) of this
rule, depreciation expense for major components of property and fixed equipment
equal to the actual cost depreciated in accordance with rule 5123-7-18 of the
Administrative Code. The provider is not to change the accumulated depreciation
that has been previously reported. This accumulated depreciation will be
carried forward as previously reported and audited. The current depreciation
will then be added to accumulated depreciation as recognized. (c) Except as otherwise required by paragraph (C)(4)(e) of this
rule, depreciation expense for major movable equipment equal to the actual cost
depreciated in accordance with rule 5123-7-18 of the Administrative Code. The
provider is not to change the accumulated depreciation that has been previously
reported. This accumulated depreciation will be carried forward as previously
reported and audited. The current depreciation will then be added to
accumulated depreciation as recognized. (d) Interest expense incurred on money borrowed for construction
or the purchase of real property, major components of that property, and
equipment. (e) Depreciation expense for costs paid or reimbursed by any
government agency, if that part of the prospective per diem rate is used to
reimburse the government agency and a loan provides for repayment over a
time-limited period. (f) Amortization expense of financing costs. (ii) The costs of
ownership directly related to renting or leasing capital assets. (iii) The costs of
ownership directly related to the amortization of leasehold improvements. These
costs will be expensed over the lesser of the remaining life of the lease, but
not less than five years, or the useful life of the improvement as specified in
rule 5123-7-18 of the Administrative Code. If the useful life of the
improvement is less than five years, it may be amortized over its useful life.
Options on leases will not be considered. Lessees who report leasehold
improvements and who leave the program before the minimum amortization period
is complete will not receive reimbursement for the balance of unamortized
costs. (b) The costs of ownership directly attributable to the purchase,
rent, or lease of property and equipment costs from one related party to
another through common ownership or control will be based upon the lesser of
the actual purchase, rent, or lease of property and equipment costs or the
actual costs of the related party. (i) If a provider leases
or transfers an interest in an ICFIID to another provider who is a related
party, the related party's allowable costs of ownership will include the
lesser of: (a) The annual lease expense or actual costs of ownership,
whichever is applicable; or (b) The reasonable cost to the lessor or provider making the
transfer. (ii) If a provider leases
or transfers an interest in an ICFIID to another provider who is a related
party, regardless of the date of the lease or transfer, the related
party's allowable costs of ownership will include the annual lease expense
or actual costs of ownership, whichever is applicable, if all of the following
conditions are met: (a) The related party is a relative of the owner. (b) In the case of a lease, if the lessor retains any ownership
interest, it is, except as provided in paragraph (C)(4)(b)(ii)(d)(i)(B) of this
rule, in only the real property and any improvements to the real
property. (c) In the case of a transfer, the provider making the transfer
retains, except as provided in paragraph (C)(4)(b)(ii)(d)(ii)(B) of this rule,
no ownership interest in the ICFIID. (d) The department determines that the lease or transfer is an
arm's length transaction when: (i) In the case of a
lease: (A) Once the lease goes into effect, the lessor has no direct or
indirect interest in the lessee or, except as provided in paragraph
(C)(4)(b)(ii)(b) of this rule, the ICFIID 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 ICFIID
except through the exercise of a lessor's rights in the event of a
default. If the lessor reacquires an interest in the ICFIID in this manner, the
department will treat the ICFIID as if the lease never occurred when the
department calculates its reimbursement rates for capital costs. (ii) In the case of a
transfer: (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 ICFIID or in the ICFIID 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 will not exceed the
lesser of: (1) The prime rate, as
published by the "Wall Street Journal" on the first business day of
the calendar year plus four per cent; or (2) Fifteen per
cent. (B) The provider that made the transfer does not reacquire an
interest in the ICFIID except through the exercise of a creditor's rights
in the event of a default. If the provider reacquires an interest in the ICFIID
in this manner, the department will treat the ICFIID as if the transfer never
occurred when the department calculates its reimbursement rates for capital
costs. (e) Except in the case of hardship caused by a catastrophic
event, as determined by the department, or in the case of a lessor or provider
making the transfer who is at least sixty-five years of age, not less than
twenty years have elapsed since, for the same ICFIID, allowable costs of
ownership was determined most recently. (c) A provider proposing to lease or transfer an interest in an
ICFIID to a related party shall provide the department with a certified
appraisal for each ICFIID to be leased or transferred at least ninety calendar
days prior to the actual change of the provider agreement. The certified
appraisal will be conducted no earlier than one hundred eighty calendar days
prior to the actual change of the provider agreement for each ICFIID leased or
transferred to a related party. (d) A provider proposing to lease or transfer an interest in an
ICFIID to a related party shall notify the department in writing and supply
sufficient documentation demonstrating compliance with the provisions of this
rule at least ninety calendar days prior to the anticipated date of completion
of the transfer or lease. A provider that fails to supply the required
documentation will not qualify for a rate adjustment. The department will issue
a written decision determining whether the lease or transfer meets the
requirements of this rule within sixty calendar days after receiving complete
information as determined by the department. (e) Reporting of accumulated depreciation (i) Upon the sale of an
ICFIID, the allowable capital asset cost basis, depreciation expense, and
interest expense for the new provider/buyer of the ICFIID will be the new
provider's/buyer's actual depreciation and interest expense subject
to the ceilings set forth in section 5124.171 of the Revised Code. If the
operating rights are separately identified and valued in a sale that includes
both the building and the operating rights, the operating rights will be
considered to be a part of the building for purposes of determining the
allowable capital asset cost basis under this paragraph. If a new
provider/buyer purchases only the operating rights to the ICFIID and uses the
operating rights to create a new ICFIID or add beds to an existing ICFIID, the
purchase price of the operating rights will be added to the capital asset cost
basis of the new ICFIID building or the additional beds. (ii) Upon the sale of an
ICFIID, the initial accumulated depreciation for the new provider/buyer of the
ICFIID will be recalculated starting at zero. (5) Except for the
employer's share of payroll taxes, workers' compensation, employee
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 which 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 ICFIID 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 ICFIID maintains adequate
documentation of hours worked in each cost center. (6) The cost of
purchasing resident transport vehicles is reported under the capital cost
component. The cost of maintaining and repairing these vehicles is reported
under the indirect care cost component. (7) As part of its cost
report, an ICFIID may complete the addendum for disputed costs to defend costs
the ICFIID believes may be disputed by the department. The costs stated on the
addendum are to have been applied to the other schedules and attachments for
the reporting period in question (either in the reimbursable or the
nonreimbursable cost centers). Any costs reported on the addendum may be
considered by the department in establishing the ICFIID's prospective
rate. (8) The following costs
are not reimbursable to an ICFIID through the prospective reimbursement cost
reporting mechanism, except as otherwise specified in Chapter 5123-7 of the
Administrative Code: (a) Recoupments, fines, penalties, or interest paid in accordance
with sections 5124.39, 5124.41, 5124.42, 5124.523, and 5124.99 of the Revised
Code. (b) Disallowances made during an audit of the ICFIID's cost
report which are sanctioned through adjudication in accordance with Chapter
119. of the Revised Code. (c) Costs which are determined not to be reasonable and allowable
costs during an audit of the ICFIID's cost report. (d) Cost of ancillary services (e.g., physicians, legend drugs,
radiology, laboratory, oxygen, or resident-specific medical equipment) rendered
to residents of the ICFIID by providers who bill medicaid
directly. (e) Cost per case mix units in excess of the applicable peer
group ceiling for direct care cost. (f) Expenses in excess of the applicable peer group ceiling for
indirect care cost. (g) Expenses in excess of the capital costs
limitations. (h) Expenses associated with lawsuits filed against the
department or the Ohio department of medicaid which are not upheld by the
courts. (i) Cost of meals sold to visitors or the public (e.g., meals on
wheels). (j) Cost of supplies or services sold to persons who do not
reside at the ICFIID. (k) Cost of operating a gift shop. (D) Required disclosures As a component of the cost report, providers
shall identify: (1) Each known related
party. (2) Each known
individual, group of individuals, or organization not otherwise publicly
disclosed that owns or has common ownership in whole or in part, in any
mortgage, deed of trust, property, or asset of the ICFIID. When the ICFIID or
the common owner is a publicly owned and traded corporation, this information
beyond basic identifying criteria is not required as part of the cost report
but must be available within two weeks when requested. Publicly disclosed
information must be available at the time of an audit. (3) Each corporate
officer or director, if the provider is a corporation. (4) Each partner, if the
provider is a partnership. (5) 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. (6) Any director,
officer, manager, employee, individual, or organization having direct or
indirect ownership or control of five per cent or more, or who has been
convicted of or pleaded guilty to a civil or criminal offense related to his or
her involvement in programs established by Title XVIII, Title XIX, or Title XX
of the Social Security Act, as in effect on the effective date of this rule.
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"). (7) Any individual
currently employed by or under contract with the provider, or a related party
in a managerial, accounting, auditing, legal, or similar capacity who was
employed by the department, the Ohio department of medicaid, the Ohio
department of health, the Ohio attorney general, the Ohio department of aging,
the Ohio department of commerce, or the industrial commission of Ohio within
the previous twelve months. (E) Contracts for service A provider shall provide upon request, each
contract for service in effect during the reporting period for which the cost
of the service from any subcontractor, 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. For
the purposes of this paragraph: (1) "Contract for
service" is defined as the component of a contract that details services
provided exclusive of supplies and equipment. It includes any contract which
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) "Subcontractor" is defined as any entity, including
an individual or individuals, who contract with a provider to supply a service,
either to the provider or directly to the beneficiary, where medicaid
reimburses the provider for 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. (F) Preliminary determination by the department (1) The department will
conduct a desk review of each cost report it receives. The desk review is an
analysis of the cost report to determine its adequacy, completeness, and
accuracy and reasonableness of the data contained therein. It is a process of
reviewing information pertaining to the cost report without detailed
verification and is designed to identify problems warranting additional
review. (2) Based on the desk
review, the department will make a preliminary determination of whether the
reported costs are reasonable and allowable costs. "Reasonable and
allowable costs" means costs established in accordance with the centers
for medicare and medicaid services provider reimbursement manual (publications
15-1 and 15-2, available at
https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals.html).
Before issuing the preliminary determination, the department will notify the
provider of any information in the cost report that requires additional
support. The provider shall provide any documentation or other information
requested by the department and may submit any information that it believes
supports the reported costs. The department will notify each provider of any
costs preliminarily determined not to be reasonable and allowable costs and
provide the reasons for the determination. (3) A provider may revise
the cost report within sixty calendar days after the original due date without
the revised information being considered an amended cost report. (4) The cost report is
considered accepted after the department has completed the desk review
process. (5) After final rates
have been issued, a provider who disagrees with a preliminary determination
based on the desk review may request a rate reconsideration in accordance with
rule 5123-7-27 of the Administrative Code. (G) Amending a cost report (1) Except as provided in
paragraph (G)(2) of this rule and not later than three years after a provider
files a cost report with the department, the provider may amend the cost report
if the provider discovers a material error in the cost report or additional
information to be included in the cost report. The department will review the
amended cost report for accuracy and notify the provider of its
determination. (2) A provider may not
amend a cost report if the Ohio department of medicaid has notified the
provider that an audit of the cost report or a cost report of the provider for
a subsequent cost reporting period is to be conducted under section 5124.109 of
the Revised Code. The provider may, however, provide the Ohio department of
medicaid information that affects the costs included in the cost report. Such
information may not be provided after the adjudication of the final settlement
of the cost report. (3) The department will
not charge interest under division (B) of section 5124.41 of the Revised Code
based on any error or additional information that is not required to be
reported under this rule. The department will review the amended cost report
for accuracy and notify the provider of its determination in accordance with
section 5124.107 of the Revised Code. (H) Retention of records (1) Financial, statistical, and medical records supporting
the cost reports or claims for services rendered to residents will
be: (a) Available to the
department, the ohio department of medicaid, and the United States department
of health and human services and other federal agencies; and (b) Retained for the
greater of seven years after the cost report is filed if the Ohio department of
medicaid issues an audit report, or six years after all appeal rights relating
to the audit report are exhausted. (2) Failure to retain the
required financial, statistical, or medical records to the extent that filed
cost reports are unauditable renders the provider liable for monetary damages
of the greater amount: (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. (3) Providers whose
records have been found to be unauditable will be allowed sixty calendar days
to provide the necessary documentation. If, at the end of the sixty calendar
days, the required records have been provided and are determined auditable, the
proposed penalty will be withdrawn. If the Ohio department of medicaid, after
review of the documentation submitted during the sixty-day period, determines
that the records are still unauditable, the department will impose the penalty
as specified in paragraph (H)(2) of this rule. (4) Refusing access to
financial, statistical, or medical records will result in a penalty as
specified in paragraph (H)(2) of this rule for outstanding medicaid services
until such time as the requested information is made available to the
department or the Ohio department of medicaid. (5) All requested
financial, statistical, and medical records supporting the cost reports or
claims for services rendered to residents will be available at a location in
the state of Ohio for an ICFIID certified for participation in the medicaid
program by this state within at least sixty calendar days after request by the
state or its subcontractors. The preferred Ohio location is the ICFIID itself,
but may be a corporate office, an accountant's office, or an
attorney's office elsewhere in Ohio. This requirement, however, does not
preclude the state or its subcontractors from the option of conducting the
audit and/or a review at the site of such records if outside of
Ohio.
View Appendix
Last updated April 12, 2024 at 11:52 AM
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Rule 5123-7-14 | Intermediate care facilities for individuals with intellectual disabilities - debt estimation, debt summary report, and successor liability agreements for change of operator, facility closure, involuntary termination, or voluntary termination.
Effective:
December 16, 2019
(A) Purpose This rule sets forth procedures for estimating
the debt an exiting operator of an intermediate care facility for individuals
with intellectual disabilities (ICFIID) owes the department and the federal
centers for medicare and medicaid services at the time of a change of operator,
facility closure, involuntary termination, or voluntary termination. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Change of
operator" has the same meaning as in section 5124.01 of the Revised
Code. (2) "Exiting
operator" has the same meaning as in section 5124.01 of the Revised
Code. (3) "Facility closure" has the
same meaning as in section 5124.01 of the Revised Code. (4) "Involuntary termination"
has the same meaning as in section 5124.01 of the Revised Code. (5) "Voluntary termination" has
the same meaning as in section 5124.01 of the Revised Code. (C) Debt estimation (1) The Ohio department
of medicaid shall use the debt estimation methodology set forth in this rule to
estimate an exiting operator's actual and potential debts to the
department and the centers for medicare and medicaid services under the
medicaid program. (2) The Ohio department
of medicaid shall total the value of all of the following that are determined
applicable in calculating the debt estimate: (a) Overpayments due to the department pursuant to section
5124.41 of the Revised Code, including: (i) Overpayments owed for
adjudicated final fiscal audit periods. (ii) Overpayments
identified in proposed adjudication orders that have been issued but not
adjudicated. (iii) 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. (b) Monies owed to the department and the centers for
medicare and medicaid services resulting from penalties authorized by federal
and state law, including but not limited to: (i) Penalties assessed
pursuant to section 5124.42 of the Revised Code for: (a) Lack of proper notice of a change of operator, facility
closure, or voluntary termination from the medicaid program; or (b) Failure to furnish invoices or other documentation that
the department requests during an audit. (ii) Late cost report
filing penalties assessed pursuant to rule 5123-7-12 of the Administrative
Code. (c) Penalties assessed pursuant to section 5124.99 of the
Revised Code for violation of cost reporting provisions or provider agreement
obligations. (d) Interest monies owed to the department pursuant to
section 5124.41 of the Revised Code and to the centers for medicare and
medicaid services pursuant to 42 C.F.R. 488.442, as in effect on the effective
date of this rule. (e) Monies owed to the department and the centers for
medicare and medicaid services pursuant to sections 5124.52 and 5124.525 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. (f) Franchise permit fee owed to the department pursuant to
section 5168.63 of the Revised Code which shall include unpaid franchise permit
fee for: (i) Amounts due for
periods assessed or to be assessed but for which payment is not yet required
pursuant to section 5168.63 of the Revised Code. (ii) Amounts due that are
certified to the Ohio attorney general's office for collection, including
penalties assessed pursuant to section 5168.63 of the Revised Code for failure
to pay the full amount when due. (g) Monies owed for recapture of excess
depreciation. (h) Monies owed due to a credit balance. (i) Monies owed pursuant to successor liability or
assumption of liability agreements the exiting operator entered
into. (j) Other amounts the department determines are
applicable. (3) The sum of the
amounts determined owed, or estimated to be owed, to the department and the
centers for medicare and medicaid services pursuant to paragraphs (C)(2)(a) to
(C)(2)(j) of this rule shall be the total estimated debt. (4) The Ohio department
of medicaid may release a portion of funds withheld pursuant to division (A) of
section 5124.521 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 5124.525 of the Revised Code. (D) Provision of debt estimate For the purposes of division (C) of section
5124.52 of the Revised Code, the debt estimate is considered provided by the
Ohio department of medicaid on the date of mailing or date of personal
service. (E) Initial debt summary report (1) Whenever the Ohio
department of medicaid issues an initial debt summary report pursuant to
section 5124.525 of the Revised Code, the Ohio department of medicaid shall
give notice to the affected party informing the affected party of the affected
party's right to request a review. Notice shall be given by registered
mail, return receipt requested, and shall include: (a) A statement informing the affected party that the
affected party is entitled to request a review of the initial debt summary
report. (b) A statement informing the affected party that if a
request for review of the initial debt summary report is not submitted on or
before thirty calendar days after the mailing of the initial debt summary
report, the initial debt summary report becomes the final debt summary report
thirty-one calendar days after the mailing of the initial debt summary report,
and that the affected party may request, in accordance with Chapter 119. of the
Revised Code, an adjudication hearing regarding a finding in the final debt
summary report that pertains to an audit or alleged overpayment made under the
medicaid program to the exiting operator. The adjudication shall be
consolidated with any other uncompleted adjudication that concerns a matter
addressed in the final debt summary report. (2) The Ohio department
of medicaid shall also mail a copy of the notice to the affected party's
attorney or other representative of record. To qualify as an attorney or
representative of record, the affected party or the attorney or representative
must notify the Ohio department of medicaid, in writing, that the attorney or
representative is to be designated the attorney or representative of record for
purposes of receiving notice of an initial debt summary report. The
notification must include the address where the Ohio department of medicaid
should mail the notice to the attorney or representative of record. The mailing
of notice to the affected party's attorney or representative is not deemed
to perfect service of the notice. Failure to mail a copy of the notice to the
attorney or representative of record will not result in failure of otherwise
perfected service upon the affected party. In those instances where an affected
party is a corporation doing business in Ohio or is incorporated in Ohio, the
mailing of notice to the corporation's statutory agent pursuant to
sections 1701.07 and 1703.19 of the Revised Code will perfect
service. (3) When any notice of an
initial debt summary report sent by registered mail pursuant to this rule is
returned because the affected party fails to claim the notice, the Ohio
department of medicaid shall send the notice by ordinary mail to the affected
party at the affected party's last known address and shall obtain a
certificate of mailing. Service by ordinary mail is complete when the
certificate of mailing is obtained unless the notice is returned showing
failure of delivery. (4) When any notice of an
initial debt summary report sent by registered mail or ordinary mail is
returned for failure of delivery, the Ohio department of medicaid shall make
personal delivery of the notice by an employee or agent of the Ohio department
of medicaid. An employee or agent of the Ohio department of medicaid may make
personal delivery of the notice upon a party at any time. (5) Refusal of delivery
of an initial debt summary report by personal service or by mail is not failure
of delivery and service is deemed to be complete at the time of personal
refusal or at the time of receipt by the Ohio department of medicaid of the
refused mail as evidenced by the Ohio department of medicaid date and time
stamp. Failure of delivery occurs only when a mailed notice is returned by the
postal authorities marked undeliverable, address or addressee unknown, or
forwarding address unknown or expired. (6) Any request for a
review made as the result of notice of an initial debt summary report issued
pursuant to this rule must be made in writing and mailed or delivered to the
Ohio department of medicaid office and address identified in the initial debt
summary report within thirty calendar days of the following, as
applicable: (a) The time of mailing the notice if notice is given
pursuant to paragraph (E)(1) of this rule. (b) The date that service is complete if notice is given
pursuant to paragraph (E)(3) or (E)(5) of this rule. (c) The date of personal service. (7) If a request for
review is mailed to the Ohio department of medicaid office and address
identified in the initial debt summary report, the request is deemed to have
been made: (a) If the request for review is mailed by certified mail,
as of the date stamped by the United States postal service on its receipt
form. (b) If the request for review is mailed by regular United
States mail, as of the date of the postmark appearing upon the envelope
containing the request. (c) If the request for review is mailed by regular United
States mail and the postmark is illegible or fails to appear on the envelope,
as of the date of its receipt by the Ohio department of medicaid office
identified in the initial debt summary report as evidenced by that
office's date and time stamp. (8) If a request for
review is made by electronic mail to the office identified in the initial debt
summary report, the request 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 initial debt summary
report. (9) If a request for
review is mailed, personally delivered, or made by electronic mail to a party
or address other than the proper office identified in the initial debt summary
report, the request is deemed to have been made as of the date of its receipt
by the office identified in the initial debt summary report as evidenced by
that office's date and time stamp. (10) If a request for
review is personally delivered to the office identified in the initial debt
summary report, the request is deemed to have been made as of the date of its
receipt as evidenced by that office's date and time stamp. (11) All requests for
review must clearly identify both the affected party involved and the initial
debt summary report that is being contested. (F) Revised debt summary report (1) Whenever the Ohio
department of medicaid issues a revised debt summary report pursuant to section
5124.525 of the Revised Code, the Ohio department of medicaid shall give notice
to the affected party informing the affected party of the affected party's
right to submit additional information. Notice shall be given by registered
mail, return receipt requested, and shall include: (a) A statement informing the affected party that the
affected party is entitled to submit additional information. (b) A statement informing the affected party that if
additional information is not submitted on or before thirty calendar days after
the mailing of the revised debt summary report, the revised debt summary report
becomes the final debt summary report thirty-one calendar days after the
mailing of the revised debt summary report, and that the affected party may
request, in accordance with Chapter 119. of the Revised Code, an adjudication
hearing regarding a finding in the final debt summary report that pertains to
an audit or alleged overpayment made under the medicaid program to the exiting
operator. The adjudication shall be consolidated with any other uncompleted
adjudication that concerns a matter addressed in the final debt summary
report. (2) The Ohio department
of medicaid shall also mail a copy of the notice to the affected party's
attorney or other representative of record. To qualify as an attorney or
representative of record, the affected party or the attorney or representative
must notify the Ohio department of medicaid, in writing, that the attorney or
representative is to be designated the attorney or representative of record for
purposes of receiving notice of a revised debt summary report. The notification
must include the address where the Ohio department of medicaid should mail the
notice to the attorney or representative of record. The mailing of notice to
the affected party's attorney or representative is not deemed to perfect
service of the notice. Failure to mail a copy of the notice to the attorney or
representative of record will not result in failure of otherwise perfected
service upon the affected party. In those instances where an affected party is
a corporation doing business in Ohio or is incorporated in Ohio, the mailing of
notice to the corporation's statutory agent pursuant to sections 1701.07
and 1703.19 of the Revised Code will perfect service. (3) When any notice of a
revised debt summary report sent by registered mail pursuant to this rule is
returned because the affected party fails to claim the notice, the Ohio
department of medicaid shall send the notice by ordinary mail to the affected
party at the affected party's last known address and shall obtain a
certificate of mailing. Service by ordinary mail is complete when the
certificate of mailing is obtained unless the notice is returned showing
failure of delivery. (4) When any notice of a
revised debt summary report sent by registered mail or ordinary mail is
returned for failure of delivery, the Ohio department of medicaid shall make
personal delivery of the notice by an employee or agent of the Ohio department
of medicaid. An employee or agent of the Ohio department of medicaid may make
personal delivery of the notice upon a party at any time. (5) Refusal of delivery
of a revised debt summary report by personal service or by mail is not failure
of delivery and service is deemed to be complete at the time of personal
refusal or at the time of receipt by the Ohio department of medicaid of the
refused mail as evidenced by the Ohio department of medicaid date and time
stamp. Failure of delivery occurs only when a mailed notice is returned by the
postal authorities marked undeliverable, address or addressee unknown, or
forwarding address unknown or expired. (6) Any submission of
additional information made as the result of notice of a revised debt summary
report issued pursuant to this rule must be made in writing and mailed or
delivered to the Ohio department of medicaid office and address identified in
the revised debt summary report within thirty calendar days of the following,
as applicable: (a) The time of mailing the notice if notice is given
pursuant to paragraph (F)(1) of this rule. (b) The date that service is complete if notice is given
pursuant to paragraph (F)(3) or (F)(5) of this rule. (c) The date of personal service. (7) If a submission of
additional information is mailed to the Ohio department of medicaid office and
address identified in the revised debt summary report, the request is deemed to
have been made: (a) If the submission of additional information is mailed
by certified mail, as of the date stamped by the United States postal service
on its receipt form. (b) If the submission of additional information is mailed
by regular United States mail, as of the date of the postmark appearing upon
the envelope containing the request. (c) If the submission of additional information is mailed
by regular United States mail and the postmark is illegible or fails to appear
on the envelope, as of the date of its receipt by the Ohio department of
medicaid office identified in the revised debt summary report as evidenced by
that office's date and time stamp. (8) If a submission of
additional information is made by electronic mail to the office identified in
the revised debt summary report, the 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
revised debt summary report. (9) If a 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
revised debt summary report, the submission is deemed to have been made as of
the date of its receipt by the office identified in the revised debt summary
report as evidenced by that office's date and time stamp. (10) If a submission of
additional information is personally delivered to the office identified in the
revised debt summary report, the submission is deemed to have been made as of
the date of its receipt as evidenced by that office's date and time
stamp. (11) All submissions of
additional information must clearly identify both the affected party involved
and the revised debt summary report that is being contested. (G) Final debt summary report Rule 5101:6-50-03 of the Administrative Code
shall apply if an affected party timely submits a request for review and
additional information in response to a revised debt summary report, and the
Ohio department of medicaid issues a final debt summary report pursuant to
section 5124.525 of the Revised Code. An adjudication on a final debt summary
report shall be conducted only with respect to findings in the final debt
summary report that pertain to an audit or alleged overpayment made under the
medicaid program to the exiting operator. The adjudication shall be
consolidated with any other uncompleted adjudication that concerns a matter
addressed in the final debt summary report. (H) Computation of time deadlines Section 1.14 of the Revised Code controls the
computing of time deadlines imposed by this rule. The time within which an act
is required by law to be completed is computed by excluding the first day and
including the last day. When the last day falls on a Saturday, Sunday, or legal
holiday, the act may be completed on the next succeeding day that is not a
Saturday, Sunday, or legal holiday. When the last day to perform an act that is
required by law is to be performed in a public office and that public office is
closed to the public for the entire day, the act may be performed on the next
succeeding day that is not a Saturday, Sunday, or legal holiday. (I) Successor liability agreements (1) Successor liability
agreements entered into pursuant to section 5124.521 of the Revised Code are
subject to approval by the Ohio department of medicaid. (2) Successor liability
agreements must be signed by the exiting operator, the Ohio department of
medicaid, and the entity assuming liability pursuant to section 5124.521 of the
Revised Code.
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Rule 5123-7-15 | Intermediate care facilities for individuals with intellectual disabilities - claim submission.
Effective:
April 27, 2023
(A) Purpose This rule establishes procedures for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to submit claims and be paid for services rendered. (B) Submission of claims for payment for services included in the ICFIID per diem rate (1) An ICFIID shall: (a) Submit claims for payment to the Ohio department of medicaid in accordance with rule 5160-1-19 of the Administrative Code. (b) Submit claims for payment either directly or through a "trading partner" as that term is defined in rule 5160-1-20 of the Administrative Code. (c) Be a medicaid provider in an active enrollment status for all dates within the claim span. (2) A single claim will include days of service provided, including qualifying leave days, for a single resident within a single calendar month and will not cross calendar months. If an ICFIID determines that a claim that has been paid should have included additional per diem service days, the ICFIID shall timely submit an adjustment claim correcting the entire calendar month's claim information. (3) When a medicaid-eligible resident of an ICFIID has a patient liability obligation, the entire monthly amount of patient liability, as determined in accordance with rule 5160:1-6-07 of the Administrative Code, will be reported by the ICFIID on the resident's monthly claim. When a resident is admitted, discharged, or transfers to another facility mid-month, the entire monthly amount of patient liability will be reported on the claim for that month. The patient liability will be applied as an offset against the amount medicaid would otherwise reimburse for the claim. When the patient liability exceeds the amount medicaid would reimburse, the claim will be processed with a payment of zero dollars. (4) The treatment of lump sum payments and their disposition regarding medicaid eligibility are addressed in rule 5160:1-3-05.8 of the Administrative Code; if however, the county department of job and family services and the medicaid-eligible resident determine that the lump sum will be assigned to the ICFIID as payment for past per diem services received by the resident, the ICFIID shall submit adjustment claims for as many prior months as necessary to fully offset the amount of the lump sum payment that was assigned to the ICFIID. When there are lump sum monies remaining after adjusting all prior payments, the ICFIID shall apply the remaining lump sum balance to current and future claims. When the resident is discharged or passes away prior to exhausting the lump sum payment, the ICFIID shall return the balance to the individual or the individual's estate.
Last updated April 27, 2023 at 8:42 AM
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Rule 5123-7-18 | Intermediate care facilities for individuals with intellectual disabilities - capital assets and depreciation.
Effective:
December 16, 2019
(A) Purpose This rule establishes requirements for
determining when an asset of an intermediate care facility for individuals with
intellectual disabilities (ICFIID) is capitalized and depreciated. (B) Capitalization of assets For purposes of determining when an asset is
capitalized, an ICFIID shall use the following guidelines: (1) Any item that costs
five hundred or more dollars and has a useful life of two or more years shall
be capitalized and depreciated over the asset's useful life. (2) An ICFIID that has a
capitalization policy in effect on the effective date of this rule to
capitalize items that cost less than five hundred dollars shall continue to
follow its policy and shall obtain prior approval from the department to change
its policy. (C) Determining useful life For purposes of determining the useful life of a
capital asset, an ICFIID shall use: (1) The internal revenue
service publication 946, "How to Depreciate Property" (2017),
available at http://www.irs.gov/publications/p946/index.html; (2) The American hospital
association's "Estimated Useful Lives of Depreciable Hospital
Assets" (2018); (3) The appendix to rule
5123:2-7-18 of the Administrative Code as it existed on the day immediately
prior to the effective date of this rule; or (4) Another method
approved by the department. (D) Depreciation (1) Depreciation on
buildings, components of a building, and medical equipment used in the
provision of resident care that is not reimbursable directly to the medical
equipment supplier in accordance with rule 5123:2-7-11 of the Administrative
Code is an allowable cost. (2) For purposes of
calculating depreciation expense, an ICFIID shall use the following
guidelines: (a) All capital assets shall be depreciated using the
straight-line method of depreciation. (b) 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. (c) In the month that a capital asset is disposed, if the
capital asset is not fully depreciated, the allowable depreciation expense is
recognized as it is defined in section 132 of the centers for medicare and
medicaid services publication 15-1, "Provider Reimbursement Manual"
(revised January 2005), available at http://www.cms.hhs.gov/manuals. At no time
shall a capital asset be depreciated more than its adjusted basis. (d) An ICFIID shall maintain, and provide to the department
upon request, detailed depreciation schedules to verify each individual capital
asset placed in service. (E) Salvage value For purposes of determining the salvage value of
a capital asset, an ICFIID shall use the following guidelines: (1) An ICFIID shall
maintain, and provide to the department upon request, documentation
demonstrating the salvage value for any capital asset determined to have a
salvage value of less than ten per cent. (2) When an ICFIID
determines that a capital asset does not have a salvage value, the ICFIID shall
record a salvage value of zero dollars in its asset ledger. (3) If an ICFIID
previously recorded a ten per cent salvage value for a capital asset that is
still in use and that has a salvage value of less than ten per cent, the
salvage value may be added to the capital asset and expensed over the remaining
useful life of the capital asset. The ICFIID may revise unaudited cost reports
accordingly for years where final cost settlement has not
occurred.
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Rule 5123-7-21 | Intermediate care facilities for individuals with intellectual disabilities - compensation cost limits for owners and relatives of owners.
Effective:
December 16, 2019
(A) Purpose This rule establishes limits, applicable to the
cost report of an intermediate care facility for individuals with intellectual
disabilities (ICFIID), for the amount of compensation that may be claimed for
owners or relatives of owners of the ICFIID. (B) Calculating compensation cost limits
for owners and relatives of owners serving in positions for which comparable
positions exist Compensation cost limits for owners and relatives
of owners shall be based upon compensation costs for persons who hold
comparable positions but who are not owners or relatives of owners, as reported
on the ICFIID's cost report from the calendar year preceding the fiscal
year in which the rate is paid. As used in this rule, "comparable
position" means the position that is held by the owner or relative of an
owner, if that position is listed separately on the ICFIID's cost report,
or if the position is not listed separately, the group of positions that is
listed on the ICFIID's cost report and that includes the position held by
the owner or relative of an owner. The compensation cost limits for owners and
relatives of owners who function in positions listed on attachment 6 of the
cost report shall be based upon the wage and hour equivalents which are
calculated as follows: (1) The compensation cost
limits for owners and relatives of owners are calculated from: (a) Cost reports with a December thirty-first end date;
and (b) Desk-reviewed and preliminarily determined to be
allowable costs. (2) For each wage and
hour chart of account number from attachment 6 of the cost report, calculate
the compensation cost limits as follows: (a) Calculate the total non-owner wages paid by summing the
total non-owner wages paid (column E) for all providers that have amounts
reported in columns (E) and (H) of attachment 6. (b) Calculate the total non-owner hours paid by summing the
total non-owner hours paid (column H) for all providers that have amounts
reported in columns (E) and (H) of attachment 6. (c) Calculate the average hourly rate by dividing the total
non-owner wages paid as calculated in accordance with paragraph (B)(2)(a) of
this rule by the total non-owner hours paid as calculated in accordance with
paragraph (B)(2)(b) of this rule. (d) Calculate the compensation cost limit by multiplying
the average hourly rate as calculated in accordance with paragraph (B)(2)(c) of
this rule by two thousand eighty hours. (C) Calculating compensation cost limits
for owners and relatives of owners serving in positions for which comparable
positions do not exist Compensation cost limits for owners and relatives
of owners who serve the ICFIID in a capacity such as corporate officer, for
which no comparable position or group of positions is listed on attachment 6 of
the cost report shall be based upon the civil service equivalents set forth in
rule 123:1-7-15 of the Administrative Code. Compensation for owners and
relatives of owners that are corporate officers is allowable for managerial,
administrative, professional, and other services related to the operation of
the ICFIID and rendered in connection with resident care. The compensation cost
limit for an owner or relative of an owner who functions in a corporate
position shall be based upon the civil service equivalents as listed below. In
the case of an owner or relative of an owner who functions as proprietor or
partner, one of the below-listed civil service equivalents shall be applied
based upon the duties performed: (1) Corporate
president (a) Business administrator 3, classification 63317, for
facilities with a combined bed total of one to ninety-nine; (b) Business administrator 4, classification 63318, for
facilities with a combined bed total of one hundred to one hundred
ninety-nine; (c) Fiscal officer 4, classification 66538, for facilities
with a combined bed total of two hundred to two hundred
ninety-nine; (d) Director 1, classification 61111, for facilities with a
combined bed total of three hundred to five hundred ninety-nine; (e) Director 2, classification 61112, for facilities with a
combined bed total of six hundred to one thousand one hundred ninety-nine;
or (f) Director 3, classification 61113, for facilities with a
combined bed total of one thousand two hundred or more. (2) Corporate
vice-president (a) Program administrator 2, classification 63123, for
facilities with a combined bed total of one to ninety-nine; (b) Program administrator 3, classification 63124, for
facilities with a combined bed total of one hundred to one hundred
ninety-nine; (c) Assistant director 1, classification 61211, for
facilities with a combined bed total of two hundred to two hundred
ninety-nine; (d) Assistant director 2, classification 61212, for
facilities with a combined bed total of three hundred to five hundred
ninety-nine; (e) Assistant director 3, classification 61213, for
facilities with a combined bed total of six hundred to one thousand one hundred
ninety-nine; or (f) Assistant director 4, classification 61214, for
facilities with a combined bed total of one thousand two hundred or
more. (3) Corporate
treasurer (a) Fiscal specialist 1, classification 66531, for
facilities with a combined bed total of one to ninety-nine; (b) Fiscal specialist 2, classification 66532, for
facilities with a combined bed total of one hundred to one hundred
ninety-nine; (c) Fiscal officer 1, classification 66535, for facilities
with a combined bed total of two hundred to two hundred
ninety-nine; (d) Fiscal officer 2, classification 66536, for facilities
with a combined bed total of three hundred to five hundred
ninety-nine; (e) Fiscal officer 3, classification 66537, for facilities
with a combined bed total of six hundred to one thousand one hundred
ninety-nine; or (f) Fiscal officer 4, classification 66538, for facilities
with a combined bed total of one thousand two hundred or more. (4) Board
secretary/member (a) Administrative professional 1, classification 16871,
for facilities with a combined bed total of one to ninety-nine; (b) Office manager, classification 16821, for facilities
with a combined bed total of one hundred to one hundred
ninety-nine; (c) Administrative professional 4, classification 16874,
for facilities with a combined bed total of two hundred to two hundred
ninety-nine; (d) Program administrator 2, classification 63123, for
facilities with a combined bed total of three hundred to five hundred
ninety-nine; (e) Board/commission secretary 1, classification 62111, for
facilities with a combined bed total of six hundred to one thousand one hundred
ninety-nine; or (f) Board/commission secretary 2, classification 62112, for
facilities with a combined bed total of one thousand two hundred or
more. (5) For those owners and
relatives of owners who serve the ICFIID in the capacity of a corporate
officer, proprietor, or partner as specified in paragraphs (C)(1) to (C)(4) of
this rule, the formula for determining the compensation cost limits is as
follows: (a) The civil service equivalent hourly rate as published
by the Ohio department of administrative services for those positions specified
in paragraphs (C)(1) to (C)(4) of this rule will be multiplied by two thousand
eighty hours to arrive at an annual salary screen for each step in the
position. If the civil service equivalent hourly rate changes during the
reporting period, the civil service equivalent hourly rate will be the hourly
rate that is in effect at the end of the cost reporting period. (b) The appropriate job step within those civil service
classifications as specified in paragraphs (C)(1) to (C)(4) of this rule will
be based upon the owner's years of service in the health care field plus
one. (D) Determining reasonable costs and
disallowances Reasonable costs for compensation and
compensation disallowances for owners and relatives of owners are the
ICFIID's desk-reviewed, actual, allowable costs reported on schedule C-2
of the cost report subject to the applicable compensation cost limits and audit
by the department. For each owner or relative of an owner that has reported
compensation on schedule C-2 of the cost report, the medicaid information
technology system will perform the following steps. (1) Calculate the
"time slice" for each owner and relative of an owner, which is
defined as either: (a) When there is no overlap of an employment period for an
owner or relative of an owner working in a related ICFIID and the functions
have the same position number, the number of days employed; or (b) When there is an overlap of an employment period for an
owner or relative of an owner working in a related ICFIID and the functions
have the same position number: (i) The number of days
employed for the overlap of an employment period when the owner or relative of
an owner is working in the related ICFIID during the same period of time;
plus (ii) The number of days
employed preceding the overlapping employment period; plus (iii) The number of days
employed subsequent to the overlapping employment period. (2) For each time slice
of an owner or relative of an owner, calculate the following: (a) Acquire the number of certified beds for the ICFIID as
of the end of the cost reporting period from schedule A, line 2, column 1 of
the cost report. (b) Acquire the number of certified beds for related
facilities that the owner or relative of an owner worked in during the time
slice, as of the end of the cost reporting period. (c) Calculate the total number of certified beds by adding
the number of certified beds for the ICFIID as determined in accordance with
paragraph (D)(2)(a) of this rule and the number of certified beds for any
related facilities that the owner or relative of an owner worked in as
determined in accordance with paragraph (D)(2)(a) of this rule. (d) For an owner or relative of an owner who received
compensation as a corporate officer, acquire the appropriate corporate duty job
step as calculated in accordance with paragraph (C)(5)(b) of this
rule. (e) Determine the applicable compensation cost limit based
on the position the owner or relative of an owner worked as
follows: (i) For an owner or
relative of an owner who performs duties that are included on attachment 6 of
the cost report, acquire the appropriate compensation cost limit as calculated
in accordance with paragraph (B)(2)(d) of this rule subject to the following
criteria: (a) Compensation is allowable only for duties performed by
an owner or relative of an owner which otherwise would require the employment
of another person; and (b) In order to qualify as a supervisor for positions
listed on attachment 6 of the cost report, a supervisor must supervise at least
two persons in an ICFIID with fifty or more beds. In an ICFIID with fewer than
fifty beds, a supervisor may supervise one person. (ii) For an owner or
relative of an owner who perform duties which otherwise would have required the
employment of another person and received compensation as a corporate officer,
acquire the appropriate compensation cost limit as calculated in accordance
with paragraph (C)(5) of this rule. (iii) For purposes of
determining the compensation cost limits, an owner or relative of an owner is
overtime exempt. There shall be no upward adjustment to the applicable
compensation cost limit to accommodate circumstances where such persons work in
excess of forty hours per week. (f) Calculate the total number of days employed for each
owner or relative of an owner by subtracting the beginning date from the ending
date for each time slice and adding one. (g) Determine the total days in the calendar
year. (h) Calculate the per cent of days allowed by dividing the
number of days in the time slice as calculated in accordance with paragraph
(D)(2)(f) of this rule by the total days in the calendar year as determined in
accordance with paragraph (D)(2)(g) of this rule. (i) Calculate the time slice adjusted compensation cost
limit by multiplying the per cent of days allowed as calculated in accordance
with paragraph (D)(2)(h) of this rule by the adjusted compensation as
calculated in accordance with paragraph (D)(2)(e) of this rule. (j) Acquire the weekly hours in the time slice for the
appropriate time period from schedule C-2 of the cost report. (k) Acquire the related weekly hours in the time slice for
the appropriate time period from the related ICFIID's schedule C-2 of the
cost report. (l) Calculate the total weekly hours in the time slice by
adding the weekly hours in the time slice as determined in accordance with
paragraph (D)(2)(j) of this rule and the related weekly hours in the time slice
as determined in accordance with paragraph (D)(2)(k) of this rule. (m) Calculate the maximum weekly hours: (i) If the total weekly
hours in the time slice as calculated in accordance with paragraph (D)(2)(l) of
this rule is less than thirty-five hours per week then the maximum weekly hours
in the time slice is forty; or (ii) If the total weekly
hours in the time slice as calculated in accordance with paragraph (D)(2)(l) of
this rule is greater than or equal to thirty-five hours per week then the
maximum weekly hours in the time slice is the total weekly hours in the time
slice. (n) Calculate the hours allocation percentage by dividing
the weekly hours in the time slice as calculated in accordance with paragraph
(D)(2)(j) of this rule by the maximum weekly hours as calculated in accordance
with paragraph (D)(2)(m) of this rule. (o) Calculate the final time slice adjusted compensation
cost limit by multiplying the time slice adjusted compensation cost limit as
calculated in accordance with paragraph (D)(2)(i) of this rule by the hours
allocation percentage as calculated in accordance with paragraph (D)(2)(n) of
this rule. (p) Calculate a daily salary amount for each owner and
relative of an owner by dividing the compensation amount by the number of days
employed as reported on schedule C-2 of the cost report. For each time slice,
calculate the prorated amount for each owner and relative of an owner by
multiplying the daily salary amount for each owner and relative of an owner by
the number of days in the time slice as calculated in accordance with paragraph
(D)(2)(f) of this rule. (q) Calculate the compensation disallowance for each owner
and relative of an owner by subtracting the final time slice adjusted
compensation cost limit as calculated in accordance with paragraph (D)(2)(o) of
this rule from the prorated amount for each owner and relative of an owner as
calculated in accordance with paragraph (D)(2)(p) of this rule. The result
cannot be less than zero.
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Rule 5123-7-22 | Intermediate care facilities for individuals with intellectual disabilities - compensation cost limits for administrators who are not owners or relatives of owners.
Effective:
December 16, 2019
(A) Purpose This rule establishes limits, applicable to the
cost report of an intermediate care facility for individuals with intellectual
disabilities (ICFIID), for the amount of compensation that may be claimed for
administrators of the ICFIID who are not owners or relatives of owners. (B) Calculating compensation cost
limits Compensation cost limits for administrators shall
be based upon compensation costs for administrators who are not owners or
relatives of owners, as reported on the ICFIID's cost report for the
calendar year preceding the fiscal year in which the rate is paid. The
compensation cost limits for administrators, excluding owners and relatives of
owners who are administrators, are calculated as follows: (1) The compensation cost
limits for administrators are calculated from: (a) Cost reports with a December thirty-first end date;
and (b) Desk-reviewed and preliminarily determined to be
allowable costs. (2) For each
administrator, calculate the hourly rate from schedule C-1 of the cost report
as follows: (a) Calculate the number of days employed by subtracting
the employment period beginning date from the employment period ending date.
Add one day to the number of days calculated to account for total days worked
as reported on the cost report; (b) Calculate the number of weeks worked by dividing the
number of days employed by seven as calculated in accordance with paragraph
(B)(2)(a) of this rule; (c) Calculate the weekly compensation amount by dividing
the compensation amount as reported on the cost report by the number of weeks
worked as calculated in accordance with paragraph (B)(2)(b) of this rule;
and (d) Calculate the hourly rate by dividing the weekly
compensation amount as calculated in accordance with paragraph (B)(2)(c) of
this rule by the weekly hours as reported on the cost report. (3) Exclude any
administrator's hourly rate as calculated in accordance with paragraph
(B)(2) of this rule that is less than the federal minimum wage rate in effect
at the end of the cost reporting period. (4) Excluding
administrators described in paragraph (B)(3) of this rule, calculate the
average annual administrator salary for each facility from schedule C-1 of the
cost report as follows: (a) For each administrator, calculate the hours worked by
multiplying the weekly hours as reported on the cost report by the number of
days employed as calculated in accordance with paragraph (B)(2)(a) of this
rule; (b) For all administrators as reported for each ICFIID,
total the following: (i) Number of days
employed as calculated in accordance with paragraph (B)(2)(a) of this
rule; (ii) Compensation amounts
as reported on the cost report; and (iii) Hours worked as
calculated in accordance with paragraph (B)(4)(a) of this rule; (c) Calculate a weighted facility average weekly hours by
dividing the sum of the weighted weekly hours as calculated in accordance with
paragraph (B)(4)(b)(iii) of this rule by the total number of days employed as
calculated in accordance with paragraph (B)(4)(b)(i) of this rule; (d) Calculate the weighted facility compensation
amount: (i) If the weighted
facility average weekly hours as calculated in accordance with paragraph
(B)(4)(c) of this rule is less than thirty-five hours per week, multiply the
total compensation amount as calculated in accordance with paragraph
(B)(4)(b)(ii) of this rule by forty; or (ii) If the weighted
facility average weekly hours as calculated in accordance with paragraph
(B)(4)(c) of this rule is thirty-five hours or more per week, multiply the
total compensation amount as calculated in accordance with paragraph
(B)(4)(b)(ii) of this rule by the weighted facility average weekly hours as
calculated in accordance with paragraph (B)(4)(c) of this rule; (e) Calculate the total salary per year by dividing the
weighted facility compensation amount as calculated in accordance with
paragraph (B)(4)(d) of this rule by the weighted facility average weekly hours
as calculated in accordance with paragraph (B)(4)(c) of this rule;
and (f) Calculate the average annual administrator salary by
multiplying the total salary per year as calculated in accordance with
paragraph (B)(4)(e) of this rule by the number of days in a calendar year and
dividing the product by the total number of days employed as calculated in
accordance with paragraph (B)(4)(b)(i) of this rule. (5) Group the average
annual administrator salary for each ICFIID calculated in accordance with
paragraph (B)(4)(f) of this rule into the following bed size categories based
on certified beds at the end of the cost reporting period: (a) One to forty-nine; (b) Fifty to ninety-nine; or (c) One hundred or more. (6) For each bed size
category in accordance with paragraph (B)(5) of this rule, calculate the
compensation cost limit by summing the average annual administrator salary as
calculated in accordance with paragraph (B)(4)(f) of this rule and dividing the
total sum of all average annual administrator salary by the number of records
summed. (C) Determining reasonable costs and
disallowances Reasonable costs for compensation and
compensation disallowances for administrators are the ICFIID's
desk-reviewed, actual, allowable costs reported on schedule C-1 of the cost
report subject to the applicable compensation cost limits and audit by the
department. (1) For each
administrator that has reported compensation on schedule C-1 of the cost
report, the medicaid information technology system shall perform the following
steps: (a) Calculate the "time slice" for each
administrator, which is defined as either: (i) When there is no
overlap of an employment period for an administrator working in a related
ICFIID, the number of days employed; or (ii) When there is an
overlap of an employment period for an administrator working in a related
ICFIID; (a) The number of days employed for the overlap of an
employment period when the administrator is working in the related ICFIID
during the same period of time; plus (b) The number of days employed preceding the overlapping
employment period; plus (c) The number of days employed subsequent to the
overlapping employment period. (b) For each time slice of an administrator, calculate the
following: (i) Acquire the number of
certified beds for the ICFIID as of the end of the cost reporting period from
schedule A, line 2, column 1 of the cost report. (ii) Acquire the number
of certified beds for related facilities that the administrator worked in
during the time slice as of the end of the cost reporting period. (iii) Calculate the total
number of certified beds by adding the number of certified beds for the ICFIID
as determined in accordance with paragraph (C)(1)(b)(i) of this rule and the
number of certified beds for any related facilities that the administrator
worked in as determined in accordance with paragraph (C)(1)(b)(ii) of this
rule. (iv) Acquire the
appropriate compensation cost limit as follows: (a) If the administrator does not work in four or more
related facilities, use the total number of certified beds determined in
accordance with paragraph (C)(1)(b)(ii) of this rule to determine the
appropriate compensation cost limit determined in accordance with paragraph
(B)(6) of this rule; or (b) If the administrator works in four or more related
facilities, the compensation cost limit is the maximum for the bed size
category determined in accordance with paragraph (B)(6) of this
rule. (v) Acquire the allowance
percentage from schedule C-1 of the cost report which shall not exceed one
hundred-fifty per cent. (vi) Calculate the
adjusted compensation cost limit by multiplying the compensation cost limit
determined in accordance with paragraph (C)(1)(b)(iv) of this rule by the
allowance percentage determined in accordance with paragraph (C)(1)(b)(v) of
this rule. (vii) Calculate the total
number of days employed for each administrator by subtracting the beginning
date from the ending date for each time slice and adding one. (viii) Determine the
total days in the calendar year. (ix) Calculate the per
cent of days allowed by dividing the number of days in the time slice as
calculated in accordance with paragraph (C)(1)(b)(vii) of this rule by the
total days in the calendar year as determined in accordance with paragraph
(C)(1)(b)(viii) of this rule. (x) Calculate the time
slice adjusted compensation cost limit by multiplying the per cent of days
allowed as calculated in accordance with paragraph (C)(1)(b)(ix) of this rule
by the adjusted compensation as calculated in accordance with paragraph
(C)(1)(b)(vi) of this rule. (xi) Acquire the weekly
hours in the time slice for the appropriate time period from schedule C-1 of
the cost report. (xii) Acquire the related
weekly hours in the time slice for the appropriate time period from the related
ICFIID's schedule C-1 of the cost report. (xiii) Calculate the
total weekly hours in the time slice by adding the weekly hours in the time
slice as determined in accordance with paragraph (C)(1)(b)(xi) of this rule and
the related weekly hours in the time slice as determined in accordance with
paragraph (C)(1)(b)(xii) of this rule. (xiv) Calculate the
maximum weekly hours: (a) If the total weekly hours in the time slice as
calculated in accordance with paragraph (C)(1)(b)(xiii) of this rule is less
than thirty-five hours per week, the maximum weekly hours in the time slice is
forty; or (b) If the total weekly hours in the time slice as
calculated in accordance with paragraph (C)(1)(b)(xiii) of this rule is greater
than or equal to thirty-five hours per week, the maximum weekly hours in the
time slice is the total weekly hours in the time slice. (xv) Calculate the hours
allocation percentage by dividing the weekly hours in the time slice as
calculated in accordance with paragraph (C)(1)(b)(xi) of this rule by the
maximum weekly hours as calculated in accordance with paragraph (C)(1)(b)(xiv)
of this rule. (xvi) Calculate the final
time slice adjusted compensation cost limit by multiplying the time slice
adjusted compensation cost limit as calculated in accordance with paragraph
(C)(1)(b)(x) of this rule by the hours allocation percentage as calculated in
accordance with paragraph (C)(1)(b)(xv) of this rule. (xvii) Calculate a daily
salary amount for each administrator by dividing the compensation amount by the
number of days employed as reported on schedule C-1 of the cost report. For
each time slice, calculate the prorated administrator compensation amount by
multiplying the daily salary amount for each administrator by the number of
days employed in each time slice as calculated in accordance with paragraph
(C)(1)(b)(vii) of this rule. (xviii) Calculate the
administrator compensation disallowance by subtracting the final time slice
adjusted compensation cost limit as calculated in accordance with paragraph
(C)(1)(b)(xvi) of this rule from the adjusted prorated administrator
compensation amount as calculated in accordance with paragraph (C)(1)(b)(xvii)
of this rule. The result cannot be less than zero. (xix) Calculate the final
adjusted prorated administrator compensation amount by subtracting the
administrator compensation disallowance as calculated in accordance with
paragraph (C)(1)(b)(xviii) of this rule from the adjusted prorated
administrator compensation amount as calculated in accordance with paragraph
(C)(1)(b)(xvii) of this rule. (2) For each ICFIID,
determine the overall facility administrator aggregate compensation
disallowance for reporting costs in excess of the adjusted compensation cost
limit as follows: (a) Acquire the number of certified beds for the ICFIID as
of the end of the cost reporting period from schedule A, line 2, column 1 of
the cost report. (b) Acquire the appropriate compensation cost limit for the
bed size category using the total number of certified beds determined in
accordance with paragraph (C)(2)(a) of this rule and the compensation cost
limit determined in accordance with paragraph (B)(6) of this rule. (c) Establish the allowance percentage as one hundred-fifty
per cent. (d) Calculate the adjusted compensation cost limit by
multiplying the compensation cost limit determined in accordance with paragraph
(C)(2)(b) of this rule by the allowance percentage determined in accordance
with paragraph (C)(2)(c) of this rule. (e) Calculate the total administrator allowable
compensation by summing the compensation reported on schedule C-1 of the cost
report for all administrators and subtracting any disallowances calculated in
accordance with paragraph (C)(1)(b)(xviii) of this rule. (f) Calculate the overall facility administrator aggregate
compensation disallowance by subtracting the adjusted compensation cost limit
as calculated in accordance with paragraph (C)(2)(d) of this rule from the
total administrator allowable compensation as calculated in accordance with
paragraph (C)(2)(e) of this rule. The result cannot be less than
zero. (D) Administrators serving in direct care
positions (1) If an administrator
works in one or more of the following direct care cost center positions, the
compensation earned for performing such duties may be expensed directly to the
direct care cost center. (a) Medical director; (b) Director of nursing; (c) Activities director; (d) Registered nurse; (e) Licensed practical nurse; (f) Recreational therapist; (g) Psychologist; (h) Respiratory therapist; (i) Qualified intellectual disability
professional; (j) Licensed social worker/counselor; (k) Chaplain; (l) Charge nurse - registered nurse; or (m) Charge nurse - licensed practical nurse. (2) Compensation for an
administrator performing a direct care cost center function is allowable only
for duties which otherwise would require the employment of another person. The
portion of the administrator's total compensation paid by the ICFIID that
may be reported in the direct care cost center shall be determined by
multiplying the total compensation by the percentage of time the administrator
spends performing the direct care cost center duties. (3) The ICFIID must
maintain records documenting the allocation of the administrator's time to
the direct care cost center duties. Time studies conducted in accordance with
the centers for medicare and medicaid services publication 15-1, "Provider
Reimbursement Manual" (revised January 2005), available at
http://www.cms.hhs.gov/manuals, shall be considered sufficient documentation of
the allocation of time. If the department finds that the ICFIID has not
sufficiently documented the allocation of time, the cost associated with the
undocumented time will be reclassified back to the indirect cost
center.
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Rule 5123-7-23 | Intermediate care facilities for individuals with intellectual disabilities - method for establishing the other protected costs component of the prospective rate.
Effective:
December 16, 2019
(A) Purpose This rule sets forth the method for establishing
the other protected costs component of the prospective rate paid to an
intermediate care facility for individuals with intellectual disabilities
(ICFIID). (B) Calculation of per diem
rate Each eligible ICFIID shall be paid a per diem for
each resident for other protected costs. This component of the rate will be
established prospectively each fiscal year. This per diem shall be calculated
by dividing the desk-reviewed, actual, allowable other protected costs total
except for the franchise permit fee (account number 6091) by the inpatient
days. This information will come from the year-end cost report preceding the
fiscal year in which the rate will be paid. This per diem will then be inflated
by the estimated inflation rate as calculated in accordance with paragraph (C)
of this rule and added to the per diem for the franchise permit fee as
calculated in accordance with paragraph (D) of this rule to determine the total
other protected costs component of the prospective rate. (C) Estimated inflation
rate The department shall estimate the rate of
inflation for the eighteen-month period using the consumer price index for all
urban consumers for nonprescription drugs and the consumer price index for all
urban consumers for medical supplies, as published by the United States bureau
of labor statistics. The estimated inflation rate is calculated by taking the
value of the indexes as of the thirty-first day of December in the fiscal year
the rate will be paid, divided by the value of the indexes as of the first day
of July in the immediately preceding calendar year. If the estimated inflation
rate for the eighteen-month period is different from the actual inflation rate
for that period, the difference shall be added to or subtracted from the
inflation rate estimated for the following fiscal year. (D) Franchise permit fee Notwithstanding the method for reimbursement for
other protected costs as set forth in rule 5123-7-12 of the Administrative
Code, the franchise permit fee rate in the amount equal to the assessment
specified in section 5168.61 of the Revised Code will be included in the other
protected costs center per diem rate for each ICFIID subject to the franchise
permit fee assessment as specified in section 5168.61 of the Revised Code. The
ICFIID will not receive reimbursement for the franchise permit fee if there is
no assessment. The franchise permit fee rate is not subject to the inflation
factor that is allowed for costs reported in the other protected costs center
in accordance with paragraph (C) of this rule.
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Rule 5123-7-24 | Intermediate care facilities for individuals with intellectual disabilities - costs of ownership payment.
(A) Purpose This rule sets forth conditions necessary for an
intermediate care facility for individuals with intellectual disabilities
(ICFIID) to receive a costs of ownership payment. This rule applies only to the
capital rate calculation prescribed in section 5124.171 of the Revised
Code. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Costs of
ownership" means the actual expense incurred for: (a) Depreciation and interest on any items capitalized
including: (i) Buildings; (ii) Building
improvements; (iii) Equipment; (iv) Extensive
renovation; (v) Transportation
equipment; and (vi) Replacement
beds. (b) Amortization and interest on land improvements and
leasehold improvements. (c) Amortization of financing costs. (d) Lease and rent of land, building, and
equipment. (2) "Extensive
renovation" means a renovation that costs more than sixty-five per cent
and no more than eighty-five per cent of the cost of constructing a new bed and
that extends the useful life of the assets for at least ten years. To calculate
the per-bed cost of a renovation project for purposes of determining whether it
is an extensive renovation, the allowable cost of the project shall be divided
by the number of beds in the facility certified for participation in the
medicaid program, even if the project does not affect all medicaid-certified
beds. Allowable extensive renovations are considered an integral part of costs
of ownership. (a) The cost of constructing a new bed shall be considered
to be forty thousand dollars, adjusted for inflation from January 1, 1993 to
the end of the calendar year during which the renovation is completed using the
consumer price index for shelter costs for all urban consumers for the midwest
region, as published by the United States bureau of labor
statistics. (b) The department may treat a renovation that costs more
than eighty-five per cent of the cost of constructing new beds as an extensive
renovation if the department determines that the renovation is more prudent
than construction of new beds. (3) "Nonextensive
renovation" has the same meaning as in rule 5123-7-25 of the
Administrative Code. (4) "Replacement
beds" are beds which are relocated to a new building or portion of a
building attached to and/or constructed outside of the original licensed
structure of an ICFIID. Replacement beds may originate from within the licensed
structure of an ICFIID or from another ICFIID. Replacement beds are eligible
for the costs of ownership efficiency incentive ceiling which corresponds to
the period in which the beds were replaced. (C) Costs of ownership
payment (1) For an ICFIID that
has dates of licensure or that has been granted project authorization by the
department on or after July 1, 1993, for which substantial commitments of funds
were not made before July 1, 1993, costs of ownership payments shall not exceed
the ceilings established in section 5124.171 of the Revised Code, if the
department gives prior approval for construction of the ICFIID. (a) Prior to commencement of construction, the provider
must submit a request in writing to the department. The request shall
include: (i) The projected
completion date for the new ICFIID. (ii) A projected budget
for the new ICFIID that includes a projected three-month cost report that
contains all cost centers and inpatient days so that an overall rate can be
calculated. For beds relocated from an existing ICFIID, the same information
must be received for the existing ICFIID and the ICFIID to which the beds are
to be relocated. (b) The department shall review the request and the
projected budget, comparing the projected cost per diem to the rate currently
associated with the beds for cost neutrality to the Ohio medicaid program. Cost
neutrality shall be evaluated across beds transferred to the new ICFIID and the
beds remaining in the existing ICFIID. (c) Approval for the increased costs of ownership payments
shall be granted contingent upon the receipt by the department of the
provider's filed actual cost report for the first three months of
operation confirming cost neutrality to the Ohio medicaid program. Until a
final determination is made by the department with regard to the request for
increased costs of ownership payments, the lower costs of ownership ceiling
shall be effective. (d) Written approval or denial of the preliminary request
shall be made by the department within sixty calendar days of the date the
initial request was made and the required documentation was received. Written
documentation of the final determination shall be provided by the department
within sixty calendar days from the date the new ICFIID's actual
three-month cost report is received. (e) If the project continues to satisfy the cost neutrality
standard, the higher costs of ownership ceiling shall be implemented
retroactively to the first day the new ICFIID's provider agreement was
effective. If the request is denied, the provider shall continue to receive the
lower costs of ownership ceiling. (2) An ICFIID that
completes extensive renovations shall receive a per diem for costs of ownership
based upon the costs as specified in paragraph (C)(1) of this
rule. (a) The date of licensure for an extensively renovated
ICFIID shall be considered to be the date of completion of the extensive
renovation. (b) The current limits as calculated in accordance with
section 5124.171 of the Revised Code shall be assigned to the extensively
renovated ICFIID using the date of licensure. (c) An extensively renovated ICFIID that obtains new
ceilings in accordance with this rule, shall not be permitted any reimbursement
for nonextensive renovation under rule 5123-7-25 of the Administrative Code
made prior to the extensive renovation project which resulted in the new
ceilings. Thereafter, the cost and accumulated depreciation of the nonextensive
renovation shall be included in costs of ownership. (d) An extensively renovated ICFIID shall not be permitted
to receive any reimbursement for nonextensive renovation under rule 5123-7-25
of the Administrative Code for a period of five years after the completion of
the extensive renovations, with the exception of those nonextensive renovation
projects necessary to meet the requirements of federal, state, or local
statutes, ordinances, rules, or policies.
Last updated April 12, 2024 at 11:52 AM
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Rule 5123-7-25 | Intermediate care facilities for individuals with intellectual disabilities - nonextensive renovation.
(A) Purpose This rule defines nonextensive renovation and
sets forth the process for calculating the per-bed cost of a nonextensive
renovation project at an intermediate care facility for individuals with
intellectual disabilities (ICFIID). (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Extensive
renovation" has the same meaning as in rule 5123-7-24 of the
Administrative Code. (2) "Nonextensive
renovation" means a project, approved by the department prior to the
effective date of this rule in accordance with rule 5123:2-7-25 of the
Administrative Code as it existed on the day immediately prior to the effective
date of this rule, for the betterment, improvement, or restoration of an ICFIID
beyond its current functional capacity through a structural change that costs
at least five hundred dollars per bed. To calculate the per-bed cost of a
renovation project for purposes of determining whether it is a nonextensive
renovation, the allowable cost of the project shall be divided by the number of
beds in the ICFIID certified for participation in the medicaid program, even if
the project does not affect all medicaid-certified beds. "Nonextensive
renovation" may include betterment, improvement, restoration, or
replacement of assets that are affixed to the building and have a useful life
of at least five years. "Nonextensive renovation" may include costs
that otherwise would be considered maintenance and repair expenses if they are
included as part of the nonextensive renovation project and are an integral
part of the structural change that makes up the nonextensive renovation
project. "Nonextensive renovation" does not mean construction of
additional space for beds that will be added to an ICFIID's licensed or
certified capacity. Allowable nonextensive renovation projects are not
considered costs of ownership. (C) Determining the cost of nonextensive
renovation (1) The desk-reviewed actual, allowable,
per diem cost of nonextensive renovation is based upon certified beds for
property costs and assets affixed to the building for the calendar year
preceding the fiscal year in which the rate will be paid. The desk-reviewed
actual, allowable, per diem cost of nonextensive renovation
includes: (a) The cost of purchasing or acquiring capital assets that
meet the requirements of nonextensive renovation in accordance with this rule
which includes: (i) Depreciation expense for the cost of buildings equal
to the actual cost depreciated in accordance with rule 5123:2-7-18 of the
Administrative Code for nonextensive renovation. The provider is not to change
the accumulated depreciation that has been previously reported. This
accumulated depreciation will be carried forward as previously reported and
audited. The current depreciation will then be added to accumulated
depreciation as recognized. (ii) Depreciation expense for major components of property
and fixed equipment equal to the actual cost depreciated in accordance with
rule 5123:2-7-18 of the Administrative Code for nonextensive renovation. The
provider is not to change the accumulated depreciation that has been previously
reported. This accumulated depreciation will be carried forward as previously
reported and audited. The current depreciation will then be added to
accumulated depreciation as recognized. (iii) Interest expense incurred on money borrowed for capital
assets that qualify for nonextensive renovation. (iv) Depreciation expense for costs paid or reimbursed by
any government agency, if that part of the prospective per diem rate is used to
reimburse the government agency and a loan provides for repayment over a
time-limited period. These capital assets must qualify for nonextensive
renovation. (v) Amortization expense of financing costs. (b) The cost of nonextensive renovation directly related to
the amortization of leasehold improvements that meet the criteria for
nonextensive renovation in accordance with this rule. These costs shall be
expensed over the lesser of the remaining life of the lease, but not less than
five years, or the useful life of the improvement as specified in rule
5123:2-7-18 of the Administrative Code. If the useful life of the improvement
is less than five years, it may be amortized over its useful life. Options on
leases will not be considered. Lessees who report leasehold improvements and
who leave the program before the minimum amortization period is complete will
not receive reimbursement for the balance of unamortized costs. (2) The cost of
nonextensive renovation directly attributable to the purchase of property and
equipment costs from one related party to another through common ownership or
control shall be based upon the lesser of the actual purchase of property and
equipment costs or the actual costs of the related party. (D) Criteria for treatment as a
nonextensive renovation (1) The following shall apply in order to
determine if a project qualifies for treatment as a nonextensive
renovation. (a) The project meets the definition of nonextensive
renovation set forth in paragraph (B)(2) of this rule. (b) The project does not increase the number of licensed
beds. (c) If the ICFIID relocates beds within the current
structure of the building, the construction for the relocated beds shall be
considered a nonextensive renovation if it meets the other criteria specified
in this rule unless the project meets the requirements of extensive
renovation. (d) The ICFIID obtained approval of the project as a
nonextensive renovation from the department prior to the effective date of this
rule. (e) The ICFIID has satisfied all requirements for notice to
the department upon completion of the project as set forth in paragraph (F) of
this rule. (2) A nonextensive
renovation project shall be started within six months after the date the
department grants approval. For the purposes of this rule, "started"
means the physical work has begun on the project at the site of the ICFIID.
Preliminary work such as planning, agency approval, feasibility surveys, and
architectural drawings are not considered "started." (3) A nonextensive
renovation project shall be completed within eighteen months after it is
started. The total cost of all portions of the nonextensive renovation project
completed within eighteen months after it is started must satisfy the per-bed
cost requirement set forth in paragraph (B)(2) of this rule. (4) Failure to satisfy
the conditions set forth in paragraphs (D)(1) to (D)(3) of this rule shall
result in the costs of the project being reported as costs of ownership in lieu
of nonextensive renovation. (E) Additional notice requirements Additional notice to the department is required
during the course of the construction of the approved nonextensive renovation
if: (1) The completion of the nonextensive
renovation project is delayed or accelerated by more than four months from the
estimated date of completion. (2) The actual cost of construction
exceeds the approved cost by the greater of ten per cent or two thousand
dollars. (a) Upon receiving notice of the increase in the cost of
construction, the department may approve the additional project costs for
inclusion as a nonextensive renovation. In reviewing a project for approval
under this paragraph, the department shall apply the criteria specified in
paragraph (D) of this rule. (b) If the department does not approve the additional cost
of construction, expenses related to all costs of construction in excess of the
approved amount shall be reported as costs of ownership. (c) If the provider fails to provide notice to the
department of the increase in the cost of construction, expenses related to all
costs of construction in excess of the approved amount shall be reported as
costs of ownership. (3) The actual amount financed exceeds
the approved amount financed by the greater of ten per cent or two thousand
dollars. (a) Upon receiving notice of the increase in the amount
financed, the department may approve the increase in the amount financed for
inclusion as a nonextensive renovation. In reviewing a project for approval
under this paragraph, the department shall apply the criteria specified in
paragraph (D) of this rule. (b) If the department does not approve the additional
amount financed, interest expense related to all amounts financed in excess of
the approved amount shall be reported as costs of ownership. (c) If the provider fails to provide notice to the
department of the increase in the amount financed, interest expense related to
all amounts financed in excess of the approved amount shall be reported as
costs of ownership. (4) The actual interest rate exceeds the
projected interest rate by two or more percentage points. (a) Upon receiving notice of the increase in the interest
rate, the department may approve the interest expense associated with the
increased interest rate for inclusion as a nonextensive renovation. In
reviewing a project for approval under this paragraph, the department shall
apply the criteria specified in paragraph (D) of this rule. (b) If the department does not approve the increased
interest rate, the interest expense associated with the incremental increase in
the approved interest rate shall be reported as costs of
ownership. (c) If the provider fails to provide notice to the
department of the increase in the interest rate, the interest expense
associated with the incremental increase in the approved interest rate shall be
reported as costs of ownership. (5) There is any increase or decrease in
the scope of the nonextensive renovation project. (a) Upon receiving notice of the change in the scope of the
nonextensive renovation project, the department may approve the project as
revised if the change in scope bears a reasonable relationship to the approved
nonextensive renovation project. (b) If the department does not approve the project as
revised, the additional costs associated with the change in scope shall be
reported as costs of ownership. (c) If the provider fails to provide notice to the
department of the change in the scope of the project, the additional costs
associated with the change in scope shall be reported as costs of
ownership. (6) Any change of cost causes the project
to exceed the threshold for being considered an extensive renovation or to fall
below the threshold for being considered a nonextensive
renovation. (F) Reporting a nonextensive renovation
project on the cost report (1) Before a nonextensive renovation or
portion thereof can be reported on the cost report, notice of completion must
be submitted to the department. The notice of completion shall
include: (a) The date the project or portion thereof was placed in
service; (b) Detailed depreciation and amortization schedules and a
narrative explanation of any material differences between the expenses stated
on the schedules and the estimated costs submitted for the project and
prior-approved by the department; and (c) A detailed reconciliation of actual financing cost to
the projected financing cost in the request for approval of a nonextensive
renovation. (2) A nonextensive renovation may be
reported on the cost report as each portion of the project is placed into
service as long as the anticipated completion of the portions of the project is
still within the period set forth in paragraphs (D)(2) and (D)(3) of this rule
and in the aggregate satisfy the per-bed cost requirement set forth in
paragraph (B)(2) of this rule. (3) If the total cost of all the portions
of the entire project that have been placed into service within the period set
forth in paragraphs (D)(2) and (D)(3) of this rule do not satisfy the per-bed
cost requirement set forth in paragraph (B)(2) of this rule, the costs and
related expenses for all the portions of the project that have been reported as
a nonextensive renovation shall be reported as costs of ownership.
Last updated April 12, 2024 at 11:52 AM
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Rule 5123-7-27 | Intermediate care facilities for individuals with intellectual disabilities - request for rate reconsideration.
(A) Purpose This rule establishes a process for an
intermediate care facility for individuals with intellectual disabilities
(ICFIID) or a group or association of ICFIID providers to request
reconsideration of an ICFIID's per diem payment rate pursuant to section
5124.38 of the Revised Code. (B) Submission of request (1) In addition to the
circumstances referenced in section 5124.38 of the Revised Code,
reconsideration of an ICFIID's per diem payment rate may be
requested: (a) On the basis of a possible error in the calculation of
the rate; or (b) Upon direct admission of a resident from a
department-operated ICFIID, on the basis of extreme hardship on the admitting
ICFIID. (2) A request for rate
reconsideration shall be submitted: (a) In the case of a possible error in the calculation of
the rate, within thirty calendar days after the later of the initial payment of
the rate or the receipt of the rate-setting calculation. (b) In the case of direct admission of a resident from a
department-operated ICFIID, within ninety calendar days after
admission. (3) A request for rate
reconsideration for items referenced in this rule or in section 5124.38 of the
Revised Code shall be submitted in writing via email to
cr-icf@dodd.ohio.gov. (a) The request shall indicate the reason for rate
reconsideration. (b) In the case of a possible error in the calculation of
the rate, the request shall include a detailed explanation of the possible
error and the proposed corrected calculation and references to the relevant
sections of the Revised Code and/or rules of the Administrative Code as
appropriate. (c) In the case of direct admission of a resident from a
department-operated ICFIID, the request shall include a detailed summary of the
facts supporting the request, including demonstration of the increased costs
and the requested adjusted per diem rate. (C) Consideration of the
request (1) The department shall
respond in writing within sixty calendar days of receiving a written request
for rate reconsideration. If the department requests additional information to
determine whether a rate adjustment is warranted, the ICFIID shall respond in
writing and provide additional supporting documentation within thirty calendar
days of receipt of the request for additional information. The department shall
respond in writing within sixty calendar days of receiving the additional
information. (2) If the department
grants a rate adjustment due to an error in the calculation of the rate, the
adjustment shall be implemented retroactively to the initial service date for
which the rate is effective. (3) If the department
grants a rate adjustment due to direct admission of a resident from a
department-operated ICFIID, the adjustment shall be implemented the first day
of the first month the former resident of a department-operated ICFIID resides
in the admitting ICFIID. (a) The adjusted rate shall be time-limited to no longer
than twelve consecutive months and may span fiscal years. There shall be no
extensions granted beyond the initial twelve months. The rate adjustment shall
be rescinded earlier than twelve months should the admitted former resident of
a department-operated ICFIID permanently leave the ICFIID for any
reason. (b) The maximum amount available for each admitted former
resident of a department-operated ICFIID shall be no more than fifty dollars
per day, with the rate determined by dividing fifty dollars by the number of
filled beds in the admitting ICFIID including the bed occupied by the former
resident of a department-operated ICFIID. The resulting amount will be added to
the ICFIID's per diem rate until the end of the state fiscal
year. (c) If the twelve consecutive months cross a state fiscal
year, the calculation in paragraph (C)(3)(b) of this rule will be repeated at
the beginning of the next state fiscal year and the adjusted per diem rate will
remain in effect until the end of the twelfth consecutive month from the date
the first adjusted per diem rate was applied. (4) If the department
grants a rate adjustment to an ICFIID that subsequently undergoes a change of
operator, the adjusted rate shall remain in place as though a change of
operator had not occurred. (5) The department's
decision at the conclusion of the rate reconsideration process shall not be
subject to any administrative proceedings under Chapter 119. or any other
provision of the Revised Code.
Last updated April 12, 2024 at 11:52 AM
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Rule 5123-7-28 | Intermediate care facilities for individuals with intellectual disabilities - intensive behavioral support rate add-on.
Effective:
September 18, 2020
(A) Purpose This rule sets forth requirements for an
intermediate care facility for individuals with intellectual disabilities
(ICFIID) to receive a per diem rate add-on established pursuant to section
5124.26 of the Revised Code for providing short-term intensive behavioral
support to youth with complex behavioral support needs in a discrete unit or
building of six or fewer beds. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Accredited
college or university" means a college or university accredited by a
national or regional association recognized by the secretary of the United
States department of education or a foreign college or university of comparable
standing. (2) "Aftercare
services" means individualized, intensive, post-discharge services driven
by input from a youth and his or her team, provided by a discharging ICFIID to
the youth and his or her family or other caregivers, as
applicable. (3) "Business
day" means a day of the week, excluding Saturday, Sunday, or a legal
holiday as defined in section 1.14 of the Revised Code. (4) "County
board" means a county board of developmental disabilities. (5) "Follow-along services"
means contact, engagement, and assistance provided by the department to support
a youth who has been discharged from an ICFIID to ensure he or she makes a
successful transition back into his or her home and community. (6) "Intensive behavioral support
rate add-on" means per diem reimbursement in the amount of three hundred
dollars paid to an ICFIID that is approved by the department in accordance with
this rule for serving a specific resident who is in middle to late childhood,
generally age ten through seventeen, and who has complex behavioral support
needs. The intensive behavioral support rate add-on is intended to compensate
an ICFIID for the additional costs associated with serving a youth with complex
behavioral support needs such as: (a) Intensive and specialized therapies (e.g.,
occupational, physical, speech, audiology, and applied behavior
analysis); (b) Non-traditional therapies (e.g., art, music, and
recreation); (c) Higher staffing levels including one-to-one
staffing; (d) Specialized training for staff; (e) Higher level and intensity of supervision; (f) Intensive engagement with family or other caregivers;
and (g) Participating in the intensive behavioral support
community of practice convened by the department. (7) "Person-centered plan"
means a written description of the services to be provided to a resident of an
ICFIID that meets the requirements set forth in 42 C.F.R. 483.440(c) as in
effect on the effective date of this rule for an individual program plan and
the requirements for person-centered planning set forth in rule 5123:2-3-03 of
the Administrative Code. (8) "Psychiatrist" means a
physician licensed in accordance with Chapter 4731. of the Revised Code to
practice psychiatry. (C) Approval to receive the intensive
behavioral support rate add-on There are two components of securing approval to
receive the intensive behavioral support rate add-on: (1) Facility
eligibility (a) An ICFIID that is interested in receiving the intensive
behavioral support rate add-on for current or prospective residents may, when
the department is seeking applications, complete and submit an application. The
ICFIID will provide information requested by the department and may be subject
to documentation reviews and on-site visits by department personnel as part of
the application process. (b) As part of its application, an ICFIID will submit a
best practices protocol for providing intensive behavioral support which will
be evaluated by the department to determine if it is acceptable. (c) To obtain and maintain approval to receive the
intensive behavioral support rate add-on, an ICFIID will: (i) Enter into an
agreement with the department for the provision of intensive behavioral
support. (ii) Agree to cooperate
with the department's oversight of intensive behavioral support as
described in paragraph (E) of this rule. (d) An ICFIID whose license has been suspended and/or
proposed for revocation by the department within the past twenty-four months is
not eligible to receive the intensive behavioral support rate
add-on. (2) Specific youth
served (a) An ICFIID that has complied with the requirements and
obtained approval in accordance with paragraph (C)(1) of this rule may request
the intensive behavioral support rate add-on which may be available for serving
a specific youth who is: (i) Within middle to late
childhood, generally age ten through seventeen. (ii) Determined by the
department, in collaboration with the youth's home county board, to need
intensive behavioral support based on a comprehensive review of the youth.
Referral of a youth to the department for a comprehensive review described in
this paragraph may be initiated by the ICFIID or by another entity (such as a
county board or the Ohio department of medicaid). The comprehensive review will
include input from the youth and his or her team and consider: (a) The
youth's: (i) Clinical diagnosis
and history; (ii) Current and past
medications; (iii) History of living
arrangements (e.g., inside or outside family home, multiple settings, or
out-of-state); (iv) Educational history
(e.g., previous educational programs, therapies, and services); (v) Sensory integration
and functioning (e.g., awareness of and response to touch, light, color, smell,
taste, and texture); (vi) Motor skills (e.g.,
sitting, standing, walking, running, climbing stairs, picking up items, and
holding objects); (vii) Cognitive abilities
(e.g., maintaining attention, organizing self, recalling information, and
connecting behavior with consequences); (viii) Most successful
and/or preferred learning style or modality; (ix) Communication skills
(e.g., level of speech and ability/method for expressing wants and
needs); (x) Emotional experience
and functioning (e.g., history of trauma; description of the type and intensity
of behaviors that present a danger to self or others; ability to adapt to
change; and if or how the youth demonstrates anxiety, fear, or symptoms of
depression); (xi) Social experience
and skills (e.g., making and keeping friends, being able to wait patiently for
assistance or attention, and maintaining personal space); (xii) Preferences and
interests, including what is important to and important for the youth, as well
as any skills the youth possesses that are not addressed in other areas;
and (xiii) Needs and
strengths identified through administration of the "Child and Adolescent
Needs and Strengths" decision-making tool. (b) Positive supports and
interventions that have been found effective in meeting the youth's needs
(e.g., successful visual and environmental supports). (c) Assistive technology
that has been used or is currently used to support the youth. (b) An ICFIID will electronically submit a request to
secure approval to receive the intensive behavioral support rate add-on for
serving a specific youth to the department. (i) The department will
determine whether the ICFIID will receive the intensive behavioral support rate
add-on for serving a specific youth based on the information contained in the
submitted request, the comprehensive review of the youth conducted in
accordance with paragraph (C)(2)(a)(ii) of this rule, the services offered by
the ICFIID, the residents currently served by the ICFIID, and other information
deemed relevant by the department. The department will notify the ICFIID of its
determination within fourteen calendar days after receipt of the comprehensive
review and other relevant information. (ii) The department may
issue initial approval for the intensive behavioral support rate add-on to an
ICFIID for serving a specific youth for a maximum period of one hundred eighty
days. (iii) The department may
issue approval for continuation of the intensive behavioral support rate add-on
beyond the previously approved period. To ensure continuity, an ICFIID will
electronically submit a request at least thirty calendar days prior to the last
day of the previously approved period. The department will make a determination
based on the submitted request, reports regarding critical events and the
status of the youth's progress, discharge planning options, assessments
conducted by the department, and other information deemed relevant by the
department. The department may approve continuation of the intensive behavioral
support rate add-on for periods of up to one hundred eighty days per
request. (iv) The department will
issue notice of determination, indicating approval or denial of the request for
the intensive behavioral support rate add-on for serving a specific youth, to
the ICFIID by electronic mail and provide a copy of the notice to the
youth's home county board. (a) When a request for
the intensive behavioral support rate add-on is denied, the notice will specify
the reason for denial. (b) When a request for
the intensive behavioral support rate add-on is approved, the notice will
include an assigned approval number, the number of days for which the intensive
behavioral support rate add-on is approved, and the date on which payment is
approved to begin. The notice will also include the name, location, and phone
number of the department staff member who is assigned to monitor the
youth's progress at the ICFIID. (D) Requirements for services
provided With regard to a youth for whom an ICFIID
receives the intensive behavioral support rate add-on, the ICFIID shall: (1) Serve the youth in a
discrete unit or building where only residents age ten through seventeen reside
and that has six or fewer beds. (2) Provide the youth
with his or her own bedroom which will not be shared by any other
resident. (3) Provide services in
accordance with the ICFIID's best practices protocol for providing
intensive behavioral support. (4) Utilize
trauma-informed approaches to care. (5) Ensure that staff who
supervise the day-to-day provision of services meet one of the
following: (a) Hold professional license or certification issued by
the Ohio board of psychology; the state medical board of Ohio; or the Ohio
counselor, social worker, and marriage and family therapist board; (b) Hold a certificate to practice as a certified Ohio
behavior analyst pursuant to section 4783.04 of the Revised Code;
or (c) Hold a bachelor's or graduate-level degree from an
accredited college or university and have at least three years of paid
full-time (or equivalent part-time) experience in developing and/or
implementing behavioral support and/or risk reduction strategies or
plans. (6) Ensure that staff who
supervise the day-to-day provision of services and staff who directly provide
services successfully complete training in: (a) Orientation to provision of intensive behavioral
support, including the rights of persons with developmental disabilities set
forth in section 5123.62 of the Revised Code and the requirements of rule
5123:2-2-06 of the Administrative Code; (b) Accepted best practices and innovative approaches, as
set forth in the ICFIID's best practices protocol for providing intensive
behavioral support, to meet residents' needs; (c) Department-provided training in comprehensive supports
for youth with complex behavioral support needs; and (d) The specific needs of, and supports to be provided to,
each resident. (7) Ensure that nursing
services are available twenty-four hours per day. (8) Ensure that
psychiatric services are available twenty-four hours per day and that a
psychiatrist reviews the youth's clinical status at least once every six
months. (9) Electronically submit
notice to the department no later than by the close of the next business day
when a youth experiences a significant change in status, including psychiatric
hospitalization. (10) Obtain the
department's approval prior to initiating a transfer or termination of
services in accordance with rule 5123:2-3-05 of the Administrative
Code. (11) Develop a
comprehensive person-centered plan including a viable discharge plan, within
thirty calendar days of a youth's admission that reflects: (a) Ongoing collaboration with the youth's parent or
guardian, as applicable, and home county board; (b) Arrangement of school services for the
youth; (c) Identifying and accessing necessary supports and
services to ensure the youth and the youth's family or other caregivers,
as applicable, are successful; and (d) Training the youth's family or other caregivers,
as applicable, in techniques that are found effective for supporting the
youth. (12) On a weekly basis,
complete progress notes which describe the youth's progress or lack of
progress, significant changes in functioning, and recommendations for
modification to the person-centered plan, if indicated. (13) In collaboration
with a youth's home county board and the department, provide three months
of aftercare services upon the youth's discharge. (E) Department oversight (1) The department will
oversee provision of intensive behavioral support to a youth for whom an ICFIID
is receiving the intensive behavioral support rate add-on. Department oversight
includes: (a) Providing support to the ICFIID, the youth, and the
youth's family or other caregivers to ensure the youth's needs are
met as determined by the team; (b) Facilitating collaboration between the ICFIID and the
youth's home county board; (c) Working closely with the ICFIID to discharge the youth
as appropriate or as the youth approaches eighteen years of age;
and (d) Providing follow-along services for three years after
the youth is discharged from the ICFIID. (2) The department may
withdraw approval of an ICFIID's facility-level eligibility to receive the
intensive behavioral support rate add-on based on: (a) The ICFIID's failure to provide services in
accordance with this rule or its agreement with the department for provision of
intensive behavioral support; (b) A pattern of refusing to serve youth referred to the
ICFIID by the department; (c) A pattern of requests to involuntarily discharge youth
for whom the ICFIID receives the intensive behavioral support rate add-on based
on the ICFIID's inability to provide necessary services; (d) The need to safeguard the health, safety, or wellbeing
of residents or staff of the ICFIID; or (e) The results of a compliance review of the ICFIID
conducted in accordance with rule 5123:2-3-06 of the Administrative
Code. (3) The department will
notify an ICFIID by certified mail of withdrawal of approval of the
ICFIID's facility-level eligibility to receive the intensive behavioral
support rate add-on no less than thirty calendar days in advance and assist the
ICFIID and the home county board of an affected resident in securing
alternative accommodations. (F) Payment of the intensive behavioral
support rate add-on (1) The department may
limit the number of intensive behavioral support rate add-ons that are
available. (2) The payment approval
date for the intensive behavioral support rate add-on will be one of the
following, but may not be earlier than the effective date of a youth's
developmental disabilities level of care determination: (a) For a youth admitted to an ICFIID on or after the
effective date of this rule, the latter of the date of approval for payment of
the intensive behavioral support rate add-on or the date of admission to the
ICFIID; or (b) For a youth admitted to an ICFIID prior to the
effective date of this rule, the date of approval for payment of the intensive
behavioral support rate add-on. (3) The intensive
behavioral support rate add-on will be billed and paid in addition to an
ICFIID's typical per diem rate for a specific youth for whom the ICFIID
has secured approval in accordance with paragraph (C)(2) of this
rule. (4) The intensive
behavioral support rate add-on will be effective on the payment approval date
determined in accordance with paragraph (F)(2) of this rule through the date
authorized by the department in accordance with paragraph (C)(2)(b)(iv)(b) of
this rule or until the date the youth no longer meets the criteria set forth in
paragraph (C)(2)(a) of this rule. (5) An ICFIID shall
electronically submit notice to the department no later than by the close of
the next business day when a youth no longer meets the criteria set forth in
paragraph (C)(2)(a) of this rule. (6) An ICFIID shall not
bill the intensive behavioral support rate add-on for a youth who is using
bed-hold days in accordance with rule 5123:2-7-08 of the Administrative
Code. (7) Payment of the
intensive behavioral support rate add-on may be denied for any service not
rendered in accordance with Chapters 5123-7, 5123:2-7, and 5160-3 of the
Administrative Code.
|
Rule 5123-7-29 | Intermediate care facilities for individuals with intellectual disabilities - ventilator services.
Effective:
August 13, 2023
(A) Purpose This rule sets forth requirements for an
intermediate care facility for individuals with intellectual disabilities
(ICFIID) to provide and be reimbursed for providing services to residents who
are dependent on invasive mechanical ventilators. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Adult"
means a person twenty-two years of age or older. (2) "Business
day" means a day of the week, excluding Saturday, Sunday, or a legal
holiday as defined in section 1.14 of the Revised Code. (3) "Designated outlier
coordinator" means a department staff member who coordinates the general
operations of the ICFIID outlier services program. The designated outlier
coordinator works with providers of outlier services, individuals requesting
and receiving outlier services, other persons whom individuals have identified,
other service agencies, and other department staff. The designated outlier
coordinator's duties include, but are not limited to: (a) Assisting with the initial approval and ongoing
monitoring of an ICFIID providing outlier services; (b) Coordinating the processing of pre-admission and
continued stay prior authorization requests for individuals; and (c) Reviewing assessments, individual service plans, day
programming plans, staffing plans, and other documents. (4) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual and includes an "individual
program plan" as that term is used in 42 C.F.R. 483.440 as in effect on
the effective date of this rule. (5) "Invasive mechanical
ventilator" means a ventilator that is interfaced directly with the
individual via an artificial airway (e.g., tracheostomy tube). Invasive
mechanical ventilators (volume and/or pressure) are life support devices
designed specifically for invasive mechanical ventilation applications and must
accommodate direct current backup power supply and include disconnect, high
pressure, low pressure, and power loss alarms. (6) "Nurse" means a person
authorized by Chapter 4723. of the Revised Code to engage in the practice of
nursing as a registered nurse or a licensed practical nurse. (7) "Outlier services" means
those clusters of services that have been determined by the department to have
reimbursement rates established pursuant to section 5124.152 of the Revised
Code when delivered by qualified providers to individuals who have been
prior-authorized to receive a category of service identified as an outlier
service by the department in accordance with Chapter 5123-7 of the
Administrative Code. (8) "Pediatric
ventilator services" means services provided by an ICFIID in accordance
with rule 5123:2-7-29 of the Administrative Code as it existed on January 17,
2018. (9) "Physician" means a person
authorized by Chapter 4731. of the Revised Code to practice medicine and
surgery, osteopathic medicine and surgery, or podiatric medicine and
surgery. (10) "Plan of correction" means
a corrective action plan prepared by an ICFIID in response to deficiencies
cited by the department or the Ohio department of health which conforms to
regulations and guidelines and includes information that describes how the
deficiency will be corrected, when it will be corrected, how other residents
that may be affected by the deficiency will be identified, and how the ICFIID
will ensure that compliance is maintained upon correction. (11) "Prior authorization assessment
for ventilator services" means an evaluation to determine if an individual
meets the eligibility criteria to receive ventilator services set forth in
paragraphs (C)(3) to (C)(6) of this rule that will take place only after the
individual is determined to meet the financial eligibility and level of care
requirements set forth in paragraphs (C)(1) and (C)(2) of this
rule. (12) "Prior authorization for
ventilator services" means department approval obtained by an ICFIID to
provide ventilator services to a specific individual for specific time-limited
initial or continued stay periods. Prior authorization for ventilator services
is required for the ICFIID to be authorized by the department to provide
ventilator services and to receive reimbursement for services rendered to the
individual. Reimbursement may be denied for any service not rendered in
accordance with Chapters 5160-3 and 5123-7 of the Administrative
Code. (13) "Registered nurse" has the
same meaning as in section 4723.01 of the Revised Code. (14) "Respiratory care
professional" means a person who is licensed under Chapter 4761. of the
Revised Code to practice the full range of respiratory care services described
in division (A) of section 4761.01 of the Revised Code. (15) "Ventilator
services" means services provided by an ICFIID that holds an effective
provider agreement with the Ohio department of medicaid and that is approved by
the department to deliver outlier services to individuals who are dependent on
invasive mechanical ventilators. (C) Individual eligibility
criteria To receive prior authorization for ventilator
services, an individual must: (1) Have been determined
by the county department of job and family services to meet the medicaid
financial eligibility standards for institutional care. (2) Have obtained a
developmental disabilities level of care determination from the department
within the last thirty calendar days, or, at the time of prior authorization
assessment for ventilator services, be determined by the department to meet the
criteria for a developmental disabilities level of care in accordance with rule
5123-8-01 of the Administrative Code. (3) Require the use of an
invasive mechanical ventilator. (4) Have been
either: (a) An adult resident of an ICFIID approved to provide
pediatric ventilator services on January 17, 2018; or (b) An inpatient, for at least ninety days within the past
twelve months, in an acute care hospital for treatment of a life-threatening or
complex medical condition. If the individual has been an inpatient in an acute
care hospital for treatment of a life-threatening or complex medical condition
within the past twelve months but for less than ninety days, an ICFIID may
submit to the department, and the department may approve, a written request to
waive the ninety-day requirement. The request will include a description of the
clinical services the individual continues to require and an attestation by the
ICFIID that it is able to meet the individual's needs. (5) Have achieved a stabilized medical
condition so that the immediate services of an acute care hospital, including
daily physician visits, are not medically necessary. (6) Require monitoring by a nurse
twenty-four hours per day and professional assessment by a registered nurse on
a daily basis. (D) ICFIID eligibility
criteria (1) An ICFIID will
complete and electronically submit to the department an application for
approval to provide ventilator services. The application is available at the
department's website (https://dodd.ohio.gov). The ICFIID will provide any
additional information requested by the department and may be subject to
documentation review and on-site visits by department personnel. (2) To be approved to
provide ventilator services and qualify for enhanced payment for provision of
ventilator services to prior-authorized individuals, an ICFIID
will: (a) Be an Ohio medicaid-certified ICFIID and agree to
cooperate with the department's oversight of ventilator
services. (b) Meet the requirements set forth in rule 5123-7-02 of
the Administrative Code in order to obtain and maintain a provider
agreement. (c) Fully meet all standards for residential facilities
licensed in accordance with section 5123.19 of the Revised Code or have an
approved and implemented plan of correction and have not demonstrated a pattern
of repeat deficiencies. (d) Fully meet all standards for Ohio medicaid ICFIID
certification or meet the medicaid program requirements of a facility for which
the Ohio department of health found deficiencies, have an approved and
implemented plan of correction, and have not demonstrated a pattern of repeat
deficiencies. (e) Have: (i) An emergency action plan in place in the event of a
power failure; (ii) An on-site backup generator service for all equipment
including suction lines, oxygen lines, and emergency power to
ventilators; (iii) Sufficient backup ventilators on-site and available in
the event of mechanical failure as well as any other equipment necessary to
meet the needs of individuals in the event of an emergency; and (iv) An emergency response plan in place in the event of
natural or human-made disasters that provides for the safe transport of
individuals to a safe area with appropriate resources available to ensure the
health and safety of the individuals. (f) Schedule direct care staff to ensure that adequately
trained staff are present and on duty twenty-four hours per day, every day of
the year. Staffing will be sufficient to ensure that urgent, emergent, and
routine resident needs are identified appropriately and in a timely manner and
are met through the implementation of intervention strategies reflected in each
resident's individual service plan. Absences of staff for breaks and meals
will not compromise this staffing arrangement. (g) Ensure that staff who manage ventilator services have
evidence of at least two years of work experience with individuals who have
complex medical conditions. (h) Address through staff training programs, the specific
medical domains a staff member must master for a thorough understanding and
demonstration of competency in order to meet the specialized needs of residents
requiring ventilator services. Initial and continuing direct care staff
training will include: (i) Orientation to the
ICFIID's status as a provider of ventilator services, including the
individual eligibility criteria set forth in paragraph (C) of this rule and the
ICFIID eligibility criteria set forth in paragraph (D) of this
rule; (ii) Information about
the specific health care needs of the current residents of the ICFIID who
receive ventilator services; (iii) Accepted best
practices and innovative approaches to meet residents' needs; (iv) Training to ensure
nursing care competence for residents, including specialized training on
developmental needs that improve an individual's overall functional
status; and (v) Due to the increased
risk of infection for residents of ICFIID who receive ventilator services,
steps to be taken to minimize risk of transmission of contagious or infectious
diseases. (i) Agree to furnish or arrange to have furnished all
medically necessary services to individuals who are dependent on invasive
mechanical ventilators, regardless of whether the services are reimbursable
through the ICFIID cost report mechanism or directly to the provider of such
services. (i) Physician services will be available twenty-four hours
per day. (ii) A physician will complete an assessment of the
individual at least once every thirty calendar days for the first ninety
calendar days and at least once every ninety calendar days thereafter if the
individual maintains a stable status with no acute complications related to
ventilator support. If acute care needs requiring hospitalization present upon
return to the ICFIID, a physician will complete an assessment of the individual
at least once every thirty calendar days for the first ninety calendar days and
at least once every ninety calendar days thereafter. (iii) Respiratory care services will be available twenty-four
hours per day. Medically necessary respiratory care services will be provided
by a respiratory care professional or by a nurse who the ICFIID has determined
has the training, knowledge, skill, and ability to complete the services in
coordination with the respiratory care professional, and as ordered by a
physician. (iv) The ICFIID, in consultation with a physician and a
respiratory care professional, will develop a facility plan for providing care
to individuals who are dependent on invasive mechanical ventilators which
addresses: (a) Maintenance of ventilators; (b) Required modification and maintenance of facilities;
and (c) Special accommodations required to ensure that all
needs, including but not limited to, hygiene, bathing, dietary, social, and
transportation, of individuals who are dependent on invasive mechanical
ventilators, are met. (v) Services by registered nurses will be available
twenty-four hours per day. (vi) Nursing care and any personal care that may be required
for the health, safety, and wellbeing of the individuals served will be
available twenty-four hours per day. Nursing personnel will be sufficient to
ensure prompt recognition of any adverse change in an individual's
condition and to facilitate nursing, medical, or other appropriate
interventions, up to and including transfers to an acute care
hospital. (vii) The need for physical, occupational, and/or speech
therapy services will be assessed and services will be provided as needed by
therapists licensed to practice in Ohio. (viii) If an individual is receiving enteral feedings and
there is a complication of medical status secondary to the nutritional status,
a dietary consultation by a person licensed to practice dietetics in Ohio will
be made available to that individual. (j) Prior to admission of an individual who requires
ventilator services, arrange for a suitable school or day program for the
individual and submit the plan for such program to the designated outlier
coordinator or other department designee. (k) Prior to admission of an individual who requires
ventilator services, develop and submit to the designated outlier coordinator
or other department designee accurate assessments or reassessments by an
interdisciplinary team that address the individual's health, social,
psychological, educational, vocational, and chemical dependency needs. Health
information will include a copy of the medical assessment completed by a
physician who has knowledge of and experience with the individual, a clinical
summary, need for invasive mechanical ventilation (including viability and plan
for weaning), detailed therapy assessment with recommended therapy plan,
medication needs, and any other medical information relevant to the
individual's care needs. (l) Ensure that a registered nurse submits a written
summary of clinical status to the primary care physician on a monthly basis.
The physician will review and sign the summary and place it in the
individual's medical record. (m) Due to the complex and intensive needs of individuals
who require ventilator services, develop a transitional plan prior to admission
of an individual to ensure that the ICFIID is able to meet the
individual's health, safety, and behavioral support needs from the day of
admission. The transitional plan will address major concerns and be provided to
the designated outlier coordinator or other department designee upon
request. (n) Within thirty calendar days after admission, develop
accurate assessments or reassessments by an interdisciplinary team that address
the individual's health, social, psychological, educational, vocational,
and chemical dependency needs in order to supplement the preliminary evaluation
described in paragraph (D)(2)(k) of this rule, which was conducted prior to
admission. The ICFIID will provide the assessments or reassessments to the
designated outlier coordinator or other department designee upon
request. (o) Develop a comprehensive individual service plan within
thirty calendar days of an individual's admission, with input from the
individual, the individual's parent, the individual's guardian, or
other person whom the individual has identified, as applicable. The ICFIID will
provide a copy of the individual service plan to the designated outlier
coordinator or other department designee upon request. (i) The individual
service plan will be reviewed by the appropriate program staff at least
quarterly and revised as necessary with input from the individual, the
individual's parent, the individual's guardian, or other person whom
the individual has identified, as applicable. (ii) The ICFIID will notify the designated outlier
coordinator or other department designee whenever an individual experiences a
significant change in medical status, including hospitalization. (iii) The ICFIID will prepare a quarterly report in a format
approved by the department that summarizes the resident's individual
service plan, progress, changes in treatment, current status relative to
discharge goals, and any updates to the discharge plan, including referrals
made and anticipated time frames. The ICFIID will provide a copy of the
quarterly report to the designated outlier coordinator or other department
designee upon request. (iv) The designated outlier coordinator or other department
designee may visit the ICFIID at any time. The ICFIID will provide any
documents or information requested by the designated outlier coordinator or
other department designee. (p) Within thirty calendar days after admission, develop a
written discharge plan with the interdisciplinary team in conjunction with the
individual and others concerned with the individual's welfare which
describes targeted medical/health status indicators that would signify the
resident could be safely discharged. The ICFIID will provide a copy of the
discharge plan to the designated outlier coordinator or other department
designee upon request. (q) Accept payment for the provision of services at the
non-outlier ICFIID reimbursement rate if prior authorization for ventilator
services requested for an individual already residing in the ICFIID is
denied. (E) Outlier per diem rate (1) An ICFIID's per diem rate will
be set in accordance with Chapter 5124. of the Revised Code and applicable
rules in Chapter 5123-7 of the Administrative Code. An outlier per diem rate
for ventilator services, determined and applied in accordance with paragraph
(H) of this rule, will be added to the ICFIID's per diem
rate. (2) With the exception of any specific
items that are direct-billed in accordance with rule 5123-7-11 of the
Administrative Code, the ICFIID will agree to accept as payment in full the per
diem rate established for ventilator services in accordance with this rule, and
to make no additional charge to the individual, to any member of the
individual's family, or to any other source for covered ventilator
services. (F) Prior authorization for services (1) Payment for
ventilator services covered by the medicaid program will be available only upon
prior authorization by the department for each individual in accordance with
the procedures set forth in this rule. The prior authorization procedures set
forth in this rule are in addition to the developmental disabilities level of
care review process set forth in rule 5123-8-01 of the Administrative
Code. (a) Unless the individual is seeking a change of payer,
prior authorization for ventilator services will occur prior to admission to
the ICFIID. (b) In the case of requests for continued stay, prior
authorization for ventilator services will occur no later than the final day of
the previously authorized ventilator services stay. (2) A request for prior
authorization for ventilator services will be electronically submitted to the
department. (3) It is the responsibility of the
ICFIID to ensure that all required information is provided to the department as
requested. An initial request for prior authorization for ventilator services
is considered complete when: (a) A request has been accurately completed and
electronically submitted; (b) A developmental disabilities level of care has been
issued in accordance with rule 5123-8-01 of the Administrative Code and a
determination regarding the feasibility of community-based care has been made;
and (c) The designated outlier coordinator has received
supporting documentation exhibiting evidence that the applicant meets the
eligibility criteria set forth in paragraphs (C)(3) to (C)(6) of this rule.
Supporting documentation may include, but is not limited to, the preliminary
evaluation, assessments, and transitional plan required prior to admission as
set forth in paragraph (D) of this rule. (4) The department's determination
will be based on the completed initial stay request and any additional
information or documentation necessary to make the determination of eligibility
for ventilator services, which may include a face-to-face visit by at least one
department representative with the individual and, if applicable, the
individual's parent, the individual's guardian, or other person whom
the individual has identified and, to the extent possible, the
individual's formal and informal care givers, to review and discuss the
individual's care needs and preferences. (5) Based upon a comparison of the
individual's condition, service needs, and the requested placement site
with the eligibility criteria set forth in paragraph (C) of this rule, the
department will conduct a review of the application, assessment report, and
supporting documentation about the individual's condition and service
needs to determine whether the individual is eligible for ventilator
services. (6) The department will issue a notice of
determination within thirty calendar days of receipt of a complete request for
prior authorization indicating approval or denial of the request to the
individual, the individual's parent, the individual's guardian, or
other person whom the individual has identified, as applicable, and the
ICFIID. (a) When a request for prior authorization for ventilator
services is denied, the notice will specify the reason for denial and explain
the individual's right to a state hearing in accordance with section
5101.35 of the Revised Code. (b) When a request for prior authorization for ventilator
services is approved, the notice will include an assigned prior authorization
number, the number of days for which ventilator services are authorized, and
the date on which payment is authorized to begin. The notice will also include
the name and email address of the department staff member who is assigned to
monitor the individual's progress at the ICFIID. (i) Individuals who are
determined to have met the eligibility criteria set forth in paragraph (C) of
this rule may be approved for an initial stay of a maximum of one hundred
eighty-four days. The number of days prior-authorized for each eligible
individual will be based upon the submitted application materials, consultation
with the individual's attending physician, and/or any additional
consultations or materials required by the assessor to make a reasonable
estimation regarding the individual's probable need for ventilator
services. (ii) Continued stay
determinations will be based on reports from the ICFIID submitted to the
designated outlier coordinator regarding critical events and the status of the
individual's condition and discharge planning options, face-to-face
assessments conducted by the department, and/or other information determined by
the department. When the department determines that the individual continues to
meet the eligibility criteria set forth in paragraph (C) of this rule, and the
ICFIID submits a request for continued stay in accordance with paragraph (F)(8)
of this rule, continued stays may be approved for maximum increments of one
hundred eighty-four days. (c) Reimbursement for ventilator services is limited to
services approved as indicated in the approval letter. (7) An individual is expected to be
discharged to the setting specified in the individual's discharge plan at
the end of the prior-authorized initial or continued stay, and progress toward
that end will be monitored by the department or its designee throughout the
individual's stay in the ICFIID. (8) Ventilator services may be extended
beyond the previously approved length of stay if the ICFIID electronically
submits a request to the department proving that it is not possible to
implement the individual's discharge plan. Such requests will be submitted
at least thirty calendar days prior to the last day of the previously
authorized stay, unless there is a significant change of circumstances within
the week preceding the expected discharge date that prevents implementation of
the discharge plan. (G) Payment authorization The payment authorization date will be one of the
following, but will not be earlier than the effective date of the
individual's developmental disabilities level of care
determination: (1) The date of admission
to the ICFIID; or (2) The date of prior
authorization for ventilator services approval, if the individual was already a
resident of an ICFIID that provides ventilator services but was using another
payer source. (H) Initial and subsequent contracted rates (1) The department will
establish the initial and subsequent contracted rates in accordance with
Chapter 5124. of the Revised Code. All rate adjustments determined in
accordance with this rule will be effective on the payment authorization date
determined in accordance with paragraph (G) of this rule through the date of
discharge from the ICFIID or until the date the individual no longer meets the
eligibility criteria set forth in paragraph (C) of this rule. (2) An ICFIID may bill
the ventilator services revenue code for each individual whose initial or
continued stay prior authorization has been approved in accordance with
paragraph (F) of this rule. (3) An ICFIID will not
bill the ventilator services revenue code for individuals who are using
bed-hold days in accordance with rule 5123-7-08 of the Administrative
Code. (4) The ICFIID will notify the designated
outlier coordinator or other department designee no later than by the close of
the next business day following the discharge of an individual or point at
which the individual no longer meets the eligibility criteria established in
paragraph (C) of this rule to ensure processing time for recalculation and
application of the ventilator services outlier per diem rate to the ICFIID per
diem rate. (5) The ventilator services outlier per
diem rate is specific to the individual approved to receive ventilator
services. (a) The ventilator services outlier per diem rate is three
hundred dollars for services rendered on or before June 30, 2023. (b) The ventilator services outlier per diem rate is nine
hundred dollars for services rendered on or after July 1, 2023.
Last updated August 14, 2023 at 10:48 AM
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Rule 5123-7-32 | Intermediate care facilities for individuals with intellectual disabilities - administration of the Ohio developmental disabilities profile.
Effective:
April 27, 2023
(A) Purpose This rule sets forth a requirement and process
for administration of the Ohio developmental disabilities profile to residents
of an intermediate care facility for individuals with intellectual disabilities
(ICFIID). (B) Definitions of terms used in this
rule For the purposes of this rule, the following
definitions apply: (1) "Certified
assessor" means a person authorized by the department to administer the
Ohio developmental disabilities profile. In order to become a certified
assessor, a person is required to complete training conducted or approved by
the department and successfully perform a post-training
demonstration. (2) "Ohio developmental disabilities
profile" means the instrument used to assess the needs and circumstances
of an individual with developmental disabilities relative to other individuals
with developmental disabilities. (3) "Reporting period" means
one of the four quarters of the calendar year, that is: (a) January through March; (b) April through June; (c) July through September; or (d) October through December. (4) "Reporting period end date"
means the last day of the last month in a reporting period. (5) "Significant
change of condition" means that an individual has experienced a change in
physical or mental condition or functional abilities which may result in a
change in the individual's support needs. (C) Administration of the Ohio
developmental disabilities profile (1) Only a certified
assessor may administer the Ohio developmental disabilities profile or attest
that the most recent Ohio developmental disabilities profile is still valid for
a resident of an ICFIID. (2) A certified assessor
of the department will administer the Ohio developmental disabilities profile
to a new resident of an ICFIID (other than a resident who transfers from
another ICFIID) within thirty calendar days of the resident's admission,
regardless of the resident's payment source or anticipated length of stay.
Within seven calendar days of administration of the Ohio developmental
disabilities profile, the department will electronically notify the ICFIID of
the results. (3) When a resident of an
ICFIID transfers to another ICFIID, the resident's most recent Ohio
developmental disabilities profile will transfer with the
resident. (4) When a resident of an
ICFIID, regardless of the resident's payment source or anticipated length
of stay, experiences a significant change of condition, a certified assessor of
the ICFIID shall administer the Ohio developmental disabilities profile and
electronically submit the results to the department with supporting
documentation for the significant change of condition within fifteen calendar
days of the significant change of condition. Within seven calendar days of
receipt of the ICFIID's electronic submission, the department will make a
determination on a question-by-question basis and electronically notify the
ICFIID that: (a) The department accepts the results of the Ohio
developmental disabilities profile administered by the ICFIID; (b) The department requires additional supporting
documentation to make a determination which will be submitted by the ICFIID
within seven calendar days; or (c) The department does not accept the results of the Ohio
developmental disabilities profile administered by the ICFIID and provide the
department's rationale for not accepting the results. (5) An ICFIID that
disputes the results of an Ohio developmental disabilities profile administered
by the department in accordance with paragraph (C)(2) of this rule or the
department's determination in accordance with paragraph (C)(4)(c) of this
rule may submit a request for reconsideration within fifteen calendar days of
receiving notification of the results or determination. The ICFIID shall
electronically submit the request for reconsideration to the department with a
detailed explanation of why the ICFIID disputes the results or determination,
relevant supporting documentation, and a proposed resolution. When an ICFIID
submits a request for reconsideration in response to the department's
determination in accordance with paragraph (C)(4)(c) of this rule, a certified
assessor of the department will re-administer the entire Ohio developmental
disabilities profile to the resident. The department will electronically
respond to the ICFIID within fifteen calendar days of receiving the request for
reconsideration. The department's decision regarding a request for
reconsideration is final and not subject to further appeal. (D) Quarterly certification of Ohio developmental
disabilities profile data (1) For each reporting
period, a certified assessor of the ICFIID shall attest that the most recent
Ohio developmental disabilities profile is still valid for each resident of the
ICFIID on the reporting period end date, regardless of a resident's
payment source or anticipated length of stay. (a) The following will be considered residents of the
ICFIID on the reporting period end date: (i) Residents admitted or
transferred to the ICFIID prior to or on the reporting period end date and
physically residing in the ICFIID on the reporting period end date;
and (ii) Residents
temporarily absent on the reporting period end date but for whom the ICFIID is
receiving payment from any source to hold a bed for the resident during a
hospital stay, visit with friends or relatives, or participation in therapeutic
programs outside the facility in accordance with rule 5123-7-08 of the
Administrative Code. (b) The following will not be considered residents of the
ICFIID on the reporting period end date: (i) Residents discharged
from the ICFIID prior to or on the reporting period end date; (ii) Residents
transferred to another ICFIID prior to or on the reporting period end date;
and (iii) Residents who die
prior to or on the reporting period end date. (2) A certified assessor of the ICFIID
shall electronically certify the Ohio developmental disabilities profile data
on behalf of the entire ICFIID no later than fifteen calendar days following
the reporting period end date. The certification will include the name of the
certified assessor who verified that an Ohio developmental disabilities profile
has been administered and attested that the most recent Ohio developmental
disabilities profile is still valid for each resident of the ICFIID on the
reporting period end date and the name and contact information of a staff
member should department staff have questions about the data. (E) Summary and correction of Ohio developmental
disabilities profile data (1) The department will
electronically notify an ICFIID of a missing or incomplete certification of
Ohio developmental disabilities profile. (2) The department will
process and summarize the ICFIID's Ohio developmental disabilities profile
data for the reporting period and electronically provide a summary of the data
to the ICFIID. (3) An ICFIID may correct
errors or omissions identified by either the department or the ICFIID by
electronically submitting corrections along with an amended certification of
Ohio developmental disabilities profile data no later than forty-five calendar
days following the reporting period end date. Timeliness of the submission will
be determined by the electronic submission date. (4) An ICFIID shall
ensure that corrections made to the Ohio developmental disabilities profile
data submitted to the department are consistent with the Ohio developmental
disabilities profiles maintained at the ICFIID.
Last updated April 27, 2023 at 8:43 AM
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Rule 5123-7-33 | Intermediate care facilities for individuals with intellectual disabilities - resident assessment classification system based on administration of the Ohio developmental disabilities profile.
Effective:
December 16, 2019
(A) Purpose This rule sets forth a method and process for
determining the per resident/per day rate paid to an intermediate care facility
for individuals with intellectual disabilities (ICFIID) for direct care costs
using the Ohio developmental disabilities profile pursuant to sections 5124.19
to 5124.193 of the Revised Code. (B) Definitions For the purposes of this rule, the following
definitions shall apply: (1) "Annual facility
average case mix score" means the ICFIID's average case mix score of
all qualifying quarters in a calendar year. (2) "Case mix score" means the
measure of the relative direct care resources needed to provide care and
rehabilitation to a resident of an ICFIID using the Ohio developmental
disabilities profile. (3) "Correction submission due
date" means the deadline for an ICFIID to submit corrected Ohio
developmental disabilities profile data to the department. The correction
submission due date applies to corrections submitted in electronic format for
facility level errors and resident record changes. (4) "Cost per case mix unit" is
calculated by dividing an ICFIID'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. (5) "Facility level errors"
means errors which must be corrected before a facility average case mix score
can be calculated and include: (a) Failure to electronically submit the certification of Ohio
developmental disabilities profile data by the filing date; and (b) Incomplete or inaccurate changes to a resident's
assessment data are submitted to the department. (6) "Filing date" means the
deadline for initial quarterly electronic submission and certification of an
ICFIID's Ohio developmental disabilities profile data, which is the
fifteenth calendar day following the reporting period end date. (7) "Individual assessment
form" means the instrument used to assess the needs and circumstances of
an individual with developmental disabilities for the purpose of calculating an
ICFIID's direct care costs pursuant to sections 5124.195 to 5124.198 of
the Revised Code. (8) "Ohio developmental disabilities
profile" means the instrument used to assess the needs and circumstances
of an individual with developmental disabilities for the purpose of calculating
an ICFIID's direct care component rate pursuant to sections 5124.19 to
5124.193 of the Revised Code. (9) "Peer group" means one of
the following groups of ICFIID: (a) "Peer group 1-A" includes each ICFIID with a
medicaid-certified capacity exceeding sixteen. (b) "Peer group 2-A" includes each ICFIID with a
medicaid-certified capacity exceeding eight but not exceeding
sixteen. (c) "Peer group 3-A" includes each ICFIID with a
medicaid-certified capacity of seven or eight. (d) "Peer group 4-A" includes each ICFIID with a
medicaid-certified capacity not exceeding six, other than an ICFIID that is in
peer group 5-A. (e) "Peer group 5-A" includes each ICFIID to which all
of the following apply: (i) The ICFIID is first
certified as an ICFIID after July 1, 2014; (ii) The ICFIID has a
medicaid-certified capacity not exceeding six; (iii) The ICFIID has a
contract with the department that is for fifteen years and includes a provision
for the department to approve all admissions to, and discharges from, the
ICFIID; and (iv) The ICFIID's
residents are admitted to the ICFIID directly from a department-operated ICFIID
or have been determined by the department to be at risk of admission to a
department-operated ICFIID. (10) "Processing quarter" means
the quarter that follows the reporting quarter and is the quarter in which the
department receives the Ohio developmental disabilities profile data for the
reporting quarter. (11) "Quarterly facility average case
mix score" means the facility average case mix score based on Ohio
developmental disabilities profile data submitted for one reporting
quarter. (12) "Record" means a
resident's Ohio developmental disabilities profile data processed by the
department. (13) "Relative resource weight"
means the measure of the relative costliness of caring for residents in one
case mix classification 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 classification. (14) "Reporting period end date"
means the last day of each calendar quarter. (15) "Reporting quarter" means
the quarter which precedes the processing quarter. (16) "Resident assessment
classification system" means the system for classifying residents of an
ICFIID into case mix classifications that reflect clusters of residents,
defined by resident characteristics, determined using data from the Ohio
developmental disabilities profile, that explain resource use. (17) "Resident case mix score"
means the relative resource weight for the classification to which a resident
is assigned based on data elements from the resident's Ohio developmental
disabilities profile. (C) Calculating direct care
costs For a period of three years commencing on the
effective date of this rule, the department shall calculate for each eligible
ICFIID, two separate per resident/per day rates for direct care costs using
data from: (1) Administration of the
individual assessment form to residents of the ICFIID in accordance with rule
5123-7-20 of the Administrative Code; and (2) Administration of the
Ohio developmental disabilities profile to residents of the ICFIID in
accordance with this rule and rule 5123:2-7-32 of the Administrative
Code. (D) Resident assessment classification
system (1) The department shall
use the resident assessment classification system to classify residents of an
ICFIID based on the data from the Ohio developmental disabilities profile.
Using point values assigned to responses to questions on the Ohio developmental
disabilities profile as set forth in the appendix to this rule, the Ohio
developmental disabilities profile for each resident will be scored in three
distinct domains: (a) Medical; (b) Behavioral; and (c) Adaptive skills. (2) The department shall
calculate a resident's assessment score for each of the medical,
behavioral, and adaptive skills domains and assign points: (a) If the resident's assessment score for the domain is
more than one standard deviation above the mean assessment score for the domain
for all ICFIID residents as of December 31, 2017, one point; (b) If the resident's assessment score for the domain is
more than one-half standard deviation above the mean assessment score for the
domain for all ICFIID residents as of December 31, 2017, and not more than one
standard deviation above that mean, two points; (c) If the resident's assessment score for the domain is
more than the mean assessment score for the domain for all ICFIID residents as
of December 31, 2017, and not more than one-half standard deviation above that
mean, three points; (d) If the resident's assessment score for the domain is not
more than the mean assessment score for the domain for all ICFIID residents as
of December 31, 2017, and not more than one-half standard deviation below that
mean, four points; (e) If the resident's assessment score for the domain is
more than one-half standard deviation below the mean assessment score for the
domain for all ICFIID residents as of December 31, 2017, and not more than one
standard deviation below that mean, five points; and (f) If the resident's assessment score for the domain is
more than one standard deviation below the mean assessment score for the domain
for all ICFIID residents as of December 31, 2017, six points. (3) The department shall
determine the weighted sum of the points assigned in accordance with paragraph
(D)(2) of this rule to each of the resident's domain assessment scores and
round the weighted sum to the nearest whole number: (a) Points assigned to the resident's assessment score for
the medical domain shall be weighted at thirty-five per cent; (b) Points assigned to the resident's assessment score for
the behavioral domain shall be weighted at thirty per cent; and (c) Points assigned to the resident's assessment score for
the adaptive skills domain shall be weighted at thirty-five per
cent. (4) The department shall
place the resident into an acuity group: (a) If the resident's weighted sum of points is five or
lower, group one; (b) If the resident's weighted sum of points is at least six
and not more than eight, group two; (c) If the resident's weighted sum of points is nine or ten,
group three; (d) If the resident's weighted sum of points is eleven or
twelve, group four; (e) If the resident's weighted sum of points is at least
thirteen and not more than fifteen, group five; and (f) If the resident's weighted sum of points is sixteen or
higher, group six. (E) Relative resource
weights (1) Analysis of staff time and resident
assessment data, collected in a work measurement study of Ohio
medicaid-certified ICFIID for the purpose of establishing common staff times
associated with all resident classifications that are standard across
residents, staff, facilities, and units, determined that the job
classifications listed in paragraphs (E)(1)(a) to (E)(1)(h) of this rule are
job types that perform activities that vary by case mix classification
established using the Ohio developmental disabilities profile. Job types
determined not to be positions participating in activities that vary by case
mix classification are not used to calculate the relative resource weights
described in paragraph (E)(2) of this rule. (a) Habilitation specialists consisting of nurse aides and
habilitation staff; (b) Licensed practical nurses; (c) Occupational therapists; (d) Program specialists; (e) Qualified intellectual disability professionals; (f) Registered nurses; (g) Social workers/counselors; and (h) Speech therapists. (2) Each of the six resident acuity
groups is assigned a relative resource weight. The relative resource weight
indicates the relative amount and cost of staff time required on average for
the job types listed in paragraphs (E)(1)(a) to (E)(1)(h) of this rule to
deliver care to residents in that classification. The relative resource weight
was calculated using the average minutes of care per job type per
classification as determined during the work measurement study, and the
averages of the wages by job type as reported on the cost report. By setting
the wage weight at one for the job type receiving the lowest hourly wage, wage
weights for the other job types are calculated by dividing the lowest wage into
the wage of each of the other job types. To calculate the total weighted
minutes for each classification, the wage weight for each job type is
multiplied by the average number of minutes staff of that job type spend caring
for a resident in that classification, and the products are summed. The
classification with the lowest total weighted minutes receives a relative
resource weight of one. Relative resource weights are calculated by dividing
the total weighted minutes of the lowest classification into the total weighted
minutes of each classification. Weight calculations are rounded to the second
decimal place. Relative resource weights for the resident acuity groups
are: (a) Resident acuity group one = 2.75. (b) Resident acuity group two = 1.86. (c) Resident acuity group three = 1.43. (d) Resident acuity group four = 1.31. (e) Resident acuity group five = 1.12. (f) Resident acuity group six = 1.00. (3) Except as provided in paragraph
(E)(3)(a) of this rule, relative resource weights may be recalibrated using
wage weights based on three-year statewide averages of wages of the job types
listed in this rule as reported on the cost report, and minutes of care per job
type per resident assessment classification. (a) The department may recalibrate the relative resource weights
no more often than every three years, using the minutes of care per job type
per classification from the most current work measurement study and the wages
per job type per hour, to be effective at the beginning of the next state
fiscal year. When recalibrating the relative resource weights, the department
shall use cost report wage data from the most recent three calendar years
available ninety calendar days prior to the start of the fiscal
year. (b) The department may recalibrate relative resource weights more
frequently if significant variances in wage ratios between job types
occur. (c) The department may rebase the relative resource weights
through the deletion or addition of job types or with revised minutes of care
per job type by conducting a new work measurement study, if significant changes
in the job types or work roles of the job types occur, or following a change in
state policy which would significantly affect statewide case mix of the ICFIID
population. (d) After recalibrating or rebasing relative resource weights in
accordance with paragraph (E)(3)(a), (E)(3)(b), or (E)(3)(c) of this rule, the
department shall use the recalibrated or rebased relative resource weights to
recalculate the annual facility average case mix score for the calendar year
preceding the fiscal year. (4) The annual facility
average case mix score is used in conjunction with the lesser of the
ICFIID's cost per case mix unit or the maximum allowable cost per case mix
unit, adjusted by the inflation rate, to establish the direct care rate, as
outlined in sections 5124.19 to 5124.193 of the Revised Code. The ICFIID's
cost per case mix unit is calculated using the annual facility average case mix
score. The method for determining the annual facility average case mix score is
described in paragraph (G) of this rule. (F) Quarterly facility average case mix
score (1) The department shall establish each
ICFIID's rate for direct care costs annually pursuant to sections 5124.19
to 5124.193 of the Revised Code. To set the rate, the department
shall: (a) Calculate the ICFIID's cost per case mix
unit; (b) Multiply the lesser of the ICFIID's cost per case mix
unit or the maximum cost per case mix unit for the ICFIID's peer group
determined pursuant to division (C) of section 5124.19 of the Revised Code by
the ICFIID's case mix score for the calendar quarter ending March
thirty-first of the calendar year in which the fiscal year for which the rate
is set begins, except that for fiscal year 2019, the department shall use the
ICFIID's case mix score for the quarter that ends December 31, 2017;
and (c) Multiply the amount determined in accordance with paragraph
(F)(1)(b) of this rule by the inflation factor specified in division (D) of
section 5124.19 of the Revised Code. (2) The quarterly facility average case
mix score for an ICFIID that submitted Ohio developmental disabilities profile
data and modifications timely, and has no facility level errors is calculated
by: (a) Adding together all residents' relative resource weights
for the quarter; and (b) Dividing the sum of relative resource weights by the total
number of residents. (3) The department shall
assign a quarterly facility average case mix score or cost per case mix unit
used to establish an ICFIID's rate for direct care costs if the ICFIID
fails to correct facility level errors. Before taking such action, the
department shall permit the ICFIID a reasonable period of time to correct the
information, in accordance with rule 5123:2-7-32 of the Administrative
Code. (a) The department may assign a quarterly facility average case
mix score that is five per cent less than the ICFIID's quarterly facility
average case mix score for the preceding calendar quarter instead of using the
quarterly facility average case mix score calculated based on the ICFIID's
submitted information as described in paragraph (F)(2) of this rule. If the
ICFIID was assigned a quarterly facility 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. (b) The department may assign a cost per case mix unit that is
five per cent less than the ICFIID's calculated or assigned cost per case
mix unit for the preceding calendar year if the ICFIID has fewer than two
acceptable quarterly facility average case mix scores as described in paragraph
(G)(1)(b) of this rule. (G) Annual facility average case mix
score (1) The annual facility average case mix
score is used pursuant to section 5124.19 of the Revised Code to compute the
cost per case mix unit for the ICFIID and the peer group maximum cost per case
mix unit. Ohio developmental disabilities profile data for all four quarters of
the calendar year shall be used to calculate the annual facility average case
mix score: (a) The department-assigned facility average case mix scores
shall be omitted from the ICFIID's annual average case mix score
calculation. (b) The annual facility average case mix score shall be
calculated from no fewer than two acceptable quarterly facility 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 facility average case mix scores for the purposes of
calculating the annual facility average case mix score and for paragraph (F)(3)
of this rule include quarterly facility average case mix scores calculated
based on the ICFIID's submitted information as described in paragraph
(F)(2) of this rule. (2) If at least two acceptable quarterly
facility average case mix scores are not available, the department shall assign
the cost per case mix unit in accordance with paragraph (F)(3)(b) of this
rule.
View Appendix
Last updated April 12, 2024 at 11:52 AM
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Rule 5123-7-34 | Intermediate care facilities for individuals with intellectual disabilities - quality indicators and the quality incentive payment program.
Effective:
December 17, 2020
(A) Purpose This rule sets forth a method and process for
determining the quality incentive payment that may be paid to an intermediate
care facility for individuals with intellectual disabilities (ICFIID) for
achieving quality indicators pursuant to section 5124.24 of the Revised
Code. (B) Definitions For the purposes of this rule, the following
definitions apply: (1) "Change of
operator" has the same meaning as in section 5124.01 of the Revised
Code. (2) "Cost report" has the same
meaning as in rule 5123-7-12 of the Administrative Code. (3) "Direct care staff" means
activity staff, habilitation staff, habilitation supervisors, nurse aides,
nurses, and qualified intellectual disability professionals. (4) "Individual plan" has the
same meaning as in rule 5123:2-3-03 of the Administrative Code. (5) "Inpatient
days" has the same meaning as in section 5124.01 of the Revised
Code. (6) "Quality incentive payment"
means a rate enhancement, available beginning with fiscal year 2022, that is a
component of an ICFIID's per diem rate, available to an eligible ICFIID
that chooses to achieve quality indicators and meets the requirements set forth
in this rule. (7) "Quality indicator" means
one of the five standards set forth in paragraph (D) of this rule. (C) Participation and eligibility for the quality incentive
payment (1) Participation in the
quality incentive payment program is voluntary. An ICFIID that chooses to
participate may elect to do so for one or more quality indicators. (2) To be eligible for
participation in the quality incentive payment program, an ICFIID is to have
been in operation for at least three months prior to the last day of the
calendar year for which it is submitting a cost report. (3) In the case of a
change of operator, an entering operator may be eligible for the quality
incentive payment determined only for a cost report period commencing after the
effective date of the change of operator. (4) An ICFIID whose license has been
suspended, proposed for revocation, or revoked at any time during a cost report
period is ineligible for a quality incentive payment for the following fiscal
year. (D) Quality indicators Five quality indicators have been established for
purposes of the quality incentive payment program: (1) The ICFIID has developed and
implemented a written policy to annually conduct satisfaction surveys for
residents of the ICFIID. The policy is to set forth that: (a) The survey will address, at a minimum: (i) The degree to which a resident feels happy and safe
living in the ICFIID; (ii) Staff interactions; (iii) The level to which a resident and/or his or her
guardian are involved in person-centered planning; (iv) Community activities; and (v) Medical care. (b) The ICFIID will ensure and document that the
satisfaction survey is completed by or offered to each resident and/or the
resident's guardian, family member, or advocate. (c) The ICFIID will summarize the survey results and share
the summarized survey results with residents, guardians, family members, and
advocates. (d) The ICFIID will develop a plan to respond to any
concerns identified through administration of the survey. (2) The ICFIID has
developed and implemented a written policy to ensure individual plans are
person-centered. At a minimum, the policy will: (a) Set forth a process for obtaining input from residents,
guardians, and direct care staff. (b) Address the seven essential elements of person-centered
planning: (i) Language in the
individual plan is descriptive, respectful, empowering, and uses everyday words
that the resident, persons important to the resident, and direct care staff
understand; (ii) The individual plan identifies positive information and
builds on the resident's strengths, using a trauma-informed
approach; (iii) Important ideas are organized and interwoven through
the individual plan so that it is clear that outcomes and services flow from
information outlined elsewhere in the individual plan; (iv) What is important for the resident and what is
important to the resident is specific, detailed, and reflected in outcomes and
services; (v) Outcomes are clear and action steps describe how
progress will be measured; (vi) The individual plan includes a clear description of
services and supports necessary to address the resident's needs and
preferred method for delivery; and (vii) The individual plan includes the type, scope, amount,
frequency, duration, and provider type of services to be
delivered. (3) The ICFIID has
developed and implemented a written policy to ensure that each resident has
opportunities to experience community integration on a person-centered
basis. (4) The ICFIID has
developed and implemented a written policy to ensure all direct care staff
successfully complete, on an annual basis, at least one hour of training
specific to resident or staff needs that is above and beyond the training
described in paragraph (F)(1)(j) of rule 5123:2-3-01 of the Administrative
Code. The training may vary among staff. (5) The ICFIID has
developed and implemented a written policy for staff retention that includes
measuring staff turnover. (E) Awarding points for quality
indicators (1) Each quality
indicator is associated with one point, for a maximum possible five
points. (2) An ICFIID will
indicate its intent to receive the point for a quality indicator by attesting
on its cost report that it has achieved the quality indicator and attaching its
written policy for the quality indicator. To continue to receive the point for
a quality indicator, the ICFIID will attach its written policy for the quality
indicator to subsequent cost reports and indicate if the written policy has
been amended since the prior submission. (3) An eligible ICFIID
will receive the point for a quality indicator when: (a) The ICFIID attests it has achieved the quality
indicator; (b) The ICFIID attaches its written policy for the quality
indicator with its cost report; and (c) Absent a determination by the department
that: (i) The written policy
for the quality indicator fails to meet the requirements set forth in this
rule; or (ii) The ICFIID fails to
implement the written policy. (F) Calculation of the quality incentive
payment An ICFIID's per diem quality incentive
payment for a fiscal year will be calculated in accordance with section 5124.24
of the Revised Code. (G) Verifying achievement of quality
indicators (1) The department will
use two methods to verify a participating ICFIID's achievement of quality
indicators. (a) Review of written policy (i) Department staff will
review each written policy for a quality indicator submitted by an ICFIID to
ensure the policy meets the requirements set forth in this rule. The written
policies will be reviewed as part of the desk review of the ICFIID's cost
report conducted in accordance with rule 5123-7-12 of the Administrative
Code. (ii) The department will
notify an ICFIID by electronic mail within fifteen calendar days of completing
the desk review when the department finds that the written policy fails to meet
the requirements set forth in this rule. The notice will inform the ICFIID that
it is ineligible to receive the quality incentive payment for that quality
indicator for the following fiscal year and should adjust its cost report
accordingly. (iii) An ICFIID may
electronically submit a request for reconsideration of the department's
finding that includes written justification within fifteen calendar days of
receipt of the desk review finding. (iv) The department will
respond by electronic mail to the request for reconsideration within fifteen
calendar days of receipt. (b) Review of implementation of written policy (i) Department staff will
review the ICFIID's implementation of the written policy for a quality
indicator during an on-site visit to the ICFIID. The department will notify an
ICFIID by electronic mail at least fifteen calendar days in advance of the
on-site visit. When an ICFIID indicates it has achieved more than one quality
indicator, department staff will review implementation of at least two quality
indicators. (a) For purposes of
reviewing implementation of the written policy for a quality indicator
described in paragraph (D)(1), (D)(2), or (D)(3) of this rule, the department
will select a random sample of residents for review. The number of residents
selected will be two or twenty per cent, whichever is larger. (b) For purposes of
reviewing implementation of the written policy for the quality indicator
described in paragraph (D)(4) of this rule, the department will select a random
sample of direct care staff for review. The number of direct care staff
selected will be two or twenty per cent, whichever is larger. (c) For purposes of
reviewing implementation of the written policy for the quality indicator
described in paragraph (D)(5) of this rule, the department will examine the
ICFIID's measurements or reports of staff turnover for the cost report
period. (ii) The department will
notify an ICFIID by electronic mail within fifteen calendar days of completing
the on-site review when the department finds that the ICFIID failed to
implement the written policy. The notice will inform the ICFIID that it is
ineligible to receive the quality incentive payment for that quality indicator
for the following fiscal year and should adjust its cost report
accordingly. (iii) An ICFIID may
electronically submit a request for reconsideration of the department's
finding that includes written justification with supporting documentation
within fifteen calendar days of receipt of the on-site review
finding. (iv) The department will
respond by electronic mail to the request for reconsideration within fifteen
calendar days of receipt. (2) If the department
determines that an ICFIID improperly attested achievement of a quality
indicator on its cost report, the department will reject the cost report and
the ICFIID will submit a corrected cost report in accordance with rule
5123-7-12 of the Administrative Code. The ICFIID will not receive a quality
incentive payment for the quality indicator.
Last updated April 12, 2024 at 11:52 AM
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